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Diabetes mellitus (DM) is a leading driver of tuberculosis (TB) disease in TB-DM burdened countries. We aimed to assess the impact on TB disease of several intervention strategies targeting people with DM in India.A previously validated TB-DM mathematical model was extended to include interventions targeting DM individuals. The model stratified the population by age, DM status, TB infection status and stage, TB disease form, treatment, recovery, and intervention status.By 2050, different TB vaccination strategies (coverage of 50 % and vaccine efficacies ranging between 50 %-60 %) reduced TB incidence and mortality rates by 4.5 %-20.8 % and 4.1 %-22.1 %, respectively, and averted 3.1 %-12.8 % of TB disease cases in the total population. Number of vaccinations needed to avert one TB case (effectiveness) was 14-105. Varying the coverage levels of latent TB treatment (coverage of 50 %-80 % and drug effectiveness of 90 %) reduced TB incidence and mortality rates by 7.1 %-11.3 % and 8.2 %-13.0 %, respectively, averting 4.2 %-6.7 % of TB cases, with effectiveness of 38-40. Different scenarios for dual and concurrent treatment of those with TB and DM, reduced TB incidence and mortality rates by 0.1 %-0.4 % and 1.3 %-4.8 %, respectively, averting 0.1 %-0.2 % of TB cases, with effectiveness of 28-107. Different scenarios for managing and controlling DM (regardless of TB status) reduced TB incidence and mortality rates by 4.5 %-16.5 % and 6.5 %-22.2 %, respectively, averting 2.9 %-10.8 % of TB cases, with effectiveness of 6-24.Gains can be attained by targeting DM individuals with interventions to reduce TB burden. Most strategies were effective with50 intervention doses needed to avert one TB disease case, informing key updates of current treatment guidelines.

© 2019 Sobers et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Although most countries face increasing population levels of obesity and diabetes their effect on coronary heart disease (CHD) mortality has not been often studied in small island developing states (SIDs) where obesity rates are among the highest in the world. We estimated the relative contributions of treatments and cardiovascular risk factors to the decline in CHD mortality from 1990 to 2012 in the Caribbean island, Barbados. Methods We used the IMPACT CHD mortality model to estimate the effect of increased coverage of effective medical/surgical treatments and changes in major CHD risk factors on mortality trends in 2012 compared with 1990. We calculated deaths prevented or postponed (DPPs) for each model risk factor and treatment group. We obtained data from WHO Mortality database, population denominators from the Barbados Statistical Service stratified by 10-year age group (ages 25–34 up to 85 plus), population-based risk factor surveys, Global Burden of Disease and Barbados’ national myocardial infarction registry. Monte Carlo probabilistic sensitivity analysis was performed. Results In 1990 the age-standardized CHD mortality rate was 109.5 per 100,000 falling to 55.3 in 2012. Implementation of effective treatment accounted for 56% DPPs (95% (Uncertainty Interval (UI) 46%, 68%), mostly due to the introduction of treatments immediately after acute myocardial infarction (AMI) (14%) and unstable angina (14%). Overall, risk factors contributed 19% DPPs (95% UI 6% to 34%) mostly attributed to decline in cholesterol (18% DPPs, 95% UI 12%, 26%). Adverse trends in diabetes: 14% additional deaths(ADs) 95% UI 8% to 21% ADs) and BMI (2% ADs 95%UI 0 to 5% ADs) limited potential for risk factor gains. Conclusions Given the significant negative impact of obesity/diabetes on mortality in this analysis, research that explores factors affecting implementation of evidenced-based preventive strategies is needed. The fact that most of the decline in CHD mortality in Barbados was due to treatment provides an example for SIDs about the advantages of universal access to care and treatment.

Background: Anaemia is a major cause of morbidity and mortality in low-income countries. Primary health-care workers in resource-poor settings usually diagnose anaemia clinically, but this is inaccurate. The WHO Haemoglobin Colour Scale (HCS) is a simple, cheap quantitative method to assess haemoglobin concentration outside of the laboratory. We systematically reviewed the literature to assess the accuracy of the HCS in primary care to diagnose anaemia, and compared this with clinical assessment. Methods: We searched the electronic databases including MEDLINE, EMBASE, SCOPUS, Web of Science, Cochrane library, CINAHL plus, Popline, Reproductive Health Library, and Google Scholar and regional databases up to Nov 14, 2014, “haemoglobin colour scale” in alternative spellings published in any language. Two reviewers independently screened studies, extracted data, and assessed quality using the QUADAS-2 instrument. Statistical analyses were carried out in STATA using the bivariate model. Findings: Of 141 records and abstracts screened, 14 studies were included. The pooled sensitivity of the HCS to diagnose anaemia was 80% (95% CI 68–88) compared with 52% for clinical assessment ([95% CI 36–67]; p=0·008). Specificity was similar between the HCS (80% [95% CI 59–91]) and clinical assessment (75% [56–88]; p=0·8250). For severe anaemia, diagnostic accuracy was again higher overall for the HCS (p

OBJECTIVE We describe in detail the burden of infections in adults with diabetes within a large national population cohort. We also compare infection rates between patients with type 1 and type 2 diabetes mellitus (T1DM and T2DM). RESEARCH DESIGN AND METHODS A retrospective cohort study compared 102,493 English primary care patients aged 40–89 years with a diabetes diagnosis by 2008 (n = 5,863 T1DM and n = 96,630 T2DM) with 203,518 age-sex-practice–matched control subjects without diabetes. Infection rates during 2008–2015, compiled from primary care and linked hospital and mortality records, were compared across 19 individual infection categories. These were further summarized as any requiring a prescription or hospitalization or as cause of death. Poisson regression was used to estimate incidence rate ratios (IRRs) between 1) people with diabetes and control subjects and 2) T1DM and T2DM adjusted for age, sex, smoking, BMI, and deprivation. RESULTS Compared with control subjects without diabetes, patients with diabetes had higher rates for all infections, with the highest IRRs seen for bone and joint infections, sepsis, and cellulitis. IRRs for infection-related hospitalizations were 3.71 (95% CI 3.27–4.21) for T1DM and 1.88 (95% CI 1.83–1.92) for T2DM. A direct comparison of types confirmed higher adjusted risks for T1DM versus T2DM (death from infection IRR 2.19 [95% CI 1.75–2.74]). We estimate that 6% of infection-related hospitalizations and 12% of infection-related deaths were attributable to diabetes. CONCLUSIONS People with diabetes, particularly T1DM, are at increased risk of serious infection, representing an important population burden. Strategies that reduce the risk of developing severe infections and poor treatment outcomes are under-researched and should be explored.

Background In the Global Burden of Disease Study 2013 (GBD 2013), knowledge about health and its determinants has been integrated into a comparable framework to inform health policy. Outputs of this analysis are relevant to current policy questions in England and elsewhere, particularly on health inequalities. We use GBD 2013 data on mortality and causes of death, and disease and injury incidence and prevalence to analyse the burden of disease and injury in England as a whole, in English regions, and within each English region by deprivation quintile. We also assess disease and injury burden in England attributable to potentially preventable risk factors. England and the English regions are compared with the remaining constituent countries of the UK and with comparable countries in the European Union (EU) and beyond. Methods We extracted data from the GBD 2013 to compare mortality, causes of death, years of life lost (YLLs), years lived with a disability (YLDs), and disability-adjusted life-years (DALYs) in England, the UK, and 18 other countries (the first 15 EU members [apart from the UK] and Australia, Canada, Norway, and the USA [EU15+]). We extended elements of the analysis to English regions, and subregional areas defined by deprivation quintile (deprivation areas). We used data split by the nine English regions (corresponding to the European boundaries of the Nomenclature for Territorial Statistics level 1 [NUTS 1] regions), and by quintile groups within each English region according to deprivation, thereby making 45 regional deprivation areas. Deprivation quintiles were defined by area of residence ranked at national level by Index of Multiple Deprivation score, 2010. Burden due to various risk factors is described for England using new GBD methodology to estimate independent and overlapping attributable risk for five tiers of behavioural, metabolic, and environmental risk factors. We present results for 306 causes and 2337 sequelae, and 79 risks or risk clusters. Findings Between 1990 and 2013, life expectancy from birth in England increased by 5·4 years (95% uncertainty interval 5·0-5·8) from 75·9 years (75·9-76·0) to 81·3 years (80·9-81·7); gains were greater for men than for women. Rates of age-standardised YLLs reduced by 41·1% (38·3-43·6), whereas DALYs were reduced by 23·8% (20·9-27·1), and YLDs by 1·4% (0·1-2·8). For these measures, England ranked better than the UK and the EU15+ means. Between 1990 and 2013, the range in life expectancy among 45 regional deprivation areas remained 8·2 years for men and decreased from 7·2 years in 1990 to 6·9 years in 2013 for women. In 2013, the leading cause of YLLs was ischaemic heart disease, and the leading cause of DALYs was low back and neck pain. Known risk factors accounted for 39·6% (37·7-41·7) of DALYs; leading behavioural risk factors were suboptimal diet (10·8% [9·1-12·7]) and tobacco (10·7% [9·4-12·0]). Interpretation Health in England is improving although substantial opportunities exist for further reductions in the burden of preventable disease. The gap in mortality rates between men and women has reduced, but marked health inequalities between the least deprived and most deprived areas remain. Declines in mortality have not been matched by similar declines in morbidity, resulting in people living longer with diseases. Health policies must therefore address the causes of ill health as well as those of premature mortality. Systematic action locally and nationally is needed to reduce risk exposures, support healthy behaviours, alleviate the severity of chronic disabling disorders, and mitigate the effects of socioeconomic deprivation. Funding Bill & Melinda Gates Foundation and Public Health England. © 2015 Newton et al. Open Access article distributed under the terms of CC BY. 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Tuberculosis (TB) remains one of the 10 leading causes of death worldwide, especially in low- and middle-income countries. We conducted a systematic review and meta-analysis including 88 studies examining the association between diabetes mellitus (DM) and TB treatment outcomes. However, we found several common methodological problems among them, including inappropriate adjustments for confounding factors, not using optimal statistical methods for ‘time to event' data, misclassification in exposure (DM) and outcomes (TB treatment outcomes) due to study design and non-standardisation of definitions, misunderstanding of basic study design concept, standardisation of TB treatment outcomes and quality control of publications. Many of these problems would apply more broadly to other ‘risk factors' for poor TB treatment outcomes. These issues need to be addressed and resolved to improve the quality of the studies and provide more accurate results for policy makers in the future to tackle the burden of TB.

