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Background: In 2011, England introduced the Public Health Responsibility Deal (RD), a public-private partnership (PPP) which gave greater freedom to the food industry to set and monitor targets for salt intakes. We estimated the impact of the RD on trends in salt intake and associated changes in cardiovascular disease (CVD) and gastric cancer (GCa) incidence, mortality and economic costs in England from 2011-2025., Methods: We used interrupted time series models with 24 hours' urine sample data and the IMPACT NCD microsimulation model to estimate impacts of changes in salt consumption on CVD and GCa incidence, mortality and economic impacts, as well as equity impacts., Results: Between 2003 and 2010 mean salt intake was falling annually by 0.20 grams/day among men and 0.12 g/d among women (P-value for trend both < 0.001). After RD implementation in 2011, annual declines in salt intake slowed statistically significantly to 0.11 g/d among men and 0.07 g/d among women (P-values for differences in trend both P < 0.001). We estimated that the RD has been responsible for approximately 9900 (interquartile quartile range (IQR): 6700 to 13,000) additional cases of CVD and 1500 (IQR: 510 to 2300) additional cases of GCa between 2011 and 2018. If the RD continues unchanged between 2019 and 2025, approximately 26 000 (IQR: 20 000 to 31,000) additional cases of CVD and 3800 (IQR: 2200 to 5300) cases of GCa may occur., Interpretation: Public-private partnerships such as the RD which lack robust and independent target setting, monitoring and enforcement are unlikely to produce optimal health gains., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Policy Points The World Health Organization has recommended sodium reduction as a "best buy" to prevent cardiovascular disease (CVD). Despite this, Congress has temporarily blocked the US Food and Drug Administration (FDA) from implementing voluntary industry targets for sodium reduction in processed foods, the implementation of which could cost the industry around $16 billion over 10 years. We modeled the health and economic impact of meeting the two-year and ten-year FDA targets, from the perspective of people working in the food system itself, over 20 years, from 2017 to 2036. Benefits of implementing the FDA voluntary sodium targets extend to food companies and food system workers, and the value of CVD-related health gains and cost savings are together greater than the government and industry costs of reformulation., Context: The US Food and Drug Administration (FDA) set draft voluntary targets to reduce sodium levels in processed foods. We aimed to determine cost effectiveness of meeting these draft sodium targets, from the perspective of US food system workers., Methods: We employed a microsimulation cost-effectiveness analysis using the US IMPACT Food Policy model with two scenarios: (1) short term, achieving two-year FDA reformulation targets only, and (2) long term, achieving 10-year FDA reformulation targets. We modeled four close-to-reality populations: food system "ever" workers; food system "current" workers in 2017; and subsets of processed food "ever" and "current" workers. Outcomes included cardiovascular disease cases prevented and postponed as well as incremental cost-effectiveness ratio per quality-adjusted life year (QALY) gained from 2017 to 2036., Findings: Among food system ever workers, achieving long-term sodium reduction targets could produce 20-year health gains of approximately 180,000 QALYs (95% uncertainty interval [UI]: 150,000 to 209,000) and health cost savings of approximately $5.2 billion (95% UI: $3.5 billion to $8.3 billion), with an incremental cost-effectiveness ratio (ICER) of $62,000 (95% UI: $1,000 to $171,000) per QALY gained. For the subset of processed food industry workers, health gains would be approximately 32,000 QALYs (95% UI: 27,000 to 37,000); cost savings, $1.0 billion (95% UI: $0.7bn to $1.6bn); and ICER, $486,000 (95% UI: $148,000 to $1,094,000) per QALY gained. Because many health benefits may occur in individuals older than 65 or the uninsured, these health savings would be shared among individuals, industry, and government., Conclusions: The benefits of implementing the FDA voluntary sodium targets extend to food companies and food system workers, with the value of health gains and health care cost savings outweighing the costs of reformulation, although not for the processed food industry., (© 2019 The Authors The Milbank Quarterly published by Wiley Periodicals, Inc. on behalf of The Millbank Memorial Fund.)

