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Low physical activity (PA) and physical fitness (PF) are well-known factors for chronic diseases generally and cardiovascular diseases specifically. The economic burden from these chronic diseases is also well documented, as is their disproportionate prevalence among states in the Southern region of the U.S. Low PA and PF have also become recognized factors impacting military readiness and national security. Specifically, low PA and PF are highly correlated with musculoskeletal injures (MSKIs), now considered the greatest medical impediment to military readiness. Prior research shows low PF and MSKI incidence are greater among Army recruits from Southern states, however no previous research has investigated the economic impact of MSKIs at the state- and regional-level. The aim of this study was to determine the economic impact of MSKIs among U.S. Army initial military trainees on a state- and regional-basis.Rosters for recruits entering U.S. Army Initial Military Training (IMT) for fiscal year 2017 were obtained (n = 103,487). Roster data included the unique personal identifier, demographics with postal zip code, training start/end dates, and height and weight and were subsequently linked to medical encounters and cost data from the Military Health System Data Repository. Trainees with one or more MSKIs were considered injury cases (n = 33,509) and were stratified by gender. The percent of trainee MSKI cases was calculated as number of injury cases divided by total number of trainees. For each injury case, the direct medical cost for MSKIs was calculated. The percent of trainees and direct medical costs for MSKIs were aggregated to home-state and regional-levels for the four U.S. Census tract regions. A test for equality of proportions was performed at state- and regional-levels to investigate differences in percent of trainees with MSKIs by state/region. A one-way ANOVA was used to investigate possible differences in medical cost/trainee by region.34% (n = 33,509) of all trainees sustained at least one MSKI. State-specific MSKI percentages showed ten states having the greatest percentage of trainees with at least one MSKI, eight of which were from the South region (AL, FL, GA, LA, MS, NC, SC, TN). The South was the only region to have a statistically significantly higher percentage of trainees with MSKIs at 34% (p0.001), as compared to all other regions. The total direct medical cost of treating MSKIs among all trainees was $14,891,563. The South was the costliest region ($7,168,997), accounted for nearly 50 % of the total national cost, and had the highest mean MSKI cost/trainee.This study was the first in demonstrating the disproportionate economic burden Southern states pose to the U.S. Department of Defense resulting from its significantly higher MSKI cost. PA and PF are known to ameliorate chronic disease and MSKI burden among general and military populations. Therefore, increasing PA and PF among all young Americans, and specifically those living in Southern states, is imperative for improving public health and reducing the economic and practical burden of MSKIs on military readiness and national security.

Cardiovascular, respiratory, and related disorders (CVRDs) are the leading causes of adult death worldwide, and substantial inequalities in care of patients with CVRDs exist between countries of high income and countries of low and middle income. Based on current trends, the UN Sustainable Development Goal to reduce premature mortality due to CVRDs by a third by 2030 will be challenging for many countries of low and middle income. We did systematic literature reviews of effectiveness and cost-effectiveness to identify priority interventions. We summarise the key findings and present a costed essential package of interventions to reduce risk of and manage CVRDs. On a population level, we recommend tobacco taxation, bans on trans fats, and compulsory reduction of salt in manufactured food products. We suggest primary health services be strengthened through the establishment of locally endorsed guidelines and ensured availability of essential medications. The policy interventions and health service delivery package we suggest could serve as the cornerstone for the management of CVRDs, and afford substantial financial risk protection for vulnerable households. We estimate that full implementation of the essential package would cost an additional US$21 per person in the average low-income country and $24 in the average lower-middle-income country. The essential package we describe could be a starting place for low-income and middle-income countries developing universal health coverage packages. Interventions could be rolled out as disease burden demands and budgets allow. Our outlined interventions provide a pathway for countries attempting to convert the UN Sustainable Development Goal commitments into tangible action.