Contains fulltext : 196372.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To describe the characteristics and management of Diabetes mellitus (DM) patients from low- and middle-income countries (LMIC). METHODS: We systematically characterised consecutive DM patients attending public health services in urban settings in Indonesia, Peru, Romania and South Africa, collecting data on DM treatment history, complications, drug treatment, obesity, HbA1c and cardiovascular risk profile; and assessing treatment gaps against relevant national guidelines. RESULTS: Patients (median 59 years, 62.9% female) mostly had type 2 diabetes (96%), half for >5 years (48.6%). Obesity (45.5%) and central obesity (females 84.8%; males 62.7%) were common. The median HbA1c was 8.7% (72 mmol/mol), ranging from 7.7% (61 mmol/mol; Peru) to 10.4% (90 mmol/mol; South Africa). Antidiabetes treatment included metformin (62.6%), insulin (37.8%), and other oral glucose-lowering drugs (34.8%). Disease complications included eyesight problems (50.4%), EGFR

To evaluate the performance of diagnostic tools for diabetes mellitus, including laboratory methods and clinical risk scores, in newly-diagnosed pulmonary tuberculosis patients from four middle-income countries.In a multicentre, prospective study, we recruited 2185 patients with pulmonary tuberculosis from sites in Indonesia, Peru, Romania and South Africa from January 2014 to September 2016. Using laboratory-measured glycated haemoglobin (HbA1c) as the gold standard, we measured the diagnostic accuracy of random plasma glucose, point-of-care HbA1c, fasting blood glucose, urine dipstick, published and newly derived diabetes mellitus risk scores and anthropometric measurements. We also analysed combinations of tests, including a two-step test using point-of-care HbA1cwhen initial random plasma glucose was ≥ 6.1 mmol/L.The overall crude prevalence of diabetes mellitus among newly diagnosed tuberculosis patients was 283/2185 (13.0%; 95% confidence interval, CI: 11.6-14.4). The marker with the best diagnostic accuracy was point-of-care HbA1c (area under receiver operating characteristic curve: 0.81; 95% CI: 0.75-0.86). A risk score derived using age, point-of-care HbA1c and random plasma glucose had the best overall diagnostic accuracy (area under curve: 0.85; 95% CI: 0.81-0.90). There was substantial heterogeneity between sites for all markers, but the two-step combination test performed well in Indonesia and Peru.Random plasma glucose followed by point-of-care HbA1c testing can accurately diagnose diabetes in tuberculosis patients, particularly those with substantial hyperglycaemia, while reducing the need for more expensive point-of-care HbA1c testing. Risk scores with or without biochemical data may be useful but require validation.Évaluer la performance des outils de diagnostic du diabète sucré, et notamment les méthodes de laboratoire et les cotes de risque clinique, chez les patients souffrant d'une tuberculose pulmonaire récemment diagnostiquée dans quatre pays à revenu intermédiaire.Dans le cadre d'une étude multicentrique et prospective, nous avons recruté 2185 patients atteints de tuberculose pulmonaire dans différents endroits en Afrique du Sud, en Indonésie, au Pérou et en Roumanie entre janvier 2014 et septembre 2016. En utilisant comme référence l'hémoglobine glyquée (HbA1c) mesurée en laboratoire, nous avons évalué la précision diagnostique de la glycémie aléatoire, de l'HbA1c sur le lieu d'intervention, de la glycémie à jeun, de la bandelette urinaire, des cotes de risque déjà publiées et récemment obtenues pour le diabète sucré et des mesures anthropométriques. Nous avons également analysé des combinaisons de tests, et notamment un test en deux étapes qui utilise l'HbA1c sur le lieu d'intervention lorsque la glycémie aléatoire initiale est ≥ 6,1 mmol/L.La prévalence brute générale du diabète sucré chez les patients souffrant d'une tuberculose récemment diagnostiquée était de 283/2185 (13,0%; intervalle de confiance, IC, à 95%: 11,6–14,4). Le marqueur fournissant la meilleure précision diagnostique était l'HbA1c sur le lieu d'intervention (aire sous la courbe ROC: 0,81; IC à 95%: 0,75–0,86). La meilleure précision diagnostique générale a été obtenue à l'aide d'une cote de risque calculée au moyen de l'âge, de l'HbA1c sur le lieu d'intervention et de la glycémie aléatoire (aire sous la courbe ROC: 0,85; IC à 95%: 0,81–0,90). Une forte hétérogénéité entre les différents endroits a été constatée pour tous les marqueurs, mais le test en deux étapes a donné de bons résultats en Indonésie et au Pérou.L'utilisation de la glycémie aléatoire suivie de l'HbA1c sur le lieu d'intervention permet de diagnostiquer avec précision le diabète chez les patients atteints de tuberculose, en particulier lorsqu'ils souffrent d'une importante hyperglycémie, tout en diminuant le besoin de tests HbA1c sur le lieu d'intervention, plus coûteux. Les cotes de risque associées ou non à des données biochimiques peuvent être utiles, mais doivent être validées.Evaluar el rendimiento de las herramientas de diagnóstico para la diabetes mellitus, incluidos los métodos de laboratorio y los índices de riesgo clínico, en pacientes recién diagnosticados con tuberculosis pulmonar de cuatro países de ingresos medios.En un estudio prospectivo multicéntrico, se seleccionaron 2185 pacientes con tuberculosis pulmonar de algunas regiones de Indonesia, Perú, Rumanía y Sudáfrica entre enero de 2014 y septiembre de 2016. Usando hemoglobina glicosilada medida en laboratorio (HbA1c) como el patrón de excelencia, se midió la precisión diagnóstica de glucosa plasmática al azar, estando HbA1c en el punto de atención, glucemia en sangre en ayunas, tira reactiva de orina, índices de riesgo de diabetes mellitus publicados recientemente y medidas antropométricas. También se analizaron combinaciones de pruebas, incluida una prueba de dos pasos con HbA1c en el punto de atención cuando la glucosa plasmática aleatoria inicial fue ≥ 6,1mmol/L.La prevalencia general cruda de diabetes mellitus entre los pacientes con tuberculosis recién diagnosticados fue de 283/2185 (13,0 %, intervalo de confianza del 95 %, IC: 11,6–14,4). El marcador con la mejor precisión diagnóstica fue la HbA1c en el punto de atención (área bajo la curva característica operativa del receptor: 0,81; IC del 95 %: 0,75–0,86). Un índice de riesgo derivado de la edad, la HbA1c en el punto de atención y la glucosa plasmática al azar obtuvieron la mejor precisión diagnóstica general (área bajo la curva: 0,85; IC del 95 %: 0,81–0,90). Hubo una heterogeneidad sustancial entre las regiones para todos los marcadores, pero la prueba combinada de dos pasos funcionó de manera correcta en Indonesia y Perú.La glucosa plasmática al azar seguida de la prueba de HbA1c en el punto de atención puede diagnosticar con precisión la diabetes en pacientes con tuberculosis, particularmente en aquellos con hiperglucemia sustancial, mientras se reduce la necesidad de pruebas más costosas de HbA1c en el punto de atención. Los índices de riesgo con o sin datos bioquímicos pueden ser útiles, pero requieren validación.تقييم أداء أدوات تشخيص مرض السكري، بما في ذلك الطرق المختبرية ودرجات المخاطر السريرية، لدى المرضى الذين تم تشخيص إصابتهم حديثاً بالسل الرئوي من أربعة بلدان متوسطة الدخل.في دراسة استباقية متعددة المراكز، قمنا بالاستعانة بـ 2185 مريضًا بمرض السل الرئوي من مواقع في إندونيسيا وبيرو وجنوب إفريقيا ورومانيا من يناير/كانون ثاني 2014 إلى سبتمبر/أيلول 2016. وعن طريق قياس الهيموغلوبين الغليكوزيلاتي في المختبر (HbA1c) كمعيار أساسي، قمنا بقياس مدى دقة تشخيص كل من جلوكوز البلازما العشوائي، واختبار HbA1c في أماكن الرعاية، وجلوكوز الدم أثناء الصيام، ومقياس البول، ودرجات المخاطر المنشورة والمستنبطة حديثا من داء السكري، والقياسات الأنثروبومترية. قمنا أيضا بتحليل مجموعات من الاختبارات، بما في ذلك اختبار من خطوتين باستخدام اختبار HbA1c في أماكن الرعاية عندما كان مستوى جلوكوز البلازما العشوائي أكبر من أو يساوي 6.1 مليمول/ لتر.كان معدل الانتشار الكلي لمرض السكري بين المرضى الذين تم تشخيص إصابتهم حديثًا بالسل هو 283/2185 (13.0%؛ بفاصل ثقة 95%، فاصل ثقة: 11.6 إلى 14.4).كانت العلامة ذات أفضل دقة تشخيصية هي اختبار HbA1c في أماكن الرعاية (المساحة تحت منحنى خاصية التشغيل للمستقبِل: 0.81؛ بفاصل ثقة 95%: 0.75 إلى 0.86). كانت درجة الخطر المشتقة باستخدام العمر، واختبار HbA1c في أماكن الرعاية، وجلوكوز البلازما العشوائي، هي أفضل دقة تشخيصية عامة (المساحة تحت المنحنى: 0.85؛ بفاصل ثقة 95%: 0.81 إلى 0.90). كانت هناك عدم تجانس واضح بين المواقع لكل العلامات، إلا أن الاختبار المكون من خطوتين قدم أداءً جيدًا في إندونيسيا وبيرو.يمكن لاختبار جلوكوز البلازما العشوائي، ويليه اختبار HbA1c في أماكن الرعاية، تشخيص مرض السكري بدقة في مرضى السل، وخاصة أولئك الذين يعانون من ارتفاع شديد في سكر الدم، مع تقليل الحاجة إلى اختبار HbA1c الأكثر تكلفة في أماكن الرعاية. قد تكون درجات الخطر مفيدة، سواء مع بيانات كيميائية حيوية أو بدونها، ولكنها تتطلب التحقق من الصحة.评估用于四个中等收入国家新诊断结核病患者的糖尿病诊断工具的表现，其中包括实验室方法和临床风险评分。.在这项多中心、前瞻性的研究中，自 2014 年 1 月起至 2016 年 9 月，我们从秘鲁、罗马尼亚、南非和印度尼西亚各地招募了 2185 名肺结核患者。使用实验室测量的糖化血红蛋白 (HbA1c) 为黄金标准，我们测量了随机血糖、糖化血红蛋白 (HbA1c) 床旁检测、空腹血糖、尿液常规检查、已发表的和新导出的糖尿病风险评分以及人体测量法的诊断准确度。我们还对组合检测法进行了分析，其中包括两步检测法：即在初始随机血糖为临界值 ≥6.1 mmol/L 时，进行糖化血红蛋白 (HbA1c) 床旁检测。.新诊断结核病患者中，糖尿病的整体患病率为 283/2185（13.0％；95％ 置信区间，CI：11.6–14.4）。最准确的诊断指标是糖化血红蛋白 (HbA1c) 床旁检测（受试者工作特征曲线下的区域：0.81；95％ 置信区间，CI：0.75-0.86）。使用年龄、糖化血红蛋白 (HbA1c) 床旁检测和随机血糖得出的风险评分整体诊断准确度最佳（受试者工作特征曲线下的区域：0.85；95％ 置信区间，CI：0.81-0.90）。不同地点的指标之间存在显著的异质性，但两步组合检测法在秘鲁和印度尼西亚表现良好。.在随机血糖检测后再进行糖化血红蛋白 (HbA1c) 床旁检测可以准确诊断结核病患者是否患有糖尿病（尤其针对患有严重高血糖的患者），同时减少对更为昂贵的糖化血红蛋白 (HbA1c) 床旁检测的需求。内附或未附生化指标的风险评分可能有用，但仍需验证。.Оценить эффективность инструментов диагностики сахарного диабета (включая лабораторные методы и показатели клинического риска) у пациентов с недавно диагностированным туберкулезом легких из четырех стран со средним уровнем доходов.С января 2014 года по сентябрь 2016 года авторы провели многоцентровое проспективное исследование, в котором приняли участие 2185 пациентов с туберкулезом легких, проживающих в Индонезии, Перу, Румынии и Южной Африке. Используя измеренный в лаборатории гликозилированный гемоглобин (HbA1c) в качестве общепринятого стандарта, авторы измерили диагностическую точность выборочного определения уровня глюкозы в плазме; уровня HbA1c, определяемого в месте предоставления медицинской помощи; уровня глюкозы в крови натощак и определения сахара в моче с помощью индикаторной полоски с учетом опубликованных и недавно полученных оценок риска заболевания сахарным диабетом и антропометрических измерений. Мы также проанализировали комбинации тестов, в том числе двухэтапный тест с использованием HbA1c, измеренного в месте предоставления медицинской помощи, при начальном случайном уровне глюкозы в плазме ≥ 6,1 ммоль/л.Общая распространенность сахарного диабета среди пациентов с недавно выявленным туберкулезом составила 283 случая на 2185 человек (13,0%, 95%-й доверительный интервал, ДИ: 11,6–14,4). Маркер с наибольшей диагностической точностью — HbA1c, измеренный в месте предоставления медицинской помощи (область под кривой ROC: 0,81; 95%-й ДИ: 0,75–0,86). Оценка риска в зависимости от возраста, HbA1c, измеренного в месте предоставления медицинской помощи, и выборочного определения глюкозы в плазме имела наилучшую общую диагностическую точность (область под кривой: 0,85; 95%-й ДИ: 0,81–0,90). В различных местах наблюдалась существенная гетерогенность всех маркеров, при этом двухступенчатый комбинированный тест дал хорошие показатели для Индонезии и Перу.Выборочно определяемый уровень глюкозы в плазме с последующим тестированием HbA1c в месте предоставления медицинской помощи может точно диагностировать диабет у пациентов с туберкулезом, особенно у пациентов с существенной гипергликемией, уменьшая необходимость в более дорогостоящем тестировании HbA1c в месте предоставления медицинской помощи. Оценки риска по данным биохимического анализа крови или без них могут быть полезными, но нуждаются в проверке.