Background: Excess added sugars, particularly from sugar-sweetened beverages, are a major risk factor for cardiometabolic diseases including cardiovascular disease and type 2 diabetes mellitus. In 2016, the US Food and Drug Administration mandated the labeling of added sugar content on all packaged foods and beverages. Yet, the potential health impacts and cost-effectiveness of this policy remain unclear., Methods: A validated microsimulation model (US IMPACT Food Policy model) was used to estimate cardiovascular disease and type 2 diabetes mellitus cases averted, quality-adjusted life-years, policy costs, health care, informal care, and lost productivity (health-related) savings and cost-effectiveness of 2 policy scenarios: (1) implementation of the US Food and Drug Administration added sugar labeling policy (sugar label), and (2) further accounting for corresponding industry reformulation (sugar label+reformulation). The model used nationally representative demographic and dietary intake data from the National Health and Nutrition Examination Survey, disease data from the Centers for Disease Control and Prevention Wonder Database, policy effects and diet-disease effects from meta-analyses, and policy and health-related costs from established sources. Probabilistic sensitivity analysis accounted for model parameter uncertainties and population heterogeneity., Results: Between 2018 and 2037, the sugar label would prevent 354 400 cardiovascular disease (95% uncertainty interval, 167 000-673 500) and 599 300 (302 400-957 400) diabetes mellitus cases, gain 727 000 (401 300-1 138 000) quality-adjusted life-years, and save $31 billion (15.7-54.5) in net healthcare costs or $61.9 billion (33.1-103.3) societal costs (incorporating reduced lost productivity and informal care costs). For the sugar label+reformulation scenario, corresponding gains were 708 800 (369 200-1 252 000) cardiovascular disease cases, 1.2 million (0.7-1.7) diabetes mellitus cases, 1.3 million (0.8-1.9) quality-adjusted life-years, and $57.6 billion (31.9-92.4) and $113.2 billion (67.3-175.2), respectively. Both scenarios were estimated with >80% probability to be cost saving by 2023., Conclusions: Implementing the US Food and Drug Administration added sugar labeling policy could generate substantial health gains and cost savings for the US population.

The prevalence of excess body weight and the associated cancer burden have been rising over the past several decades globally. Between 1975 and 2016, the prevalence of excess body weight in adults-defined as a body mass index (BMI) ≥ 25 kg/m 2 -increased from nearly 21% in men and 24% in women to approximately 40% in both sexes. Notably, the prevalence of obesity (BMI ≥ 30 kg/m 2 ) quadrupled in men, from 3% to 12%, and more than doubled in women, from 7% to 16%. This change, combined with population growth, resulted in a more than 6-fold increase in the number of obese adults, from 100 to 671 million. The largest absolute increase in obesity occurred among men and boys in high-income Western countries and among women and girls in Central Asia, the Middle East, and North Africa. The simultaneous rise in excess body weight in almost all countries is thought to be driven largely by changes in the global food system, which promotes energy-dense, nutrient-poor foods, alongside reduced opportunities for physical activity. In 2012, excess body weight accounted for approximately 3.9% of all cancers (544,300 cases) with proportion varying from less than 1% in low-income countries to 7% or 8% in some high-income Western countries and in Middle Eastern and Northern African countries. The attributable burden by sex was higher for women (368,500 cases) than for men (175,800 cases). Given the pandemic proportion of excess body weight in high-income countries and the increasing prevalence in low- and middle-income countries, the global cancer burden attributable to this condition is likely to increase in the future. There is emerging consensus on opportunities for obesity control through the multisectoral coordinated implementation of core policy actions to promote an environment conducive to a healthy diet and active living. The rapid increase in both the prevalence of excess body weight and the associated cancer burden highlights the need for a rejuvenated focus on identifying, implementing, and evaluating interventions to prevent and control excess body weight., (© 2018 American Cancer Society.)

