[Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice]

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

Challenges to the Mediterranean diet at a time of economic crisis

AIMS

The traditional Mediterranean diet (MD) is reportedly associated with lower risk of major chronic diseases and long considered to contribute to the reduced rates of cardiovascular and cerebrovascular events and to the highest life expectancy in adults who lived near the Mediterranean Sea. But despite its widely documented health benefits, adherence to this dietary pattern has been rapidly declining over the last decades due to a clear socioeconomic influence. The present review provides an overview of the evidence on the current major determinants of adherence to the Mediterranean diet, with a particular emphasis on Mediterranean Countries at a time of economic crisis; second it explores emerging socioeconomic inequalities in other domains of healthy dietary behaviours such as dietary variety, access to organic foods and food purchasing behaviour.

DATA SYNTHESIS

According to ecological evidence, the Mediterranean Countries that used to have the highest adherence to the Mediterranean pattern in the Sixties, more recently experienced the greatest decrease, while Countries in Northern Europe and some other Countries around the world are currently embracing a Mediterranean-like dietary pattern. A potential cause of this downward trend could be the increasing prices of some food items of the Mediterranean diet pyramid. Recent evidence has shown a possible involvement of the economic crisis, material resources becoming strong determinants of the adherence to the MD just after the recession started in 2007-2008. Beyond intake, the MD also encourages increasing dietary diversity, while international dietary recommendations suggest replacing regular foods with healthier ones.

CONCLUSIONS

Socioeconomic factors appear to be major determinants of the adherence to MD and disparities also hold for other indices of diet quality closely related to this dietary pattern.

Association between junk food consumption and fast-food outlet access near school among Quebec secondary-school children: findings from the Quebec Health Survey of High School Students (QHSHSS) 2010–11

Objective

We investigated the association between junk food consumption at lunchtime (JCL) and fast-food outlet access near school among secondary-school children in Quebec.

Design

A geographic information system database was used to characterize the food environment around a sub-sample of 374 public schools in which 26 655 students were enrolled. The outcome variable was JCL during the previous week, dichotomized into low JCL (none or once)v. high JCL (twice or more). Access to fast-food outlets near school was assessed using an existing database of fast-food outlets in Quebec. Covariates included student (age, sex and self-rated perceived health), family (familial status and parental education) and school (urban/rural status and deprivation) variables. Hierarchical logistic regression models were employed for analyses using PROC GLIMMIX of SAS version 9.3.

Setting

Province of Quebec, Canada.

Subjects

We used data from the Quebec Health Survey of High School Students (QHSHSS) 2010–11, a survey of secondary-school Quebec students.

Results

Exposure to two or more fast-food outlets within a radius of 750 m around schools was associated with a higher likelihood of excess JCL (OR=1·50; 95 % CI 1·28, 1·75), controlling for the characteristics of the students, their families and their schools.

Conclusions

The food environment surrounding schools can constitute a target for interventions to improve food choices among secondary-school children living in the province of Quebec. Transforming environments around schools to promote healthy eating includes modifying zoning regulations that restrict access to fast-food outlets around schools.

Effect of general health screening and lifestyle counselling on incidence of diabetes in general population: Inter99 randomised trial

We aimed to examine the effect of a large population-based multifactorial screening and lifestyle intervention programme on 10-year incidence of diabetes. In a randomised trial of the general Danish population initiated in 1999-2001 59,616 men and women aged 30-60years were assigned to a five year screening and lifestyle counselling programme (n=11,629) or control group (n=47,987) and followed for ten years in nationwide registers. Intention to treat was applied and risk of diabetes was modeled by Cox regression and expressed as hazard ratios (HRs). We found that 1692 individuals had diabetes at baseline. Among 57,924 individuals without diabetes at baseline, 1267 emigrated, 2593 died and 3369 (Intervention group=684, Control group=2685) developed diabetes. We saw no significant difference in diabetes incidence between the groups after 10-year follow-up (Grey's test: p=0.22). In the first year of follow-up, incidence of diabetes was significantly higher in the intervention group than the control group (HR=1.68, 95%CI 1.29 to 2.29). We observed no difference in incidence of diabetes between the groups in the follow-up intervals from 1 to 6years or after 6-10years (HR=0.94, 0.83 to 1.06; HR=1.03, 0.91 to 1.17). Inviting the general population to participate in a repeated screening and lifestyle counselling programme over five years did not result in lower incidence of diabetes after 10years of follow-up. As expected, significantly more individuals were diagnosed with diabetes in the intervention group during the first year, but this was not followed by a decrease in the following years.

TRIALS REGISTRATION

Clinical trials NCT00289237.

Untreated hypertension in the UK household population - Who are missed by the general health checks?