The prevalence of obesity among adults in Saudi Arabia increased from 22% in 1990-1993 to 36% in 2005, and future projections of the prevalence of adult obesity are needed by health policy-makers. In a secondary analysis of published data, a number of assumptions were applied to estimate the trends and projections in the age-and sex-specific prevalence of adult obesity in Saudi Arabia over the period 1992-2022. Five studies conducted between 1989 and 2005 were eligible for inclusion, using body mass index (BMI) ≥ 30 kg/m(2) to define obesity. The overall prevalence of obesity was projected to increase from around 12% in 1992 to 41% by 2022 in men, and from 21% to 78% in women. Women had much higher projected prevalence than men, particularly in the age groups 35-44, 45-54 and 55-64 years. Effective national strategies are needed to reduce or halt the projected rise in obesity prevalence.

Objectives Dietary salt intake has been causally linked to high blood pressure and increased risk of cardiovascular events. Cardiovascular disease causes approximately 35% of total UK deaths, at an estimated annual cost of £30 billion. The World Health Organization and the National Institute for Health and Care Excellence have recommended a reduction in the intake of salt in people's diets. This study evaluated the cost-effectiveness of four population health policies to reduce dietary salt intake on an English population to prevent coronary heart disease (CHD). Methods The validated IMPACT CHD model was used to quantify and compare four policies: 1) Change4Life health promotion campaign, 2) front-of-pack traffic light labeling to display salt content, 3) Food Standards Agency working with the food industry to reduce salt (voluntary), and 4) mandatory reformulation to reduce salt in processed foods. The effectiveness of these policies in reducing salt intake, and hence blood pressure, was determined by systematic literature review. The model calculated the reduction in mortality associated with each policy, quantified as life-years gained over 10 years. Policy costs were calculated using evidence from published sources. Health care costs for specific CHD patient groups were estimated. Costs were compared against a "do nothing" baseline. Results All policies resulted in a life-year gain over the baseline. Change4life and labeling each gained approximately 1960 life-years, voluntary reformulation 14,560 life-years, and mandatory reformulation 19,320 life-years. Each policy appeared cost saving, with mandatory reformulation offering the largest cost saving, more than £660 million. Conclusions All policies to reduce dietary salt intake could gain life-years and reduce health care expenditure on coronary heart disease.

The purpose of this study is to estimate the prevalence and the number of people with type 2 diabetes (T2DM) in 2025 in Turkey and to evaluate the impact of possible policy options on T2DM prevalence. We developed a model to predict future prevalence of T2DM using trend data for adults aged 25–74 in Turkey from 1997 to 2025. The model integrates population, obesity and smoking trends to estimate the future T2DM prevalence using a Markov approach. T2DM prevalence was 7.5 % (95 % CI: 6.0–9.0 %) in 1997 increasing to 16.2 % (95 % CI: 15.5–21.1 %) in 2010. The forecasted prevalence for 2025 was 31.5 % (28.6 % in men and 35.1 % in women). If obesity prevalence declines by 10 % and smoking decreases by 20 % in 10 years from 2010, a 10 % relative reduction in diabetes prevalence (1,655,213 individuals) could be achieved by 2025. Diabetes burden is now a significant public health challenge, and our model predicts that its burden will increase significantly over the next two decades. Tackling obesity and other diabetes risk factors needs urgent action.

Background Consistent declines in coronary heart disease (CHD) death rates have been previously observed in Ireland since1985. Aims & Methods To use the previously validated Irish IMPACT CHD mortality model to further examine the subsequent CHD mortality falls from 1985 through to 2006, and to determine the contribution of risk factor changes and "evidence based" treatments to this decline by age and gender. Results CHD mortality rates fell by 68% in men (63% in 65–84years) and by 69% in women (66% in 65–84years). This resulted in approximately 6450 fewer CHD deaths than if mortality rates had not changed. Overall, approximately 40% (38% in men; 45% in women) of the CHD mortality decline could be attributed to improvements in treatment uptake, particularly secondary prevention (12%), angina (9%), and heart failure therapies (8%). Approximately 48% of the CHD mortality decline was attributable to risk factor improvements ( 54% in men; 37% in women); the biggest contributions came from falls in population systolic pressure (28%), cholesterol (24%), and physical inactivity levels (10%). Negative trends in diabetes and obesity levels generated an estimated 17% additional CHD deaths. The largest benefits from improvements in risk factors were seen in men aged 25–64years, while the greatest treatment benefits occurred in women aged 65–84years. The model explained approximately 88% of the observed mortality declines. Conclusion Falls in CHD mortality have continued in both sexes in Ireland, but with notable gender and age differences. The continued increase in diabetes and obesity levels is particularly worrying.

Summary Background The effects of corticosteroids are systemic, but their benefits in tuberculosis are thought to be organ specific, with clinicians using them routinely to treat some forms of tuberculosis (such as meningitis), but not others. We aimed to assess the effects of steroids on mortality attributable to all forms of tuberculosis across organ systems. Methods We did a systematic review and meta-analysis to estimate the efficacy of steroids for the prevention of mortality in all forms of tuberculosis, and to quantify heterogeneity in this outcome between affected organ systems. We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Central Register of Controlled Trials, Medline, Embase, and Literatura Latino-Americana e do Caribe em Ciencias da Saude (LILACS) for studies published up to Sept 6, 2012, and checked reference lists of included studies and relevant reviews. We included all trials in people with tuberculosis in any organ system, with tuberculosis defined clinically or microbiologically. There were no restrictions by age, comorbidity, publication language, or type, dose, or duration of steroid treatment. We used the Mantel-Haenszel method to summarise mortality across trials. Findings We identified 41 eligible trials, 18 of which assessed pulmonary tuberculosis. 20 of the 41 trials (including 13 of those for pulmonary tuberculosis) were done before the introduction of modern rifampicin-containing antituberculosis chemotherapy. Meta-analysis stratified by affected organ systems identified no heterogeneity; steroids reduced mortality by 17% (risk ratio [RR] 0·83, 95% CI 0·74–0·92; I 2 0%), consistent across all organ groups. In a sensitivity analysis that only included trials that used rifampicin-containing regimens, the results were similar (RR 0·85, 95% CI 0·74–0·98; I 2 21%). A sensitivity analysis in pulmonary tuberculosis that excluded trials with high potential risks of bias suggested a slight benefit, but the point estimate was closer to no effect and the difference was not significant (RR 0·93, 95% CI 0·60–1·44). Interpretation Steroids could be effective in reducing mortality for all forms of tuberculosis, including pulmonary tuberculosis. However, further evidence is needed since few recent trials have assessed the effectiveness of corticosteroids in patients with pulmonary tuberculosis. Funding UK Department for International Development.