Objectives: To estimate the potential impacts of different Brexit trade policy scenarios on the price and intake of fruits and vegetables (F&V) and consequent cardiovascular disease (CVD) deaths in England between 2021 and 2030., Design: Economic and epidemiological modelling study with probabilistic sensitivity analysis., Setting: The model combined publicly available data on F&V trade, published estimates of UK-specific price elasticities, national survey data on F&V intake, estimates on the relationship between F&V intake and CVD from published meta-analyses and CVD mortality projections for 2021-2030., Participants: English adults aged 25 years and older., Interventions: We modelled four potential post-Brexit trade scenarios: (1) free trading agreement with the EU and maintaining half of non-EU free trade partners; (2) free trading agreement with the EU but no trade deal with any non-EU countries; (3) no-deal Brexit; and (4) liberalised trade regime that eliminates all import tariffs., Outcome Measures: Cumulative coronary heart disease and stroke deaths attributed to the different Brexit scenarios modelled between 2021 and 2030., Results: Under all Brexit scenarios modelled, prices of F&V would increase, especially for those highly dependent on imports. This would decrease intake of F&V between 2.5% (95% uncertainty interval: 1.9% to 3.1%) and 11.4% (9.5% to 14.2%) under the different scenarios. Our model suggests that a no-deal Brexit scenario would be the most harmful, generating approximately 12 400 (6690 to 23 390) extra CVD deaths between 2021 and 2030, whereas establishing a free trading agreement with the EU would have a lower impact on mortality, contributing approximately 5740 (2860 to 11 910) extra CVD deaths., Conclusions: Trade policy under all modelled Brexit scenarios could increase price and decrease intake of F&V, generating substantial additional CVD mortality in England. The UK government should consider the population health implications of Brexit trade policy options, including changes to food systems., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Life expectancy inequalities in England have increased steadily since the 1980s. Our aim was to investigate how much deaths from different diseases and injuries and at different ages have contributed to this rise to inform policies that aim to reduce health inequalities., Methods: We used vital registration data from the Office for National Statistics on population and deaths in England, by underlying cause of death, from 2001 to 2016, stratified by sex, 5-year age group, and decile of the Index of Multiple Deprivation (based on the ranked scores of Lower Super Output Areas in England in 2015). We grouped the 7·65 million deaths by their assigned International Classification of Diseases (10th revision) codes to create categories of public health and clinical relevance. We used a Bayesian hierarchical model to obtain robust estimates of cause-specific death rates by sex, age group, year, and deprivation decile. We calculated life expectancy at birth by decile of deprivation and year using life-table methods. We calculated the contributions of deaths from each disease and injury, in each 5-year age group, to the life expectancy gap between the most deprived and affluent deciles using Arriaga's method., Findings: The life expectancy gap between the most affluent and most deprived deciles increased from 6·1 years (95% credible interval 5·9-6·2) in 2001 to 7·9 years (7·7-8·1) in 2016 in females and from 9·0 years (8·8-9·2) to 9·7 years (9·6-9·9) in males. Since 2011, the rise in female life expectancy has stalled in the third, fourth, and fifth most deprived deciles and has reversed in the two most deprived deciles, declining by 0·24 years (0·10-0·37) in the most deprived and 0·16 years (0·02-0·29) in the second-most deprived by 2016. Death rates from every disease and at every age were higher in deprived areas than in affluent ones in 2016. The largest contributors to life expectancy inequalities were deaths in children younger than 5 years (mostly neonatal deaths), respiratory diseases, ischaemic heart disease, and lung and digestive cancers in working ages, and dementias in older ages. From 2001 to 2016, the contributions to inequalities declined for deaths in children younger than 5 years, ischaemic heart disease (for both sexes), and stroke and intentional injuries (for men), but increased for most other causes., Interpretation: Recent trends in life expectancy in England have not only resulted in widened inequalities but the most deprived communities are now seeing no life expectancy gain. These inequalities are driven by a diverse group of diseases that can be effectively prevented and treated. Adoption of the principle of proportionate universalism to prevention and health and social care can postpone deaths into older ages for all communities and reduce life expectancy inequalities., Funding: Wellcome Trust., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

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

Background: Suboptimal diets are a major contributor to cardiometabolic disease (CMD) mortality, and substantial disparities exist for both dietary quality and mortality risk across income groups in the USA. Research is needed to quantify how food pricing policies to subsidise healthy foods and tax unhealthy foods could affect the US CMD mortality, overall and by Supplemental Nutrition Assistance Program (SNAP) eligibility and participation., Methods: Comparative risk analysis based on national data on diet (National Health and Nutrition Examination Survey, 2003-2012) and mortality (mortality-linked National Health Interview Survey) and meta-analyses of policy-diet and diet-disease relationships., Results: A national 10% price reduction on fruits, vegetables, nuts and whole grains was estimated to prevent 19 600 CMD deaths/year, including 2.6% (95% UI 2.4% to 2.8%) of all CMD deaths among SNAP participants, 2.7% (95% UI 2.4% to 3.0%) among SNAP-eligible non-participants and 2.6% (95% UI 2.4% to 2.8%) among SNAP-ineligible non-participants. Adding a national 10% tax on sugar-sweetened beverages (SSBs) and processed meats would prevent a total of 33 700 CMD deaths/year, including 5.9% (95% UI 5.4% to 7.4%) of all CMD deaths among SNAP participants, 4.8% (95% UI 4.4% to 5.2%) among SNAP-eligible non-participants and 4.1% (95% UI 3.8% to 4.5%) among SNAP-ineligible non-participants. Adding a SNAP-targeted 30% subsidy for the same healthy foods would offer the largest reductions in both CMD mortality and disparities., Conclusion: National subsidies for healthy foods and taxes on SSBs and processed meats would each reduce CMD mortality; taxes would also reduce CMD mortality more steeply for SNAP participants than for non-participants., Competing Interests: Competing interests: DM reports personal fees from Haas Avocado Board, Pollock Communications, Life Sciences Research Organization, Boston Heart Diagnostics, GOED, DSM, Unilever North American and UpToDate. RM reports research funding from Unilever and personal fees from the World Bank and Bunge, all outside the submitted work. JLPe now is employed by Merck KGaA. For all other authors: none declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Promising school policies to improve children's diets include providing fresh fruits and vegetables (F&V) and competitive food restrictions on sugar-sweetened beverages (SSBs), yet the impact of national implementation of these policies in US schools on cardiometabolic disease (CMD) risk factors and outcomes is not known. Our objective was to estimate the impact of national implementation of F&V provision and SSB restriction in US elementary, middle, and high schools on dietary intake and body mass index (BMI) in children and future CMD mortality., Methods: We used comparative risk assessment (CRA) frameworks to model the impacts of these policies with input parameters from nationally representative surveys, randomized-controlled trials, and systematic reviews and meta-analyses. For children ages 5-18 years, this incorporated national data on current dietary intakes and BMI, impacts of these policies on diet, and estimated effects of dietary changes on BMI. In adults ages 25 and older, we further incorporated the sustainability of dietary changes to adulthood, effects of dietary changes on CMD, and national CMD death statistics, modeling effects if these policies had been in place when current US adults were children. Uncertainty across inputs was incorporated using 1000 Monte Carlo simulations., Results: National F&V provision would increase daily fruit intake in children by as much as 25.0% (95% uncertainty interval (UI): 15.4, 37.7%), and would have small effects on vegetable intake. SSB restriction would decrease daily SSB intake by as much as 26.5% (95% UI: 6.4, 46.4%), and reduce BMI by as much as 0.7% (95% UI: 0.2, 1.2%). If F&V provision and SSB restriction were nationally implemented, an estimated 22,383 CMD deaths/year (95% UI: 18735, 25930) would be averted., Conclusion: National school F&V provision and SSB restriction policies implemented in elementary, middle, and high schools could improve diet and BMI in children and reduce CMD mortality later in life., Competing Interests: The authors have declared that no competing interests exist.