Introduction: Excess added sugars, particularly from sugar-sweetened beverages (SSBs), are linked to cardiometabolic risk including obesity, type 2 diabetes (T2D) and CVD. Despite recent declines in SSB intake in the US, added sugar intake from SSBs and foods remains high and exceeds dietary recommendations. In May 2016, the US Food and Drug Administration (FDA) announced major revisions to the Nutrition Facts panel, including mandatory labeling of added sugar content, as a strategy to target added sugars from packaged foods and beverages. Yet, potential health effects remain unclear; and the FDA recently announced delays in implementation. Aim: To estimate the cardiometabolic and economic effects of implementing FDA’s added sugar labeling policy over a 20-year horizon. Methods: A validated microsimulation model, the US IMPACT Food Policy Model, was used to estimate the T2D and CVD cases averted and quality-adjusted life-years (QALYs) gained from the FDA policy for US adults age 30+ years. Model inputs included: nationally representative demographics and added sugar intakes from NHANES; policy effects on consumer intake from labeling intervention studies; obesity-mediated effects and direct independent effects of added sugars from SSBs and other foods, considered separately, on T2D and CVD from meta-analyses; policy costs including government administrative costs and industry compliance costs from federal government reports; national health statistics from the CDC; and healthcare costs including medical, productivity, and indirect costs from the AHA and American Diabetes Association. All costs were inflated to constant 2017 US dollars, discounted annually at 3%. We took a societal perspective and assumed a willingness to pay of $100,000 per QALY. Probabilistic sensitivity analysis accounted for model parameter uncertainty and population heterogeneity. Results: Between 2018 and 2037, the FDA added sugar labeling policy could prevent approximately 580,000 (95% UI: 270,000–960,000) T2D cases and 210,000 (96,000–440,000) CVD cases, generating 600,000 (290,000–970,000) discounted QALYs. The policy would produce discounted net cost savings (health savings minus policy costs) of $47.3bn (21.7-78.6), including $25.6bn (11.9-43.1) from direct healthcare cost reductions. Most (>60%) savings were driven by costs related to T2D. Incorporating modelling and input uncertainty, the FDA added sugar label was estimated with >80% probability to be cost-effective by 2020 and cost-saving by 2022. Potential additional reductions from industry reformulations were not included and could further increase cost-savings. Conclusions: Implementing the FDA added sugar labeling mandate would generate substantial health gains and cost savings for the US population, highlighting the need for timely implementation, monitoring and evaluation.

© 2015 Mayo Foundation for Medical Education and Research, and the European Society of Cardiology. This article is being published concurrently in Mayo Clinic Proceedings [1]. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation can be used when citing this article. [1] Arena R, Guazzi M, Lianov L, Whitsel L, Berra K, Lavie CJ, Kaminsky L, Williams M, Hivert M-F, Franklin NC, Myers J, Dengel D, Lloyd-Jones DM, Pinto FJ, Cosentino F, Halle M, Gielen S, Dendale P, Niebauer J, Pelliccia A, Giannuzzi P, Corra U, Piepoli MF, Guthrie G, Shurney D. Healthy Lifestyle Interventions to Combat Noncommunicable Diseased - A Novel Nonhierarchical Connectivity Model for Key Stakeholders: A Policy Statement From the American Heart Association, European Society of Cardiology, European Association for Cardiovascular Prevention and Rehabilitation, and American College of Preventive Medicine. Mayo Clinic Proceedings 2015; DOI: 10.1016/j.mayocp.2015.05.001 [In Press], Noncommunicable diseases (NCDs) have become the primary health concern for most countries around the world. Currently, more than 36 million people worldwide die from NCDs each year, accounting for 63% of annual global deaths; most are preventable. The global financial burden of NCDs is staggering, with an estimated 2010 global cost of $6.3 trillion (US dollars) that is projected to increase to $13 trillion by 2030. A number of NCDs share one or more common predisposing risk factors, all related to lifestyle to some degree: (1) cigarette smoking, (2) hypertension, (3) hyperglycemia, (4) dyslipidemia, (5) obesity, (6) physical inactivity, and (7) poor nutrition. In large part, prevention, control, or even reversal of the aforementioned modifiable risk factors are realized through leading a healthy lifestyle (HL). The challenge is how to initiate the global change, not toward increasing documentation of the scope of the problem but toward true action-creating, implementing, and sustaining HL initiatives that will result in positive, measurable changes in the previously defined poor health metrics. To achieve this task, a paradigm shift in how we approach NCD prevention and treatment is required. The goal of this American Heart Association/European Society of Cardiology/European Association for Cardiovascular Prevention and Rehabilitation/American College of Preventive Medicine policy statement is to define key stakeholders and highlight their connectivity with respect to HL initiatives. This policy encourages integrated action by all stakeholders to create the needed paradigm shift and achieve broad adoption of HL behaviors on a global scale.