There is growing interest in the re-emerging interaction between type 2 diabetes (DM) and TB, but the underlying biologic mechanisms are poorly understood despite their possible implications in clinical management. Experts in epidemiologic, public health, basic science, and clinical studies recently convened and identified research priorities for elucidating the underlying mechanisms for the co-occurrence of TB and DM. We identified gaps in current knowledge of altered immunity in patients with DM during TB, where most studies suggest an underperforming innate immunity, but exaggerated adaptive immunity to Mycobacterium tuberculosis. Various molecular mechanisms and pathways may underlie these observations in the DM host. These include signaling induced by excess advanced glycation end products and their receptor, higher levels of reactive oxidative species and oxidative stress, epigenetic changes due to chronic hyperglycemia, altered nuclear receptors, and/or differences in cell metabolism (immunometabolism). Studies in humans at different stages of DM (no DM, pre-DM, and DM) or TB (latent or active TB) should be complemented with findings in animal models, which provide the unique opportunity to study early events in the host-pathogen interaction. Such studies could also help identify biomarkers that will complement clinical studies in order to tailor the prevention of TB-DM, or to avoid the adverse TB treatment outcomes that are more likely in these patients. Such studies will also inform new approaches to host-directed therapies.

There is growing interest in the interaction between type 2 diabetes mellitus (DM) and TB, but many research questions remain unanswered. Epidemiologists, basic scientists, and clinical experts recently convened and identified priorities. This is the first of two reviews on this topic, summarizing priority areas of research regarding epidemiology, clinical management, and public health. First, from an epidemiologic point of view, more study is needed to determine the importance of transient hyperglycemia in patients with TB and on the importance of DM for the global epidemic of multidrug resistant (MDR)-TB. Second, regarding the screening and clinical management of combined TB and DM (TB-DM), clinical trials and large cohort studies should examine the benefits of improved DM care as well as prolonged or intensified TB treatment on the outcome of TB-DM and investigate the cost-effectiveness of screening methods for DM among patients newly diagnosed with TB. Third, from a public health and health systems point of view, the population health impact and cost-effectiveness of different interventions to prevent or treat DM and TB in high-burden populations should be examined, and health-system interventions should be developed for routine TB-DM screening, management of DM after completion of TB treatment, and better access to DM services worldwide. Studies are needed across different ethnicities and settings given the heterogeneity of metabolic perturbations, inflammatory responses, medications, and access to health care. Finally, studies should address interactions between TB, DM, and HIV because of the convergence of epidemics in sub-Saharan Africa and some other parts of the world.

Aims We developed and demonstrated a novel mathematical modeling approach to forecast the burden of type 2 diabetes mellitus (T2DM) and to investigate T2DM epidemiology for the purpose of informing public health policy and programming. Methods A population-level compartmental mathematical model was constructed and applied to Qatar. The model was stratified according to sex, age group, risk factor status, and T2DM status, and was parameterized by nationally-representative data. Results T2DM prevalence increased from 16.7% in 2012 to at least 24.0% by 2050. The rise in T2DM was most prominent among 45–54 years old. T2DM health expenditure was estimated to increase by 200–600% and to account for up to 32% of total health expenditure by 2050. Prevalence of obesity, smoking, and physical inactivity was predicted to increase from 41.4% to 51.0%, from 16.4% to 19.4%, and from 45.9% to 53.0%, respectively. The proportion of T2DM incidence attributed to obesity, smoking and physical inactivity was estimated at 57.5%, 1.8%, and 5.4%, respectively in 2012, and 65.7%, 2.1%, and 6.0%, respectively in 2050. Exploring different scenarios for the trends in risk factors, T2DM prevalence reached up to 37.7% by 2050. Conclusions Using our innovative approach, a rising T2DM epidemic is predicted to continue in the next decades, driven by population growth, ageing and adverse trends in risk factors. Obesity was the principal risk factor explaining two-thirds of T2DM incidence. T2DM must be a national priority addressed by preventive and therapeutic interventions targeting T2DM and its modifiable risk factors.

Background The authors aimed to determine whether, and by how much, diabetes mellitus (DM) increases the risk of tuberculosis (TB) and conversely whether TB increases the risk of DM. Methods Retrospective cohort analyses using data from two Oxford Record Linkage Study (ORLS) datasets, containing information on hospital admissions and day-case care between 1963 and 1998 (ORLS1) and between 1999 and 2005 (ORLS2), were carried out. The rate ratio (RR) for tuberculosis after admission to hospital with diabetes and for diabetes after hospital admission with tuberculosis was calculated. Results In ORLS1, the RR for TB in people admitted to hospital with DM, comparing the latter with a reference cohort, was 1.83 (95% CI 1.26 to 2.60), and in ORLS2 the RR was 3.11 (1.17 to 7.03). RRs for pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) within ORLS1 were similar at, respectively, 1.80 (1.16 to 2.67) and 1.98 (0.88 to 3.92). In ORLS 2 the RR for PTB was 2.63 (0.91 to 6.30). In ORLS1, there was no indication that TB was a risk factor for DM (RR 1.12, 0.76 to 1.60). The ORLS2 dataset was too small to analyse whether TB led to DM. Discussion DM was associated with a two- to threefold increased risk of TB within this predominantly white, English population. The authors found no evidence that TB increases the risk of DM. Our findings suggest that the risks of PTB and EPTB were both raised among individuals with DM. As DM prevalence rises, this association will become increasingly important for TB control and treatment.

Public policy plays a key role in improving population health and in the control of diseases, including non-communicable diseases. However, an evidence-based approach to formulating healthy public policy has been difficult to implement, partly on account of barriers that hinder integrated work between researchers and policy-makers. This paper describes a "policy effectiveness-feasibility loop" (PEFL) that brings together epidemiological modelling, local situation analysis and option appraisal to foster collaboration between researchers and policy-makers. Epidemiological modelling explores the determinants of trends in disease and the potential health benefits of modifying them. Situation analysis investigates the current conceptualization of policy, the level of policy awareness and commitment among key stakeholders, and what actually happens in practice, thereby helping to identify policy gaps. Option appraisal integrates epidemiological modelling and situation analysis to investigate the feasibility, costs and likely health benefits of various policy options. The authors illustrate how PEFL was used in a project to inform public policy for the prevention of cardiovascular diseases and diabetes in four parts of the eastern Mediterranean. They conclude that PEFL may offer a useful framework for researchers and policy-makers to successfully work together to generate evidence-based policy, and they encourage further evaluation of this approach.

To quantify how much of the coronary heart disease (CHD) mortality decline in Northern Ireland between 1987 and 2007 could be attributed to medical and surgical treatments and how much to changes in population cardiovascular risk factors.The IMPACT mortality model was used to integrate data on uptake and effectiveness of cardiological treatments and risk factor trends in the Northern Ireland population between 1987 and 2007. The main data sources were official population and mortality statistics, hospital administration systems, primary care datasets, published trials and meta-analyses, clinical audits, and national surveys. Between 1987 and 2007, CHD mortality rates in Northern Ireland decreased by 52% in men and 60% in women aged 25-84 years. This resulted in 3180 fewer deaths in 2007 than expected if 1987 mortality rates had persisted. Approximately 35% of this decrease was attributed to increased uptake of treatments in individuals and 60% to population risk factor reductions (principally blood pressure, total cholesterol, and smoking); however, these reductions were partially offset by adverse trends in diabetes, physical inactivity, and obesity.Approximately 60% of the substantial CHD mortality decline in Northern Ireland between 1987 and 2007 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.

ObjectivesIn Barbados, high case fatality rates have been reported after myocardial infarction (MI) with higher rates in women than men. To explore this inequality, we examined documented pharmacological interventions for ST-segment elevated myocardial infarction (STEMI), non-STEMI (NSTEMI) and unstable and chronic angina in women and men.DesignProspective cohort registry data for STEMI and NSTEMI and retrospective chart review for unstable and chronic angina.SettingTertiary care (acute coronary syndromes) and primary care (chronic angina) centres in Barbados.ParticipantsFor the years 2009–2016, a total of 1018 patients with STEMI or NSTEMI were identified via the prospective study. For unstable and chronic angina, 136 and 272 notes were reviewed respectively for the years 2010–2014.Outcome measuresThe proportions of patients prescribed recommended medication during the first 24 hours after an acute event, at discharge and for chronic care were calculated. Prescribed proportions were analysed by gender after adjustment for age.ResultsBetween 2009 and 2016, for the acute management of patients with NSTEMI and STEMI, only two (aspirin and clopidogrel) of six drugs had documented prescription rates of 80% or more. Patients with STEMI (n=552) had higher prescription rates than NSTEMI (n=466), with gender differences being more pronounced in the former. Among patients with STEMI, after adjustment for age, diabetes, hypertension and smoking, men were more likely to receive fibrinolytics acutely, OR 2.28 (95% CI 1.24 to 4.21). Compared with men, a higher proportion of women were discharged on all recommended treatments; this was only statistically significant for beta-blockers: age-adjusted OR 1.87 (95% CI 1.16 to 3.00). There were no statistically significant differences in documented prescription of drugs for chronic angina.ConclusionFollowing acute MI in Barbados, the proportion of patients with documented recommended treatment is relatively low. Although women were less likely to receive appropriate acute care than men, by discharge gender differences were reversed.