The classical portrayal of poor health in tropical countries is one of infections and parasites, contrasting with wealthy Western countries, where unhealthy diet and behaviours cause non-communicable diseases (NCDs) such as heart disease and cancer. Using international mortality data, we show that most NCDs cause more deaths at every age in low- and middle-income tropical countries than in high-income Western countries. Causes of NCDs in low- and middle-income countries include poor nutrition and living environment, infections, insufficient taxation and regulation of tobacco and alcohol, and under-resourced and inaccessible healthcare. We identify a comprehensive set of actions across health, social, economic and environmental sectors that could confront NCDs in low- and middle-income tropical countries and reduce global health inequalities.

Background: Diabetes and high body-mass index (BMI) are associated with increased risk of several cancers, and are increasing in prevalence in most countries. We estimated the cancer incidence attributable to diabetes and high BMI as individual risk factors and in combination, by country and sex., Methods: We estimated population attributable fractions for 12 cancers by age and sex for 175 countries in 2012. We defined high BMI as a BMI greater than or equal to 25 kg/m 2 . We used comprehensive prevalence estimates of diabetes and BMI categories in 2002, assuming a 10-year lag between exposure to diabetes or high BMI and incidence of cancer, combined with relative risks from published estimates, to quantify contribution of diabetes and high BMI to site-specific cancers, individually and combined as independent risk factors and in a conservative scenario in which we assumed full overlap of risk of diabetes and high BMI. We then used GLOBOCAN cancer incidence data to estimate the number of cancer cases attributable to the two risk factors. We also estimated the number of cancer cases in 2012 that were attributable to increases in the prevalence of diabetes and high BMI from 1980 to 2002. All analyses were done at individual country level and grouped by region for reporting., Findings: We estimated that 5·7% of all incident cancers in 2012 were attributable to the combined effects of diabetes and high BMI as independent risk factors, corresponding to 804 100 new cases. 187 600 (24·5%) of 766 000 cases of liver cancer and 121 700 (38·4%) of 317 000 cases of endometrial cancer were attributable to these risk factors. In the conservative scenario, about 4·5% (629 000 new cases) of all incident cancers assessed were attributable to diabetes and high BMI combined. Individually, high BMI (544 300 cases) was responsible for almost twice as many cancer cases as diabetes (293 300 cases). 25·8% of diabetes-related cancers (equating to 75 600 new cases) and 31·9% of high BMI-related cancers (174 040 new cases) were attributable to increases in the prevalence of these risk factors from 1980 to 2002., Interpretation: A substantial number of cancer cases are attributable to diabetes and high BMI. As the prevalence of these cancer risk factors increases, clinical and public health efforts should focus on identifying optimal preventive and screening measures for whole populations and individual patients., Funding: NIHR and Wellcome Trust., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Sodium consumption is a modifiable risk factor for higher blood pressure (BP) and cardiovascular disease (CVD). The US Food and Drug Administration (FDA) has proposed voluntary sodium reduction goals targeting processed and commercially prepared foods. We aimed to quantify the potential health and economic impact of this policy., Methods and Findings: We used a microsimulation approach of a close-to-reality synthetic population (US IMPACT Food Policy Model) to estimate CVD deaths and cases prevented or postponed, quality-adjusted life years (QALYs), and cost-effectiveness from 2017 to 2036 of 3 scenarios: (1) optimal, 100% compliance with 10-year reformulation targets; (2) modest, 50% compliance with 10-year reformulation targets; and (3) pessimistic, 100% compliance with 2-year reformulation targets, but with no further progress. We used the National Health and Nutrition Examination Survey and high-quality meta-analyses to inform model inputs. Costs included government costs to administer and monitor the policy, industry reformulation costs, and CVD-related healthcare, productivity, and informal care costs. Between 2017 and 2036, the optimal reformulation scenario achieving the FDA sodium reduction targets could prevent approximately 450,000 CVD cases (95% uncertainty interval: 240,000 to 740,000), gain approximately 2.1 million discounted QALYs (1.7 million to 2.4 million), and produce discounted cost savings (health savings minus policy costs) of approximately $41 billion ($14 billion to $81 billion). In the modest and pessimistic scenarios, health gains would be 1.1 million and 0.7 million QALYS, with savings of $19 billion and $12 billion, respectively. All the scenarios were estimated with more than 80% probability to be cost-effective (incremental cost/QALY < $100,000) by 2021 and to become cost-saving by 2031. Limitations include evaluating only diseases mediated through BP, while decreasing sodium consumption could have beneficial effects upon other health burdens such as gastric cancer. Further, the effect estimates in the model are based on interventional and prospective observational studies. They are therefore subject to biases and confounding that may have influenced also our model estimates., Conclusions: Implementing and achieving the FDA sodium reformulation targets could generate substantial health gains and net cost savings.