Quantifying reductions in US cardiovascular deaths and disparities by different diet policies Background: Large 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 Methods: Using a US IMPACT Food Policy Model and probabilistic sensitivity analyses, we estimated and compared the reductions in CVD mortality and disparities in the US population potentially achievable from 2015 to 2030 with specific dietary policy scenarios a) a national mass media campaign (Media campaign) aimed to increase consumption of fruits and vegetables (F&V) or reduce sugar sweetened beverages (SSBs), b) national fiscal policies to tax SSB and increase price by 10% and subsidize F&V to reduce prices by 10%; and c) a targeted policy, to subsidize F&V to reduce prices by 30% among Supplemental Nutrition Assistance Programme (SNAP) participants only. We also evaluated a combined multi-component approach, combining each of the above policies. Results: Among individual policy options, a national 10% F&V subsidy was estimated to be most effective, resulting in approximately 150,500 (95% CI, 142,700-157,900) CVD deaths potentially prevented or postponed (DPPs) by 2030. This far exceed the approximately 35,100 (32,000-37,900) DPPs from a 30% F&V subsidy targeting SNAP participants, or some 23,000 (21,700-24,600) DPPs from a 1-year Media campaign or approximately 21,400 (19,500-23,600) DPPs from a 10% SSB tax. Neither the Media campaign nor individual national economic policies would significantly reduce CVD disparities. However, the SNAP-targeted intervention would significantly reduce CVD disparities between SNAP participants and SNAP-ineligible individuals, by approximately 7% (10 DPPs per 100,000 population). The combined policy approach would save more lives than any single policy studied (approximately 215,500 DPPs by 2030) while also significantly reducing disparities by approximately 5% (7 DPPs per 100,000 population). Conclusions: Fiscal strategies targeting diet could reduce CVD burdens. A national 10% F&V subsidy would save by far the most lives, while a SNAP-targeted 30% F&V subsidy would most reduce disparities. A combined policy would have the greatest overall impact on both mortality and disparities.

Jamie Devereaux, Features EditorIntroductionThe American Heart Association is a well-respected nonprofit agency and opinion leader on cardiovascular health strategies in the United States. They provide scientific statements and practice guidelines for healthcare professionals and the public as well as resources and tools for researchers. Here, Laurie Whitsel, PhD, director of policy research for the AHA, discusses why they believe the new school meal standards are working and should receive continued support in 2015; how worksite health care could benefit children; and the association's 2020 goal, which is to improve the cardiovascular health of the nation by 20 percent by 2020.What is your view on the current status of the school food guidelines in the US?Dr. Whitsel: We have made tremendous progress since the Child Nutrition Reauthorization Act of 2010 across the school food environment.More than 90% of schools nationwide are implementing the standards. Bridging the Gap published a research brief in summer 2014 showing that, overall, kids are happy with the school meal standards.1Now, we are doing a lot of work to maintain the great progress we've made; and I do believe the school environment has been transformed. It is still a work in progress to get the standards fully in place and to provide the resources, equipment, and reimbursement that school food service directors need to optimize implementation. But we have made great strides, and there have been many successes so far that I think that we have to celebrate.The challenge is going to be maintaining those gains through the next reauthorization, this year, in 2015, within the context of significant pushback in Congress.The political environment is something that many people are wondering about as far as the reauthorization of the standards. Do you foresee what the impact will be from the changes that were put forth in the 2015 federal spending bill?Dr. Whitsel: The overarching point I will make is that we are always concerned when Congress begins to meddle with evidence-based standards. We think that implementation is the work of the respective regulatory agency, and there is ample evidence for the standards that are in place.That said, the US Department of Agriculture is talking to food service directors and understanding where there might be some need for adjustment and so forth. If schools are struggling in terms of availability of whole-grain foods, for instance, giving them a little more time to overcome some of those barriers is okay.For sodium, in the language of the spending bill, what was said is that the USDA cannot move further through reduction until they show more evidence for sodium reduction in children. We feel that there is already evidence for that sodium reduction.The Dietary Guidelines Advisory Committee report just reaffirmed the target for 2300 mg of sodium for a majority of the population and reaffirmed the importance of sodium reduction in children and adults.2 The final sodium targets in the school meal program are based on the 2300-mg recommendation; so we feel the science is there and that the USDA will be able to progress over time to that final target.The committee report you mention is the first to point to a specific sugar intake recommendation, correct?Dr. Whitsel: It was. And that is further to the point that the USDA will make adjustments to the guidelines where needed.Will schools be able to scale back on changes they have already made as far as sodium in foods they are offering?Dr. Whitsel: Well, no they cannot. They are already supposed to be at the tier 1 reduction and that is where they have to stay. The language in the spending bill does not allow schools to backtrack at all. The sodium reduction was gradual over time to get to the final endpoint, and all that the bill says is that the USDA cannot move on to the next tier reduction until they show that there is enough science. …