Background: This paper examines one EC-funded multinational project (RESCAP-MED), with a focus on research capacity building (RCB) concerning non-communicable diseases (NCDs) in the Mediterranean Middle East and North Africa. By the project’s end (2015), the entire region was engulfed in crisis.\ud \ud Objective: Designed before this crisis developed in 2011, the primary purpose of RESCAP-MED was to foster methodological skills needed to conduct multi-disciplinary research on NCDs and their social determinants. RESCAP-MED also sought to consolidate regional networks for future collaboration, and to boost existing regional policy engagement in the region on the NCD challenge. This analysis examines the scope and sustainability of RCB conducted in a context of intensifying political turmoil.\ud \ud Methods: RESCAP-MED linked two sets of activities. The first was a framework for training early- and mid-career researchers through discipline-based and writing workshops, plus short fellowships for sustained mentoring. The second integrated public-facing activities designed to raise the profile of the NCD burden in the region, and its implications for policymakers at national level. Key to this were two conferences to showcase regional research on NCDs, and the development of an e-learning resource (NETPH).\ud \ud Results: Seven discipline-based workshops (with 113 participants) and 6 workshops to develop writing skills (84 participants) were held, with 18 fellowship visits. The 2 symposia in Istanbul and Beirut attracted 280 participants. Yet the developing political crisis tagged each activity with a series of logistical challenges, none of which was initially envisaged. The immediacy of the crisis inevitably deflected from policy attention to the challenges of NCDs.\ud \ud Conclusions: This programme to strengthen research capacity for one priority area of global public health took place as a narrow window of political opportunity was closing. The key lessons concern issues of sustainability and the paramount importance of responsively shaping a context-driven RCB.

Background Coronary heart disease (CHD) mortality rates in the U.S. have halved since 1980. However, CHD remains a leading cause of death. The relative importance of secondary and primary prevention in explaining falls in coronary heart disease mortality is debated. Purpose The aim of this study was to quantify the primary and secondary preventive contributions to the U.S. CHD mortality fall between 1980 and 2000. Methods The IMPACT model was used to estimate contributions to the U.S. CHD mortality fall from risk factor declines in asymptomatic individuals (primary prevention) and in CHD patients (secondary prevention). Analyses were carried out in 2008. Results Approximately 316,100 fewer deaths were attributable to risk factor declines: 64,930 in CHD patients (21%) and 251,170 in asymptomatic individuals (79%). Smoking declines accounted for approximately 8390 fewer deaths in CHD patients and for 46,315 fewer deaths in asymptomatic people. Cholesterol falls gave approximately 22,210 fewer deaths in CHD patients and 107,300 fewer deaths in asymptomatic people. Statins accounted for approximately 16,580 fewer deaths, that is, one sixth of this mortality fall. Systolic blood pressure declines accounted for approximately 34,330 fewer deaths among CHD patients and 97,555 fewer deaths in asymptomatic individuals. Antihypertensive medications accounted for approximately 23,845 fewer deaths. Conclusions Half of the U.S. mortality fall in coronary heart disease between 1980 and 2000 was attributable to risk factor declines, with primary prevention producing substantially larger mortality reductions than secondary.

OBJECTIVE: China has about 350 million smokers, more commonly men. Using data from National Health Service Surveys conducted in 1993, 1998 and 2003, we (i) estimated trends in smoking prevalence and cessation according to sociodemographic variables and (ii) analysed cessation rates, quitting intentions, reasons for quitting and reasons for relapsing. METHODS: Data were collected from approximately 57 000 households and 200 000 individuals in each survey year. Household members > 15 years of age were interviewed about their smoking habits, quitting intentions and attitudes towards smoking. We present descriptive data stratified by age, sex, income level and rural versus urban residence. FINDINGS: In China, current smoking in those > 15 years old declined 60-49% in men and 5-3.2% in women over 1993-2003. The decline was more marked in urban areas. However, heavy smoking (> 20 cigarettes daily) increased substantially overall and doubled in men. The average age of uptake also dropped by about 3 years. In 2003, 7.9% of smokers reported intending to quit, and 6% of people who had ever smoked reported having quit. Of former smokers, 40.6% quit because of illness, 26.9% to prevent disease and 10.9% for financial reasons. CONCLUSION: Smoking prevalence declined in China over the study period, perhaps due to the combined effect of smoking cessation, reduced uptake in women and selective mortality among men over 40 years of age. However, heavy smoking increased. People in China rarely quit or intend to quit smoking, except at older ages. Further tobacco control efforts are urgently needed, especially in rural areas.

OBJECTIVE: To examine the potential for reducing cardiovascular risk factors in the United States of America enough to cause age-adjusted coronary heart disease (CHD) mortality rates to drop by 20% (from 2000 baseline figures) by 2010, as targeted under the Healthy People 2010 initiative. METHODS: Using a previously validated, comprehensive CHD mortality model known as IMPACT that integrates trends in all the major cardiovascular risk factors, stratified by age and sex, we calculated how much CHD mortality would drop between 2000 and 2010 in the projected population of the United States aged 25-84 years (198 million). We did this for three assumed scenarios: (i) if recent risk factor trends were to continue to 2010; (ii) success in reaching all the Healthy People 2010 risk factor targets, and (iii) further drops in risk factors, to the levels already seen in the low-risk stratum. FINDINGS: If age-adjusted CHD mortality rates observed in 2000 remained unchanged, some 388 000 CHD deaths would occur in 2010. First scenario: if recent risk factor trends continued to 2010, there would be approximately 19 000 fewer deaths than in 2000. Although improved total cholesterol, lowered blood pressure in men, decreased smoking and increased physical activity would account for some 51 000 fewer deaths, these would be offset by approximately 32 000 additional deaths from adverse trends in obesity and diabetes and in blood pressure in women. Second scenario: If Healthy People 2010 cardiovascular risk factor targets were reached, approximately 188 000 CHD deaths would be prevented. Scenario three: If the cardiovascular risk levels of the low-risk stratum were reached, approximately 372 000 CHD deaths would be prevented. CONCLUSION: Achievement of the Healthy People 2010 cardiovascular risk factor targets would almost halve the predicted CHD death rates. Additional reductions in major risk factors could prevent or postpone substantially more deaths from CHD.

Background Diarrhoea is a common cause of morbidity and a leading cause of death among children aged less than five years, particularly in low- and middle-income countries. It is transmitted by ingesting contaminated food or drink, by direct person-to-person contact, or from contaminated hands. Hand washing is one of a range of hygiene promotion interventions that can interrupt the transmission of diarrhoea-causing pathogens. Objectives To evaluate the effects of interventions to promote hand washing on diarrhoeal episodes in children and adults. Search strategy In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE, LILACS, PsycINFO, Science Citation Index and Social Science Citation Index, ERIC, SPECTR, Bibliomap, RoRe, The Grey Literature, and reference lists of articles. We also contacted researchers and organizations in the field. Selection criteria Randomized controlled trials, where the unit of randomization is an institution (eg day-care centre), household, or community, that compared interventions to promote hand washing or a hygiene promotion that included hand washing with no intervention to promote hand washing. Data collection and analysis Two authors independently assessed trial eligibility and risk of bias. We stratified the analyses for cluster adjusted and non-adjusted trials. Where appropriate, incidence rate ratios (IRR) were pooled using the generic inverse variance method and random-effects model with 95% confidence intervals (CI). Main results Fourteen randomized controlled trials met the inclusion criteria. Eight trials were institution-based in high-income countries, five were community-based in low or middle-income countries, and one was in a high-risk group (people with acquired immune deficiency syndrome (AIDS)). Considering only trial results that adjusted for cluster randomization, interventions promoting hand washing resulted in a 39% reduction in diarrhoea episodes in children in institutions in high-income countries (IRR 0.61, 95% CI 0.40 to 0.92; 2 trials) and a 32% reduction in such episodes in children living in communities in low- or middle-income countries (IRR 0.68, 95% CI 0.52 to 0.90; 4 trials). Authors' conclusions Interventions that promote hand washing can reduce diarrhoea episodes by about one-third. This significant reduction is comparable to the effect of providing clean water in low-income areas. However, trials with longer follow up and that test different methods of promoting hand washing are needed. Plain Language Summary Strategies to encourage hand washing can reduce the incidence of diarrhoea by about one third Diarrhoea is a serious global public health problem, particularly in low-income and middle-income countries. The World Health Organization estimates that over three million episodes occur each year, with many people dying, especially children aged less than five years in low- and middle-income countries. Persistent diarrhoea can also contribute to malnutrition, reduced resistance to infections, and sometimes impaired growth and development. The organisms causing diarrhoea can be transmitted from infected faeces to people through food and water, person-to-person contact, or direct contact. Hand washing after defecation and handling faeces, and before preparing and eating food can reduce the risk of diarrhoea. This review looked at trials of interventions to increase the use of hand washing in institutions in high-income countries and in communities in low- or middle-income countries, and found many of the interventions like educational programmes, leaflets, and discussions to be effective.

Background: Smoking remains very common in Chinese men, and the economic burden caused by cigarette consumption on smokers and their families may be substantial. Using a large nationally representative household survey, the third National Health Services Survey (NHSS, 2003), we estimated the economic impact of smoking on households.\ud Methods: Smoking status of all household members (over 15 years) was collected by interview for the NHSS, and households classified into one of seven categories based on their smoking status. Information on household income and expenditure, and use of health services was also obtained. We assessed both the "direct'' costs (reducing funds available for spending on other commodities such as food, education, medical care, etc, using a fractional logit model), and "indirect costs'' (increasing medical expenditures, using a log-linear model).\ud Results: Every five packets of cigarettes consumed per capita per month reduces household spending on other commodities, most notably on education (by about 17 yuan per capita per annum) and medical care (11 yuan). The effects are greatest among low-income rural households. Households with quitters spend substantially more on medical care than never-smoking households (64 yuan for households with two or more quitters).\ud Conclusions: If a household member smokes, there is less money available for commodities such as education and medical care. Medical care expenditure is substantially higher among households with quitters, as ill-health is the main reason for quitting smoking in China. Smoking impoverishes a substantial number of poorer rural households.