Objective: To systematically review published studies of interventions to reduce people's intake of dietary trans-fatty acids (TFAs)., Methods: We searched online databases (CINAHL, the CRD Wider Public Health database, Cochrane Database of Systematic Reviews, Ovid®, MEDLINE®, Science Citation Index and Scopus) for studies evaluating TFA interventions between 1986 and 2017. Absolute decrease in TFA consumption (g/day) was the main outcome measure. We excluded studies reporting only on the TFA content in food products without a link to intake. We included trials, observational studies, meta-analyses and modelling studies. We conducted a narrative synthesis to interpret the data, grouping studies on a continuum ranging from interventions targeting individuals to population-wide, structural changes., Results: After screening 1084 candidate papers, we included 23 papers: 12 empirical and 11 modelling studies. Multiple interventions in Denmark achieved a reduction in TFA consumption from 4.5 g/day in 1976 to 1.5 g/day in 1995 and then virtual elimination after legislation banning TFAs in manufactured food in 2004. Elsewhere, regulations mandating reformulation of food reduced TFA content by about 2.4 g/day. Worksite interventions achieved reductions averaging 1.2 g/day. Food labelling and individual dietary counselling both showed reductions of around 0.8 g/day., Conclusion: Multicomponent interventions including legislation to eliminate TFAs from food products were the most effective strategy. Reformulation of food products and other multicomponent interventions also achieved useful reductions in TFA intake. By contrast, interventions targeted at individuals consistently achieved smaller reductions. Future prevention strategies should consider this effectiveness hierarchy to achieve the largest reductions in TFA consumption.

Background: Fiscal interventions are promising strategies to improve diets, reduce cardiovascular disease and diabetes (cardiometabolic diseases; CMD), and address health disparities. The aim of this study is to estimate the impact of specific dietary taxes and subsidies on CMD deaths and disparities in the US., Methods: Using nationally representative data, we used a comparative risk assessment to model the potential effects on total CMD deaths and disparities of price subsidies (10%, 30%) on fruits, vegetables, whole grains, and nuts/seeds and taxes (10%, 30%) on processed meat, unprocessed red meats, and sugar-sweetened beverages. We modeled two gradients of price-responsiveness by education, an indicator of socioeconomic status (SES), based on global price elasticities (18% greater price-responsiveness in low vs. high SES) and recent national experiences with taxes on sugar-sweetened beverages (65% greater price-responsiveness in low vs. high SES)., Results: Each price intervention would reduce CMD deaths. Overall, the largest proportional reductions were seen in stroke, followed by diabetes and coronary heart disease. Jointly altering prices of all seven dietary factors (10% each, with 18% greater price-responsiveness by SES) would prevent 23,174 (95% UI 22,024-24,595) CMD deaths/year, corresponding to 3.1% (95% UI 2.9-3.4) of CMD deaths among Americans with a lower than high school education, 3.6% (95% UI 3.3-3.8) among high school graduates/some college, and 2.9% (95% UI 2.7-3.5) among college graduates. Applying a 30% price change and larger price-responsiveness (65%) in low SES, the corresponding reductions were 10.9% (95% UI 9.2-10.8), 9.8% (95% UI 9.1-10.4), and 6.7% (95% UI 6.2-7.6). The latter scenario would reduce disparities in CMD between Americans with lower than high school versus a college education by 3.5 (95% UI 2.3-4.5) percentage points., Conclusions: Modest taxes and subsidies for key dietary factors could meaningfully reduce CMD and improve US disparities.