Background: Food taxes and subsidies are promising strategies for improving diets and reducing cardiometabolic diseases (CMD). Both dietary habits and CMD burdens are unequally distributed in the US, with major disparities by socioeconomic status (SES). Information on impacts of national food price policies on disparities is lacking. Aim: To estimate the impact on CMD deaths and health disparities in US adults of price interventions (taxes, subsidies) targeting 7 key dietary factors. Methods: Using nationally representative data, we conducted comparative risk assessment analysis to estimate the impact of a 10% price subsidy on fruits, vegetables, whole grains, and nuts and a 10% tax on processed meat, unprocessed red meat, and sugar-sweetened beverages, on CMD deaths and disparities in SES subgroups. We evaluated 18% (based on global price elasticity data) and 50% (based on recent experience from soda taxes in Mexico) greater price responsiveness in lowest vs. highest SES groups. Results: Each separate price intervention would reduce CMD deaths (Figure). Jointly subsidizing and taxing these 7 dietary factors (10% price change each) and assuming 18% greater price-responsiveness in lowest vs. highest SES, this intervention would prevent 5.27% of CMD deaths in those with Conclusions: Introducing modest price changes on key dietary factors could reduce CMD burdens and improve disparities in the US. Policy-based strategies targeting disparities will require considering both baseline dietary habits as well as price responsiveness in specific population subgroups.

Introduction: Cardiovascular disease (CVD) accounts for over 800,000 US deaths annually, with substantial disparities by race. Poor diet is a leading CVD risk factor, including low intake of fruit and vegetable (F&V). Few data exist regarding the potential population level impact and effect on race disparities of policies aimed at increasing F&V intake. Aim: To estimate CVD mortality reductions, including by race, potentially achievable by price reduction and mass media campaign interventions in the US population up to 2030. Methods: We developed a US IMPACT Food Policy Model to compare three contrasting policies targeting F&V intake: A - a national mass media campaign (MMC); B and C - a universal F&V price reduction of 10 and 30% respectively. The MMC assumed unequal coverage by age, gender and race, and duration of either 1 or 15 years. Data sources included the National Vital Statistics System, SEER single year population estimates, the US Bureau 2012 National Population projections and NHANES. We used US population and CVD projections to 2030, F&V mortality effect sizes and best evidence effect sizes for each policy. We modelled cumulative deaths prevented or postponed and life years gained (LYG) by age, gender, race and CVD subtype from 2015 to 2030. Results were tested in a probabilistic sensitivity analysis using Monte Carlo simulation. Results: Scenario A (MMC) could result in 27,000 (95% CI: 21,000-33,000) to 85,000 (83,000-89,000) fewer deaths dependent upon media campaign duration (from 1 to 15 years), gaining up to 1,280,000 LYGs (1,250,000-1,320,000) by 2030. Approximately 62% of deaths prevented would be CHD; and 53% would be in men, with 20% being saved in year 1. Scenario B (10% price decrease) could prevent approximately 90,000 deaths (71,000-114,000) and gain 1,450,000 LYGs (1,180,000-1,740,000) by 2030. Scenario C (30% price decrease) could prevent some 270,000 deaths (215,000-338,000) by 2030, representing a 3.9% reduction in expected CVD mortality. Price reduction policies would have equitable effects in non-hispanic whites vs. blacks. In comparison, a MMC would be ~ 35% less effective in preventing CVD deaths in non-Hispanic blacks. Conclusions: Price reduction policies (10 or 30%) and a nationwide MMC would each effectively reduce US CVD mortality. A 30% price reduction policy would save most lives and do so most equitably. Deaths prevented via a MMC might reduce substantially after year 1 and also increase disparities. These results inform potential fiscal and population level strategies to reduce CVD mortality in the US.