Febrile illnesses are common among children in Ghana and are often diagnosed as malaria, thus overlooking urinary tract infection (UTI) as a possible cause of fever.To determine the prevalence of UTI among febrile children5 years and to estimate the sensitivity, specificity and positive and negative predictive values of urine dipstick as a screening test.From March to July 2004, children aged 3-60 months attending an outpatient clinic at Komfo Anokye Teaching Hospital, Kumasi were systematically screened for UTI using Combi 10 dipstick (CyBow TM). All dipstick-positive and a sample of dipstick-negative urines underwent microscopy and culture (i.e. gold standard) from clean-catch or catheterised urine.Of 1393 children (median age 20 months), 112 (8%) had a positive dipstick and 29 of these (25.9%) had UTIs; 118/1278 (9.2%) children with a negative dipstick had urine cultured, one of whom (0.8%) had a UTI. The prevalence of UTIs was 2.1% (30/1393) and was higher among females (RR 3.99, 95% CI 1.76-9.04). 70% of UTIs were in children2 years of age (p=0.08). The sensitivity, specificity and positive and negative predictive values of dipstick were 96.7%, 58.8%, 26.1% and 99.2%, respectively. Use of dipstick as a screening test for UTI was comparable to microscopic analysis for pyuria. 90% of all UTIs were clinically misdiagnosed (70% as malaria). Escherichia coli was the predominant isolate (60%). Co-trimoxazole and ampicillin, commonly used to treat uncomplicated UTIs at first level in Ghana, showed 0% and 8.3% in-vitro sensitivities, respectively. Ciprofloxacin and cefuroxime (widely used at regional/tertiary level) showed good sensitivities, 99.0% and 86.2%, respectively.Urine dipstick should be promoted as a screening test for UTI. First-line use of cotrimoxazole and ampicillin for UTI should be reviewed.

Objective To describe recent trends in prevalence, outcomes and indicators of care for women with pre-existing type I or type II diabetes. Design Regional population-based survey. Setting All maternity units in the North of England. Population A total of 1258 pregnancies in women with pre-existing diabetes delivered between 1996 and 2004. Methods Data from the Northern Diabetic Pregnancy Survey. Outcome of pregnancy cross-validated with the Northern Congenital Abnormality Survey and the Northern Perinatal Mortality Survey. Main outcome measures Perinatal mortality, congenital anomaly and total adverse perinatal outcome (perinatal mortality and live births with congenital anomaly). Results The prevalence of pregestational diabetes increased from 3.1 per 1000 births in 1996–98 to 4.7 per 1000 in 2002–04 (test for linear trend, P < 0.0001), driven mainly by a sharp increase in type II diabetes. Perinatal mortality declined from 48 per 1000 births in 1996–98 to 23 per 1000 in 2002–04 (P = 0.064). There was a significant reduction in total adverse perinatal outcome rate (P = 0.0194) from 142 per 1000 in 1996–98 to 86 per 1000 in 2002–04. There were substantial improvements in indicators of care before and during pregnancy and in glycaemic control throughout pregnancy, but indicators of preconceptual care, such as use of folic acid, remained disappointing. Conclusion We observed improvements in pregnancy care and outcomes for women with diabetes in a region with an established audit and feedback cycle. There remains considerable scope for further improvement, particularly in periconceptual glycaemic control. The rising prevalence of type II diabetes presents a challenge to further improvement.

Background Coronary heart disease (CHD) death rates have fallen across most of Europe in recent decades. However, substantial risk factor reductions have not been achieved across all Europe. Our aim was to quantify the potential impact of future policy scenarios on diet and lifestyle on CHD mortality in 9 European countries. Methods We updated the previously validated IMPACT CHD models in 9 European countries and extended them to 2010–11 (the baseline year) to predict reductions in CHD mortality to 2020(ages 25–74years). We compared three scenarios: conservative, intermediate and optimistic on smoking prevalence (absolute decreases of 5%, 10% and 15%); saturated fat intake (1%, 2% and 3% absolute decreases in % energy intake, replaced by unsaturated fats); salt (relative decreases of 10%, 20% and 30%), and physical inactivity (absolute decreases of 5%, 10% and 15%). Probabilistic sensitivity analyses were conducted. Results Under the conservative, intermediate and optimistic scenarios, we estimated 10.8% (95% CI: 7.3–14.0), 20.7% (95% CI: 15.6–25.2) and 29.1% (95% CI: 22.6–35.0) fewer CHD deaths in 2020. For the optimistic scenario, 15% absolute reductions in smoking could decrease CHD deaths by 8.9%–11.6%, Salt intake relative reductions of 30% by approximately 5.9–8.9%; 3% reductions in saturated fat intake by 6.3–7.5%, and 15% absolute increases in physical activity by 3.7–5.3%. Conclusions Modest and feasible policy-based reductions in cardiovascular risk factors (already been achieved in some other countries) could translate into substantial reductions in future CHD deaths across Europe. However, this would require the European Union to more effectively implement powerful evidence-based prevention policies.

OBJECTIVE: In Sweden, previous favourable trends in blood cholesterol levels have recently levelled off or even increased in some age groups since 2003, potentially reflecting changing fashions and attitudes towards dietary saturated fatty acids (SFA). We aimed to examine the potential effect of different SFA intake on future coronary heart disease (CHD) mortality in 2025. METHODS: We compared the effect on future CHD mortality of two different scenarios for fat intake a) daily SFA intake decreasing to 10 energy percent (E%), and b) daily SFA intake rising to 20 E%. We assumed that there would be moderate improvements in smoking (5%), salt intake (1g/day) and physical inactivity (5% decrease) to continue recent, positive trends. RESULTS: In the baseline scenario which assumed that recent mortality declines continue, approximately 5,975 CHD deaths might occur in year 2025. Anticipated improvements in smoking, dietary salt intake and physical activity, would result in some 380 (-6.4%) fewer deaths (235 in men and 145 in women). In combination with a mean SFA daily intake of 10 E%, a total of 810 (-14%) fewer deaths would occur in 2025 (535 in men and 275 in women). If the overall consumption of SFA rose to 20 E%, the expected mortality decline would be wiped out and approximately 20 (0.3%) additional deaths might occur. CONCLUSION: CHD mortality may increase as a result of unfavourable trends in diets rich in saturated fats resulting in increases in blood cholesterol levels. These could cancel out the favourable trends in salt intake, smoking and physical activity.

Objectives: Tuberculosis (TB) remains a major global public health problem. In the past, a relationship between TB and diabetes mellitus (DM) was recognized, and its importance was acknowledged through joint treatment clinics. However, this is rarely highlighted in current research or control priorities. This paper aims to evaluate the evidence for an association between these two diseases.Methods: A Medline literature search was undertaken, supplemented by checking references and contacting experts. We critically appraised studies that quantified the association between TB and DM, and were published after 1995. We assessed study quality according to criteria such as sample size, method of selection of cases and controls, losses to follow-up, quality and method of control of confounding, and summarized the results narratively and in tabular form.Results: All studies identified statistically significant and clinically important associations, with the increase in risk or odds of TB varying between 1.5- and 7.8-fold for those with DM. Risk was highest at younger ages. Most studies had not measured and controlled adequately for potential major confounders.Discussion: There is strong evidence for an association between TB and DM, which has potential public health implications. Further well-designed studies are needed to assess the magnitude precisely.

SUMMARY Intravenous iron administration is an effective method of treating iron deficiency anemia, but there have been concerns about adverse side effects, particularly serious events such as anaphylactic reaction. Several different forms of intravenous iron are available, but few studies have attempted to compare the frequency of adverse events. We carried out a systematic review to assess the frequency of adverse drug events (ADEs) associated with (i) low-molecular-weight intravenous iron dextran and (ii) iron sucrose. We searched several electronic databases; two reviewers screened all studies identified and extracted data. We included 60 studies, but few directly compared adverse events associated with two or more forms of iron, and most were not specifically designed to evaluate adverse events. In general, with the exception of high-molecular-weight iron dextran (HMWID), serious or life-threatening adverse events appeared rare. Several studies showed lower risks of ADEs on low-molecular-weight iron dextran (LMWID) compared with HMWID, and one large review found a reduced risk on LMWID compared with iron gluconate. Two studies showed little difference between iron sucrose and iron gluconate, and two further studies had similar rates of adverse drug events between iron sucrose and LMWID; however, the sample size for most of these studies was too small to draw firm conclusions. Adequately powered direct comparisons of different forms of intravenous iron are required to assess the safety profiles.