Introduction: Coronary heart disease (CHD) remains a leading cause of UK mortality. Dietary trans fats (TFA) represent a powerful CHD risk factor. However, UK efforts to reduce intake have been less successful than other nations. We modelled the potential health and economic effects of eliminating industrial and all TFA up to 2020., Methods: We extended the previously validated IMPACTsec model, to estimate the potential effects on health and economic outcomes of mandatory reformulation or a complete ban on dietary TFA in England and Wales from 2011 to 2020. We modelled two policy scenarios: 1) Elimination of industrial TFA consumption, from 0.8% to 0.4% daily energy 2) Elimination of all TFA consumption, from 0.8% to 0., Results: Elimination of industrial TFA across the England and Wales population could result in approximately 1600 fewer deaths per year, with some 4000 fewer hospital admissions; gaining approximately 14 000 additional life years. Health inequalities would be substantially reduced in both scenarios. Elimination of industrial TFA would be cost saving. This would include approximately £100 m saved in direct healthcare costs. Elimination of all TFA would double the health and economic gains., Conclusions: Eliminating industrial or all UK dietary intake of TFA could substantially reduce CHD mortality and inequalities, while resulting in substantial annual savings., (© The Author 2016. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: A low intake of fruits and vegetables (F&Vs) is a major risk factor for cardiovascular disease (CVD) in the United States. Both mass media campaigns (MMCs) and economic incentives may increase F&V consumption. Few data exist on their comparative effectiveness. Objective: We estimated CVD mortality reductions potentially achievable by price reductions and MMC interventions targeting F&V intake in the US population. Design: We developed a US IMPACT Food Policy Model to compare 3 policies targeting F&V intake across US adults from 2015 to 2030: national MMCs and national F&V price reductions of 10% and 30%. We accounted for differences in baseline diets, CVD rates, MMC coverage, MMC duration, and declining effects over time. Outcomes included cumulative CVD (coronary heart disease and stroke) deaths prevented or postponed and life-years gained (LYGs) over the study period, stratified by age, sex, and race. Results: A 1-y MMC in 2015 would increase the average national F&V consumption by 7% for 1 y and prevent ∼18,600 CVD deaths (95% CI: 17,600, 19,500), gaining ∼280,100 LYGs by 2030. With a 15-y MMC, increased F&V consumption would be sustained, yielding a 3-fold larger reduction (56,100; 95% CI: 52,400, 57,700) in CVD deaths. In comparison, a 10% decrease in F&V prices would increase F&V consumption by ∼14%. This would prevent ∼153,300 deaths (95% CI: 146,400, 159,200), gaining ∼2.51 million LYGs. For a 30% price decrease, resulting in a 42% increase in F&V consumption, corresponding values would be 451,900 CVD deaths prevented or postponed (95% CI: 433,100, 467,500) and 7.3 million LYGs gained. Effects were similar by sex, with a smaller proportional effect and larger absolute effects at older ages. A 1-y MMC would be 35% less effective in preventing CVD deaths in non-Hispanic blacks than in whites. In comparison, price-reduction policies would have equitable proportional effects. Conclusion: Both national MMCs and price-reduction policies could reduce US CVD mortality, with price reduction being more powerful and sustainable., (© 2017 American Society for Nutrition.)

Background: Large socio-economic disparities exist in US dietary habits and cardiovascular disease (CVD) mortality. While economic incentives have demonstrated success in improving dietary choices, the quantitative impact of different dietary policies on CVD disparities is not well established. We aimed to quantify and compare the potential effects on total CVD mortality and disparities of specific dietary policies to increase fruit and vegetable (F&V) consumption and reduce sugar-sweetened beverage (SSB) consumption in the US., Methods and Findings: Using the US IMPACT Food Policy Model and probabilistic sensitivity analyses, we estimated and compared the reductions in CVD mortality and socio-economic disparities in the US population potentially achievable from 2015 to 2030 with specific dietary policy scenarios: (a) a national mass media campaign (MMC) aimed to increase consumption of F&Vs and reduce consumption of SSBs, (b) a national fiscal policy to tax SSBs to increase prices by 10%, (c) a national fiscal policy to subsidise F&Vs to reduce prices by 10%, and (d) a targeted policy to subsidise F&Vs to reduce prices by 30% among Supplemental Nutrition Assistance Program (SNAP) participants only. We also evaluated a combined policy approach, combining all of the above policies. Data sources included the Surveillance, Epidemiology, and End Results Program, National Vital Statistics System, National Health and Nutrition Examination Survey, and published meta-analyses. Among the individual policy scenarios, a national 10% F&V subsidy was projected to be most beneficial, potentially resulting in approximately 150,500 (95% uncertainty interval [UI] 141,400-158,500) CVD deaths prevented or postponed (DPPs) by 2030 in the US. This far exceeds the approximately 35,100 (95% UI 31,700-37,500) DPPs potentially attributable to a 30% F&V subsidy targeting SNAP participants, the approximately 25,800 (95% UI 24,300-28,500) DPPs for a 1-y MMC, or the approximately 31,000 (95% UI 26,800-35,300) DPPs for a 10% SSB tax. Neither the MMC nor the individual national economic policies would significantly reduce CVD socio-economic disparities. However, the SNAP-targeted intervention might potentially reduce CVD disparities between SNAP participants and SNAP-ineligible individuals, by approximately 8% (10 DPPs per 100,000 population). The combined policy approach might save more lives than any single policy studied (approximately 230,000 DPPs by 2030) while also significantly reducing disparities, by approximately 6% (7 DPPs per 100,000 population). Limitations include our effect estimates in the model; these estimates use interventional and prospective observational studies (not exclusively randomised controlled trials). They are thus imperfect and should be interpreted as the best available evidence. Another key limitation is that we considered only CVD outcomes; the policies we explored would undoubtedly have additional beneficial effects upon other diseases. Further, we did not model or compare the cost-effectiveness of each proposed policy., Conclusions: Fiscal strategies targeting diet might substantially reduce CVD burdens. A national 10% F&V subsidy would save by far the most lives, while a 30% F&V subsidy targeting SNAP participants would most reduce socio-economic disparities. A combined policy would have the greatest overall impact on both mortality and socio-economic disparities.

