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Chronic disease pandemics have challenged societies and public health throughout history and remain ever-present. Despite increased knowledge, awareness and advancements in medicine, technology, and global initiatives the state of global health is declining. The coronavirus disease 2019 (COVID-19) pandemic has compounded the current perilous state of global health, and the long-term impact is yet to be realised. A coordinated global infrastructure could add substantial benefits to public health and yield prominent and consistent policy resulting in impactful change. To achieve global impact, research priorities that address multi-disciplinary social, environmental, and clinical must be supported by unified approaches that maximise public health. We present a call to action for established public health organisations and governments globally to consider the lessons from the COVID-19 pandemic and unite with true collaborative efforts to address current, longstanding, and growing challenges to public health., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Introduction: 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., Methods: 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., Results: 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% (p < 0.001), 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., Discussion: 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., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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.

Purpose of Review: Suboptimal diet is a leading cause of cardiometabolic disease and economic burdens. Evidence-based dietary policies within 5 domains-food prices, reformulation, marketing, labeling, and government food assistance programs-appear promising at improving cardiometabolic health. Yet, the extent of new dietary policy adoption in the US and key elements crucial to define in designing such policies are not well established. We created an inventory of recent US dietary policy cases aiming to improve cardiometabolic health and assessed the extent of their proposal and adoption at federal, state, local, and tribal levels; and categorized and characterized the key elements in their policy design., Recent Findings: Recent federal dietary policies adopted to improve cardiometabolic health include reformulation (trans-fat elimination), marketing (mass-media campaigns to increase fruits and vegetables), labeling (Nutrition Facts Panel updates, menu calorie labeling), and food assistance programs (financial incentives for fruits and vegetables in the Supplemental Nutrition Assistance Program (SNAP) and Women, Infant and Children (WIC) program). Federal voluntary guidelines have been proposed for sodium reformulation and food marketing to children. Recent state proposals included sugar-sweetened beverage (SSB) taxes, marketing restrictions, and SNAP restrictions, but few were enacted. Local efforts varied significantly, with certain localities consistently leading in the proposal or adoption of relevant policies. Across all jurisdictions, most commonly selected dietary targets included fruits and vegetables, SSBs, trans-fat, added sugar, sodium, and calories; other healthy (e.g., nuts) or unhealthy (e.g., processed meats) factors were largely not addressed. Key policy elements to define in designing these policies included those common across domains (e.g., level of government, target population, dietary target, dietary definition, implementation mechanism), and domain-specific (e.g., media channels for food marketing domain) or policy-specific (e.g., earmarking for taxes) elements. Characteristics of certain elements were similarly defined (e.g., fruit and vegetable definition, warning language used in SSB warning labels), while others varied across cases within a policy (e.g., tax base for SSB taxes). Several key elements were not always sufficiently characterized in government documents, and dietary target selections and definitions did not consistently align with the evidence-base. These findings highlight recent action on dietary policies to improve cardiometabolic health in the US; and key elements necessary to design such policies.

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.

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.

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.

Introduction: Racial disparities in acute myocardial infarctions (AMIs) are increasing over time. Previous studies have shown that the implementation of smoke-free policies is associated with reduced AMI rates. The objective of this study was to determine the association between smoke-free policy and AMI hospitalization rates and smoking by race., Methods: Healthcare Cost and Utilization Project data from Florida from 2000-2013 were analyzed using interrupted time series analysis to determine the relationship between Florida's smoke-free restaurant and workplace laws and AMI among the total adult population (aged ≥18years), by age, race, and gender. Behavioral Risk Factor Surveillance System data from Florida from 2000 to 2010 were analyzed using logistic regression to determine the association between policy and the adult smoking prevalence., Results: After implementation of the smoke-free policy, no statistically significant associations between AMI hospitalization rates or smoking prevalence were detected in the total population. In the subgroup analysis, the policy was associated with declines in AMI hospitalization rates among non-Hispanic white adults aged 18-44years (β=-0.001 per 10,000, p-value=0.0083). No other relationships with AMI hospitalization rates and smoking prevalence were found in the subgroup analysis., Conclusions: More comprehensive smoke-free and tobacco control policies are needed to further reduce AMI hospitalization rates, particularly among minority populations. Further research is needed to understand and address how the implementation of smoke-free policies affects secondhand smoke exposure among racial and ethnic minorities., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The antecedents of elevated blood pressure (BP) and its major consequences (cardiovascular disease and stroke) begin in childhood. Higher levels of BP early in life track into adulthood and are associated with subclinical target organ damage in children and adults. Diet behaviors, including the choice of high sodium containing foods, are established during childhood. On average, children, ages 2-19, consume more than 3,100 mg of sodium per day, with substantially greater sodium intakes in boys than girls. Importantly, studies show that lowering sodium intake in children lowers blood pressure. In view of this evidence, U.S. Dietary Guidelines recommend a reduced sodium intake in children. Current federal nutrition standards include a step-wise reduction in the sodium levels of school meals. The ultimate goal is to help children achieve daily sodium intakes that do not exceed upper levels recommended by the Institute of Medicine and the Dietary Guidelines for Americans. In summary, available data are sufficiently strong to recommend a lower sodium intake beginning in early in life as an effective and well-tolerated approach to reducing BP in children. Current efforts to weaken nutrition standards for school meals undermine an effective strategy aimed at improving the health of our children and our nation., (© 2015 The Authors. The Journal of Clinical Hypertension Published by Wiley Periodicals, Inc.)

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., (© 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].)

Most Americans are not sufficiently physically active, even though regular physical activity improves health and reduces the risk of many chronic diseases. Those living in rural, non-White, and lower-income communities often have insufficient access to places to be active, which can contribute to their lower level of physical activity. The shared use of school recreational facilities can provide safe and affordable places for communities. Studies suggest that challenges to shared use include additional cost, liability protection, communication among constituencies interested in sharing space, and decision-making about scheduling and space allocation. This American Heart Association policy statement has provided recommendations for federal, state, and local decision-makers to support and expand opportunities for physical activity in communities through the shared use of school spaces.