Background Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing. Objectives To assess the effects of hand washing promotion interventions on diarrhoeal episodes in children and adults. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register (27 May 2015); CENTRAL (published in the Cochrane Library 2015, Issue 5); MEDLINE (1966 to 27 May 2015); EMBASE (1974 to 27 May 2015); LILACS (1982 to 27 May 2015); PsycINFO (1967 to 27 May 2015); Science Citation Index and Social Science Citation Index (1981 to 27 May 2015); ERIC (1966 to 27 May 2015); SPECTR (2000 to 27 May 2015); Bibliomap (1990 to 27 May 2015); RoRe, The Grey Literature (2002 to 27 May 2015); World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), metaRegister of Controlled Trials (mRCT), and reference lists of articles up to 27 May 2015. We also contacted researchers and organizations in the field. Selection criteria Individually randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand washing interventions on diarrhoea episodes in children and adults with no intervention. Data collection and analysis Three review authors independently assessed trial eligibility, extracted data, and assessed risk of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, incidence rate ratios (IRR) were pooled using the generic inverse variance method and random-effects model with 95% confidence intervals (CIs). We used the GRADE approach to assess the quality of evidence. Main results We included 22 RCTs: 12 trials from child day-care centres or schools in mainly high-income countries (54,006 participants), nine community-based trials in LMICs (15,303 participants), and one hospital-based trial among people with acquired immune deficiency syndrome (AIDS) (148 participants). Hand washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevents around one-third of diarrhoea episodes in high income countries (rate ratio 0.70; 95% CI 0.58 to 0.85; nine trials, 4664 participants, high quality evidence), and may prevent a similar proportion in LMICs but only two trials from urban Egypt and Kenya have evaluated this (rate ratio 0.66, 95% CI 0.43 to 0.99; two trials, 45,380 participants, low quality evidence). Only three trials reported measures of behaviour change and the methods of data collection were susceptible to bias. In one trial from the USA hand washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; three trials, 1845 participants, low quality evidence). Hand washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (rate ratio 0.72, 95% CI 0.62 to 0.83; eight trials, 14,726 participants, moderate quality evidence). However, six of these eight trials were from Asian settings, with only single trials from South America and sub-Saharan Africa. In six trials, soap was provided free alongside hand washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: rate ratio 0.66, 95% CI 0.56 to 0.78; six trials, 11,422 participants; education only: rate ratio: 0.84, 95% CI 0.67 to 1.05; two trials, 3304 participants). There was increased hand washing at major prompts (before eating/cooking, after visiting the toilet or cleaning the baby's bottom), and increased compliance to hand hygiene procedure (behavioural outcome) in the intervention groups than the control in community trials (data not pooled: three trials, 3490 participants, high quality evidence). Hand washing promotion for the one trial conducted in a hospital among high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (Mean difference 1.68, 95% CI 1.93 to 1.43; one trial, 148 participants, moderate quality evidence). There was increase in hand washing frequency, seven times per day in the intervention group versus three times in the control in this hospital trial (one trial, 148 participants, moderate quality evidence). We found no trials evaluating or reporting the effects of hand washing promotions on diarrhoea-related deaths, all-cause-under five mortality, or costs. Authors' conclusions Hand washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. However, less is known about how to help people maintain hand washing habits in the longer term. PLAIN LANGUAGE SUMMARY Hand washing promotion for preventing diarrhoea Review question This Cochrane Review summarises trials evaluating the effects of promoting hand washing on the incidence of diarrhoea among children and adults in day-care centres, schools, communities, or hospitals. After searching for relevant trials up to 27 May 2015, we included 22 randomized controlled trials conducted in both high-income countries (HICs) and low- and middle-income countries (LMICs). These trials enrolled 69,309 children and 148 adults. How does hand washing prevent diarrhoea and how might hand washing be promoted Diarrhoea causes many deaths in children below five years of age, mostly in LMICs. The organisms causing diarrhoea are transmitted from person to person through food and water contaminated with faeces, or through person-to-person contact. Hand washing after defecation, or after cleaning a baby's bottom, and before preparing and eating food, can therefore reduce the risk of diarrhoea. Hand washing can be promoted through group or individual training on hygiene education, germ-health awareness, use of posters, leaflets, comic books, songs, and drama. What this review says Hand washing promotion at child day-care facilities or schools in HICs probably prevents around 30% of diarrhoea episodes (high quality evidence), and may prevent a similar proportion in schools in LMICs (low quality evidence). Among communities in LMICs hand washing promotion prevents around 28% of diarrhoea episodes (moderate quality evidence). In the only hospital-based trial included in this review, hand washing promotion also had important reduction in the mean episodes of diarrhoea (moderate quality evidence). This is based on only a single trial with few participants and thus there is need for more trials to confirm this. Effects of hand washing promotion on related hand hygiene behaviour changes improved more in the intervention groups than in the control in all the settings (low to high quality evidence). None of the included trials assessed the effect of handwashing promotion on diarrhoeal-related deaths, all-cause under-five mortality, or the cost-effectiveness of hand washing promotions. Conclusion Hand washing promotion in HICs and LMICs settings may reduce incidence of diarrhoea by about 30%. However, less is known about how to help people maintain hand washing habits in the longer term.

Diabetes is a leading cause of morbidity and mortality. The global burden of diabetes is rising because of increased obesity and population ageing. Although preventive and treatment measures are well documented for macrovascular and microvascular complications, little such guidance exists for infections in people with diabetes, despite evidence suggesting greater susceptibility to infections, and worse outcomes. In particular, few studies have characterised the relation between glycaemic control and infectious disease, which we discuss in this Review. Some large population-based observational studies have reported strong associations between higher HbA1c and infection risks for both type 1 and type 2 diabetes. However, studies are contradictory, underpowered, or do not control for confounders. Evidence suggests that better glycaemic control might reduce infection risk, but further longitudinal studies with more frequent measures of HbA1c are needed. Older people (aged 70 years or older) with diabetes are at increased risk of complications, including infectious diseases. There is more uncertainty about appropriate glycaemic control targets in this age group, and evidence suggests that glycaemic control is often neglected. Robust evidence from cohorts with sufficient numbers of older people would help to develop clinically relevant guidelines and targets to reduce mortality, morbidity, and antibiotic use, and to improve quality of life.

Background: Coronary heart disease (CHD) mortality rates have been decreasing in many industrialized countries since the 1980s. Up to half this decrease can be attributed to evidence-based medical and surgical cardiology interventions. However, recent studies suggest that modern cardiology treatment uptake levels remain disappointingly low in many patient categories. Aim: To determine the potential for further reductions in CHD mortality in Ireland from increasing the number of eligible patients receiving cardiology treatments. Methods: A previously validated, cell-based IMPACT CHD mortality model was used to integrate large amounts of data describing CHD patient numbers, and the effectiveness and uptake levels of specific medical and surgical treatments. The CHD mortality reductions potentially achievable through the increased use of specific treatments were then calculated, stratified by age and gender and tested using sensitivity analyses. Results: In 2000, medical and surgical coronary disease treatments together prevented or postponed approximately 1950 CHD deaths in the adult population aged 25–84. However, increasing treatment levels to reach 80% of eligible patients might have prevented or postponed a further 2280 CHD deaths in 2000 (minimum estimate 860, maximum estimate 4000). The biggest gain was from maximizing the treatment uptake of eligible heart failure patients, followed by those receiving statins and secondary prevention therapies. Discussion: Many eligible patients are currently not receiving appropriate evidence-based treatments that would reduce CHD mortality and morbidity. Our results suggest that increasing cardiology treatment uptake in Ireland could at least double the current therapeutic reduction in CHD mortality.

Background It is unclear how much of the reduction in cardiac mortality in coronary heart disease (CHD) patients with exercise training is the result of direct effects on the heart and coronary vasculature, or to indirect effects, via primary risk factors. Objective The aim of this article was to quantify the cardiac mortality benefits of exercise-based rehabilitation attributable to risk factor reductions versus the direct effects on the heart and vasculature. Methods The I M PACT coronary heart disease model was used to examine the reduction in cardiac mortality attributable to changes in risk factors from a meta-analysis of cardiac rehabilitation randomized, controlled trials. Patients were receiving rehabilitation following an acute myocardial infarction, angina pectoris or revascularization. Outcomes considered were primary risk factors (total cholesterol, systolic blood pressure and smoking behaviour) and cardiac mortality. Results Nineteen exercise-only cardiac rehabilitation trials (including 2984 patients) were identified. Across these trials, exercise training reduced pooled cardiac mortality by 28% (relative risk, 0.72, 95% confidence interval 0.55-0.95), with 30 fewer deaths than in the control group. Applying the CHD model, approximately 17 (58%) of these 30 fewer deaths were attributable to reductions in major cardiovascular risk factors: 7.1 deaths (minimum estimate 6.2, maximum estimate 9.5) attributable to an 18% reduction in smoking prevalence; 5.9 deaths (minimum -0.6, maximum 12.6) to a 0.11 mmol/l reduction in cholesterol, and 4.4 deaths (-1.0 minimum, 6.7 maximum) to a 2.0 mmHg reduction in systolic blood pressure. Conclusions Approximately half of the 28% reduction in cardiac mortality achieved with exercise-based cardiac rehabilitation may be attributed to reductions in major risk factors, particularly smoking. (c) 2006 The European Society of Cardiology.

Study objectives: To examine the proportion of the recent decline in coronary heart disease (CHD) deaths in Ireland attributable to ( a) "evidence based'' medical and surgical treatments, and (b) changes in major cardiovascular risk factors.\ud Design setting: IMPACT, a previously validated model, was used to combine and analyse data on the use and effectiveness of specific cardiology treatments and risk factor trends, stratified by age and sex. The main data sources were published trials and meta-analyses, official statistics, clinical audits, and observational studies.\ud Results: Between 1985 and 2000, CHD mortality rates in Ireland fell by 47% in those aged 25 - 84. Some 43.6% of the observed decrease in mortality was attributed to treatment effects and 48.1% to favourable population risk factor trends; specifically declining smoking prevalence (25.6%), mean cholesterol concentrations (30.2%), and blood pressure levels (6.0%), but offset by increases in adverse population trends related to obesity, diabetes, and inactivity (-13.8%).\ud Conclusions: The results emphasise the importance of a comprehensive strategy that maximises population coverage of effective treatments, and that actively promotes primary prevention, particularly tobacco control and a cardioprotective diet.

Objective To compare the outcomes of pregnancies in women with pre-existing, type 1 and type 2, diabetes and to examine the influence of ethnicity on these outcomes. Design Prospective cohort study. Setting Large district hospital in Yorkshire with an ethnically mixed population. Sample Case series of all 202 pregnancies in women with pre-existing diabetes, ending in miscarriage, termination of pregnancy or delivery between January 1994 and December 2002. Methods Univariate and multivariate logistic regression analysis comparing outcomes in type of diabetes and in ethnic group. Main outcome measures Fetal loss, perinatal and infant mortality and congenital anomaly. Results All 14 stillbirths and infant deaths and 13 of the 15 congenital malformations were to Asian women. Analysis within this ethnic group showed a very high rate of adverse birth outcome for type 1 diabetic women and for type 2 diabetic women on insulin before the pregnancy. Total pregnancy loss among type 1 diabetic women was 156 per 1000 and among type 2 diabetic women on insulin was 167 per 1000. Congenital abnormality rates were 156 per 1000 for type 1 diabetic women and 261 per 1000 for type 2 diabetic women on insulin. Asian type 2 diabetic women not on insulin prior to pregnancy had significantly better outcomes: Total pregnancy loss was 123 per 1000 and congenital abnormality rate was 32 per 1000. After adjustment for confounders, including type of diabetes, Asian women had significantly worse outcomes (combined perinatal loss and malformation) than Caucasian women [odds ratio (OR) 4.96, 95% confidence interval (CI) 1.16–21.1]. Conclusion Ethnicity has a significant impact on the outcome of diabetic pregnancies, with worse outcomes for babies born to Asian mothers compared with Caucasian mothers. The use of insulin pre-pregnancy rather than type of diabetes appears to predict adverse outcome.