Background: Valvular heart disease (VHD) is expected to become more common as the population ages. However, current estimates of its natural history and prevalence are based on historical studies with potential sources of bias. We conducted a cross-sectional analysis of the clinical and epidemiological characteristics of VHD identified at recruitment of a large cohort of older people., Methods and Results: We enrolled 2500 individuals aged ≥65 years from a primary care population and screened for undiagnosed VHD using transthoracic echocardiography. Newly identified (predominantly mild) VHD was detected in 51% of participants. The most common abnormalities were aortic sclerosis (34%), mitral regurgitation (22%), and aortic regurgitation (15%). Aortic stenosis was present in 1.3%. The likelihood of undiagnosed VHD was two-fold higher in the two most deprived socioeconomic quintiles than in the most affluent quintile, and three-fold higher in individuals with atrial fibrillation. Clinically significant (moderate or severe) undiagnosed VHD was identified in 6.4%. In addition, 4.9% of the cohort had pre-existing VHD (a total prevalence of 11.3%). Projecting these findings using population data, we estimate that the prevalence of clinically significant VHD will double before 2050., Conclusions: Previously undetected VHD affects 1 in 2 of the elderly population and is more common in lower socioeconomic classes. These unique data demonstrate the contemporary clinical and epidemiological characteristics of VHD in a large population-based cohort of older people and confirm the scale of the emerging epidemic of VHD, with widespread implications for clinicians and healthcare resources., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Background: Accurate forecasting of cardiovascular disease mortality is crucial to guide policy and programming efforts. Prior forecasts often have not incorporated past trends in rates of reduction in cardiovascular disease mortality. This creates uncertainties about future trends in cardiovascular disease mortality and disparities., Methods and Results: To forecast US cardiovascular disease mortality and disparities to 2030, we developed a hierarchical bayesian model to determine and incorporate prior age, period, and cohort effects from 1979 to 2012, stratified by age, sex, and race, which we combined with expected demographic shifts to 2030. Data sources included the National Vital Statistics System, Surveillance, Epidemiology, and End Results (SEER) single-year population estimates, and US Bureau of Statistics 2012 national population projections. We projected coronary disease and stroke deaths to 2030, first on the basis of constant age, period, and cohort effects at 2012 values, as is most commonly done (conventional), and then with the use of more rigorous projections incorporating expected trends in age, period, and cohort effects (trend based). We primarily evaluated absolute mortality. The conventional model projected total coronary and stroke deaths by 2030 to increase by ≈18% (67 000 additional coronary deaths per year) and 50% (64 000 additional stroke deaths per year). Conversely, the trend-based model projected that coronary mortality would decrease by 2030 by ≈27% (79 000 fewer deaths per year) and stroke mortality would remain unchanged (200 fewer deaths per year). Health disparities will be improved in stroke deaths but not coronary deaths., Conclusions: After prior mortality trends and expected demographic shifts are accounted for, total US coronary deaths are expected to decline, whereas stroke mortality will remain relatively constant. Health disparities in stroke but not coronary deaths will be improved but not eliminated. These age, period, and cohort approaches offer more plausible predictions than conventional estimates., (© 2016 American Heart Association, Inc.)