Anaemia is a major public health problem, in poor countries most of the cases are diagnosed clinically. This is inaccurate and the haemoglobin colour scale (HCS) has been developed as an inexpensive, simple alternative for assessing anaemia. Laboratory and community studies have assessed its diagnostic accuracy, but controversy over its validity and usefulness remains. We carried out a systematic review to identify and summarize studies, explain heterogeneity, and make recommendations for future research.We searched electronic databases (MEDLINE, EMBASE, CINAHL, and Science Citation Index), checked documents and references, and contacted experts. We included all the studies comparing HCS diagnostic accuracy with a reference standard. Both reviewers independently screened titles and abstracts, assessed studies for inclusion, appraised quality, and extracted data.We included 14 studies, mostly from sub-Saharan Africa. Studies had heterogeneous populations, health care settings, anaemia prevalence, and findings. HCS sensitivity for detecting anaemia was high in most of the studies (75-97%); specificity was generally lower (41-98%). Sensitivity and specificity were higher for laboratory-based studies compared with more pragmatic 'real-life' studies, and the 'study setting' appeared to explain some of the heterogeneity. Five studies compared the HCS with clinical diagnosis; sensitivity was higher for the HCS in four studies, but specificity was often higher with clinical diagnosis. A few studies evaluated the HCS in situations where there was no laboratory.The HCS may improve anaemia diagnosis where there is no laboratory, but there is a need for policy-relevant diagnostic research which is pragmatic, implementation-focused and assesses clinical outcomes. This requires a different approach and research skill-mix from efficacy studies.

Background and Objective The U.K. government recently called for a 40% reduction in cardiovascular disease mortality by 2010. We examined the potential for cardiovascular risk factor changes to achieve that target. Methods We applied a previously validated mortality model, IMPACT, to an England and Wales population (37.1 million, aged 25–84). The model integrates information on trends in all the major cardiovascular risk factors, plus the uptake and effectiveness of all medical and surgical treatments. The potential reductions in coronary heart disease mortality from the base year, 2000, were calculated for two contrasting scenarios: (a) if recent risk factor trends simply continued to 2010 and (b) if further small reductions in risk factors were achieved, as in Scandinavia and the United States. Results Continuation of recent risk factor trends should result in ∼10,685 fewer coronary deaths in 2010 (minimum estimate 10,110; maximum 16,460) than in 2000. Modest additional reductions in cholesterol and smoking could potentially achieve 51,270 fewer deaths (minimum 39,435; maximum 71,510). Optimistic changes in obesity, diabetes, and physical activity, however, would have relatively small effects. Conclusion Modest additional risk factor reductions in cholesterol and smoking already achieved in the United States and Scandinavia could prevent or postpone >50,000 deaths by 2010, halving current coronary mortality.

Background— Coronary heart disease (CHD) mortality is rising in many developing countries. We examined how much of the increase in CHD mortality in Beijing, China, between 1984 and 1999 could be attributed to changes in major cardiovascular risk factors and assessed the impact of medical and surgical treatments. Methods and Results— A validated, cell-based mortality model synthesized data on (1) patient numbers, (2) uptake of specific medical and surgical treatments, (3) treatment effectiveness, and (4) population trends in major cardiovascular risk factors (smoking, total cholesterol, blood pressure, obesity, and diabetes). Main data sources were the WHO MONICA and Sino-MONICA studies, the Chinese Multi-provincial Cohort Study, routine hospital statistics, and published meta-analyses. Age-adjusted CHD mortality rates increased by ≈50% in men and 27% in women (1608 more deaths in 1999 than expected by application of 1984 rates). Most of this increase (≈77%, or 1397 additional deaths) was attributable to substantial rises in total cholesterol levels (more than 1 mmol/L), plus increases in diabetes and obesity. Blood pressure decreased slightly, whereas smoking prevalence increased in men but decreased substantially in women. In 1999, medical and surgical treatments in patients together prevented or postponed ≈642 deaths, mainly from initial treatments for acute myocardial infarction (≈41%), hypertension (24%), angina (15%), secondary prevention (11%), and heart failure (10%). Multiway sensitivity analyses did not greatly influence the results. Conclusions— Much of the dramatic CHD mortality increases in Beijing can be explained by rises in total cholesterol, reflecting an increasingly “Western” diet. Without cardiological treatments, increases would have been even greater.

Background— Coronary heart disease mortality rates have been decreasing in the United Kingdom since the 1970s. Our study aimed to examine how much of the decrease in England and Wales between 1981 and 2000 could be attributed to medical and surgical treatments and how much to changes in cardiovascular risk factors. Methods and Results— The IMPACT mortality model was used to combine and analyze data on uptake and effectiveness of cardiological treatments and risk factor trends in England and Wales. The main data sources were published trials and meta-analyses, official statistics, clinical audits, and national surveys. Between 1981 and 2000, coronary heart disease mortality rates in England and Wales decreased by 62% in men and 45% in women 25 to 84 years old. This resulted in 68 230 fewer deaths in 2000. Some 42% of this decrease was attributed to treatments in individuals (including 11% to secondary prevention, 13% to heart failure treatments, 8% to initial treatments of acute myocardial infarction, and 3% to hypertension treatments) and 58% to population risk factor reductions (principally smoking, 48%; blood pressure, 9.5%; and cholesterol, 9.5%). Adverse trends were seen for physical activity, obesity and diabetes. Conclusions— More than half the coronary heart disease mortality decrease in Britain between 1981 and 2000 was attributable to reductions in major risk factors, principally smoking. This emphasizes the importance of a comprehensive strategy that promotes primary prevention, particularly for tobacco and diet, and that maximizes population coverage of effective treatments, especially for secondary prevention and heart failure. These findings may be cautiously generalizable to the United States and other developed countries.

Coronary Heart Disease (CHD) death rates have fallen considerably in many countries. We estimated the life-years-gained (LYG) in Scotland between 1975 and 1994 attributable to cardiology treatments, and population reductions in major CHD risk factors, using a previously validated mortality model. This combines published effectiveness data with information on uptake of CHD treatments; risk factor trends; and median survival by age and sex. Compared with 1975, there were 4,536 fewer CHD deaths in 1994, resulting in approximately 48,016 LYG among those aged 45-84 (maximum estimate 53,317; minimum estimate 36,867). Medical and surgical treatments for CHD patients gained approximately 12,025 life-years; the largest contribution coming from pharmacologic secondary prevention. Population reductions in major risk factors (smoking, cholesterol, and blood pressure) accounted for some 35,991 LYG, reductions in smoking accounted for over 50% of this. Modern cardiologic treatments gained many thousands of life-years in Scotland, but modest reductions in risk factors gained almost three times as many life-years.

BACKGROUND Prospective cohort studies have made enormous contributions to our understanding of coronary heart disease (CHD) epidemiology in the UK. However, identification of cohorts and dissemination of key characteristics and results can be haphazard, and it is difficult to identify studies which are at the planning stage. METHODS We carried out a systematic review of cohort studies by searching MEDLINE and relevant websites and consulting key individuals. We included all large prospective UK cohort studies that focused on the development of CHD in predominantly healthy subjects. RESULTS The MEDLINE search retrieved 1558 hits and we identified 39 cohorts that met inclusion criteria. 'Early' cohorts were important in defining the major risk factors for CHD, particularly smoking, cholesterol, blood pressure, physical activity and body mass index. Prospective cohort studies have subsequently appraised potentially important novel risk factors including nutritional status, genetic determinants, haemostatic factors, lipid sub-fractions, psychosocial factors and the 'life course' perspective. Psychosocial factors have been relatively neglected, as have women, ethnic minorities and the elderly. Key methodological issues include minimizing losses to follow up, standardized measurements, quality assurance systems, change in risk factors over time, residual confounding, regression dilution bias, detection of non-fatal events, measurement of quality of life, and generalizability. CONCLUSIONS The current and proposed prospective UK cohorts have sufficient power potentially to determine the importance of many traditional and newer CHD risk factors on cardiovascular risk in men, women and even ethnic minorities. However, secure financial support and hence sustainability will remain essential to maximize long-term benefits.

Objective:\ud \ud Despite rapid declines over the last two decades, coronary heart disease (CHD) mortality rates in the British Isles are still amongst the highest in Europe. This study uses a modelling approach to compare the potential impact of 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.\ud \ud Methods:\ud \ud 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. Risk factor trends data from recent surveys at baseline were used to model alternative future risk factor scenarios: Absolute decreases in (i) smoking prevalence and (ii) physical inactivity rates of up to 15% by 2030; relative decreases in (iii) dietary salt intake of up to 30% by 2030 and (iv) dietary saturated fat of up to 6% by 2030. Probabilistic sensitivity analyses were then conducted.\ud \ud Results:\ud \ud Projected populations in 2030 were 1.3, 3.4 and 3.9 million in NI, RoI and Scotland respectively (adults aged 25–84). In 2030: assuming recent declining mortality trends continue: 15% absolute reductions in smoking could decrease CHD deaths by 5.8–7.2%. 15% absolute reductions in physical inactivity levels could decrease CHD deaths by 3.1–3.6%. Relative reductions in salt intake of 30% could decrease CHD deaths by 5.2–5.6% and a 6% reduction in saturated fat intake might decrease CHD deaths by some 7.8–9.0%. These projections remained stable under a wide range of sensitivity analyses.\ud \ud Conclusions:\ud \ud Feasible reductions in four cardiovascular risk factors (already achieved elsewhere) could substantially reduce future coronary deaths. More aggressive polices are therefore needed in the British Isles to control tobacco, promote healthy food and increase physical activity.

Many Eastern Mediterranean countries are undergoing dramatic socioeconomic, demographic and life style changes and face noncommunicable disease (NCD) epidemics. We evaluated recent trends in major NCD risk factors in occupied Palestinian territories (OPT), Turkey, Syria and Tunisia.We searched published and unpublished sources for systolic blood pressure (SBP), diabetes, smoking, body mass index (BMI), and cholesterol trends for both men and women aged 35-84 in each country from 1995 to 2009.Smoking prevalence was stable over time in Tunisia and Syria, but decreasing in Turkey (annual change -0.9%) and OPT (annual change -0.7%). Mean BMI (annual change of 0.1% for Turkey, 0.2% for OPT and Tunisia and 0.3% in Syria) and diabetes (annual change of 0.3% for Turkey, 0.4% for OPT and Tunisia and 0.7% in Syria) prevalence increased in each country. SBP levels increased slightly in Tunisia and Syria but decreased in OPT and Turkey.Recent risk factor trends are worrying. Good quality data on the extent and determinants of NCDs are essential to respond the changing health needs of populations with burgeoning NCD epidemics.

This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required.This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification.The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied.Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months.Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI).We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status).Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.