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., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Poor diet is the leading cause of cardiovascular disease in the USA and globally. Evidence-based policies are crucial to improve diet and population health. We reviewed the effectiveness for a range of policy levers to alter diet and diet-related risk factors. We identified evidence to support benefits of focused mass media campaigns (especially for fruits, vegetables, salt), food pricing strategies (both subsidies and taxation, with stronger effects at lower income levels), school procurement policies (for increasing healthful or reducing unhealthful choices), and worksite wellness programs (especially when comprehensive and multicomponent). Evidence was inconclusive for food and menu labeling (for consumer or industry behavior) and changes in local built environment (e.g., availability or accessibility of supermarkets, fast food outlets). We found little empiric evidence evaluating marketing restrictions, although broad principles and large resources spent on marketing suggest utility. Widespread implementation and evaluation of evidence-based policy strategies, with further research on other strategies with mixed/limited evidence, are essential "population medicine" to reduce health and economic burdens and inequities of diet-related illness worldwide.

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

Background: Coronary Heart Disease (CHD) remains a leading cause of UK mortality, generating a large and unequal burden of disease. Dietary trans fatty acids (TFA) represent a powerful CHD risk factor, yet to be addressed in the UK (approximately 1% daily energy) as successfully as in other nations. Potential outcomes of such measures, including effects upon health inequalities, have not been well quantified. We modelled the potential effects of specific reductions in TFA intake on CHD mortality, CHD related admissions, and effects upon socioeconomic inequalities., Methods & Results: We extended the previously validated IMPACTsec model, to estimate the potential effects of reductions (0.5% & 1% reductions in daily energy) in TFA intake in England and Wales, stratified by age, sex and socioeconomic circumstances. We estimated reductions in expected CHD deaths in 2030 attributable to these two specific reductions. Output measures were deaths prevented or postponed, life years gained and hospital admissions. A 1% reduction in TFA intake energy intake would generate approximately 3,900 (95% confidence interval (CI) 3,300-4,500) fewer deaths, 10,000 (8,800-10,300) (7% total) fewer hospital admissions and 37,000 (30,100-44,700) life years gained. This would also reduce health inequalities, preventing five times as many deaths and gaining six times as many life years in the most deprived quintile compared with the most affluent. A more modest reduction (0.5%) would still yield substantial health gains., Conclusions: Reducing intake of industrial TFA could substantially decrease CHD mortality and hospital admissions, and gain tens of thousands of life years. Crucially, this policy could also reduce health inequalities. UK strategies should therefore aim to minimise industrial TFA intake.

Following Sir Bruce Keogh's review of 14 NHS Trusts, Buckinghamshire NHS Trust was found to have higher mortality rates than the England average. As part of a series of implementations and investigations to address this, a quality improvement project looking at clinical responses to the deteriorating patients was designed. Buckinghamshire NHS Trust utilises the National Early Warning Score (NEWS) metric for observations and escalation, and this was the standard used for the project. Episodes were eligible for inclusion if the NEWS score was increased to 5 or above. Data was collected by junior doctors from acute wards across the trust using notes and charts available. The initial cycle identified that in 57% of cases the high NEWS was escalated for review. Only half of cases were reviewed by a doctor; only a third were reviewed within an hour. In only 20% of cases were all criteria of the NEWS guidelines met. The first intervention was through education. After this, the project was completed on a monthly basis for 6 months with additional interventions introduced, including increased medical staff availability, grand round presentations, and increased outreach provision. Over this 6 month period, there was an increase to 87% of cases being reviewed by a doctor of appropriate seniority. Whilst this is a surrogate for reducing mortality and improving the clinical care given in the hospital, these results suggest successful interventions for improving clinical response to deteriorating patients across the trust. The project has recruited a new cohort of juniors to continue the quality improvement cycle.

Introduction: The burden of coronary heart disease (CHD) in the UK is substantial. However, recent trends and associated socioeconomic inequalities are not well studied. We aim to identify and analyse these trends stratified by age, gender and socioeconomic quintiles., Methods: We quantified the CHD burden and analysed trends from 1999 to 2007 in all adults aged over 25 years resident in England. Data sources included deaths (from ONS), health surveys, and hospital admissions (from Hospital Episode Statistics), all using ICD9 and ICD10 coding. Socioeconomic inequalities were calculated in both absolute and relative terms., Results: In 2007, the CHD burden comprised approximately 205 000 hospital admissions (acute and elective), including approximately 110 000 admissions with acute coronary syndrome. There were approximately 1.5 million CHD patients with chronic disease living in the community. Approximately 67 500 of these were admitted during 2007 for revascularisation. There were approximately 173 000 CHD patients living with heart failure, of whom some 14% required hospital admission during 2007. Between 1999 and 2007, age-specific hospital admission rates generally decreased by 20%-35%. Community prevalence decreased by 10%-20%. Strong socioeconomic gradients were apparent in all patient groups, persisting or worsening between 1999 and 2007., Conclusions: The burden of CHD is immense, costly and unequal. Hospital admissions attract more attention than the far more numerous patients living with chronic disease in the community. Population-based rates for hospital admissions and CHD prevalence have been declining by 3%-4% per annum. However, marked socioeconomic gradients have persisted or worsened-there is no room for complacency.