Hypertension is an age-related, long-term condition and a leading risk factor for premature death and disability worldwide. Due to its asymptomatic nature it can often be left undiagnosed. Long-term treatment is available, but blood pressure can also be reduced through health behaviour changes in weight control, smoking cessation, higher physical activity levels, reduced salt and alcohol intake, and healthful diets if discovered early. This paper investigates the prevalence and characteristics of those with untreated (compared to treated) hypertension who did not have a history of cardiovascular disease (CVD); a group who is in effect missed by general health checks. Untreated hypertension was studied in 8933 individuals aged 40-74 years representative of the UK household population, who were interviewed and underwent a physical health examination in their home, 2010-2012. The prevalence of untreated hypertension without a history of CVD was 7% for men, 2% for women, and 5% overall. Untreated hypertension was particularly high among the 55-64 year age group. Age and sex-adjusted analyses found strong positive associations with male gender, smoking, self-reported good-excellent health, full fat dairy preference, white bread preference, higher alcohol consumption, and living alone. Strong negative associations were found for possessing 5 + prescription drugs, statins or antiplatelets, being diagnosed with diabetes or possessing antidiabetics, and long-term limiting illness status. Notably, many reported their health as good to excellent. A fact which emphasises the importance of motivating individuals to take part in the general health checks for an asymptomatic condition such as hypertension.

Lifestyle and risk factor management in people at high cardiovascular risk from Bulgaria, Croatia, Poland, Romania and the United Kingdom who participated in both the EUROASPIRE III and IV primary care surveys

OBJECTIVE

The objective of this study was to determine time trends in the implementation of European guidelines on the management of cardiovascular disease prevention in people at high cardiovascular risk.

METHODS

Cardiovascular disease prevention as reflected in the primary care arms of the EUROASPIRE III and IV surveys were compared in centres from Bulgaria, Croatia, Poland, Romania and the United Kingdom that participated in both surveys. All patients were free of cardiovascular disease but considered at high cardiovascular disease risk since they had been started on blood pressure and/or lipid and/or glucose lowering treatments. They were interviewed and examined by means of standardized methods ≥6 months after the start of therapy.

RESULTS

EUROASPIRE III comprised 2604 and EUROASPIRE IV 3286 subjects whereof 76% and 56% were interviewed. There were no major differences between the two surveys in age, gender, centres and reasons for inclusion. The prevalence of smoking was similar between EUROASPIRE III and IV. The proportion of smokers who did not intend to quit was significantly greater in EUROASPIRE IV compared with III. The prevalence of overweight or obesity was high and identical in both surveys. No significant differences were observed in physical activity. In participants not on blood pressure lowering treatment an elevated blood pressure was observed in 47% in both EUROASPIRE III and IV. In participants not on lipid lowering drugs the low-density lipoprotein cholesterol was ≥2.5 mmol/l in 87% and 88% in EUROASPIRE III and IV respectively. In participants free from known diabetes fasting plasma glucose was ≥7 mmol/l in 12% and 18% in EUROASPIRE III and IV. In subjects with known arterial hypertension blood pressure was at or below guideline recommended targets in 28% in EUROASPIRE III and 35% in IV. In participants on lipid lowering drugs the low-density lipoprotein cholesterol was < 2.5 mmol/l in 28% and 37% in EUROASPIRE III and IV. Glycated haemoglobin was < 7.0% in participants with known diabetes in 62% and 60% in EUROASPIRE III and IV.

CONCLUSIONS

The results from EUROASPIRE III and IV clearly demonstrate that the control of modifiable risk factors in people at high cardiovascular disease risk remains poor.

Barriers to healthy eating in Switzerland: A nationwide study

BACKGROUND & AIMS

Several barriers can hinder healthy eating in the population. We aimed to assess the prevalence of self-reported barriers to healthy eating in Switzerland and examine their socioeconomic and demographic determinants.

METHODS

Using representative cross-sectional data from the Swiss Health Survey 2012, we assessed, separately by gender, the prevalence of ten barriers and their association with demographic and socioeconomic determinants; we used age- and multivariable-adjusted logistic regression and report the odds ratio for likelihood to identify each barrier according to each demographic and socioeconomic determinant.

RESULTS

The most prevalent barriers were "price" (43.2% in women, 35.8% in men), "daily habits, constraints" (39.8%, 37.5%), "fondness of good food" (38.8%, 51.0%), "time constraint" (34.8%, 29.0%) and "lack of willpower" (22.0%, 21.2%). Prevalence of most barriers decreased with age, increased for "fondness of good food" and remained constant for "price." After multivariable adjustment, obese participants were more likely to report "fondness of good food" [Odds ratio (95% confidence interval) for obese vs. normal weight women and men, respectively: 1.63 (1.38-1.91), 2.02 (1.72-2.38)]. Participants with lower education were more likely to report "fondness of good food" [mandatory vs. tertiary women and men, respectively: 1.93 (1.62-2.39), 1.51 (1.26-1.81)], but less likely to report "lack of willpower" [0.45 (0.38-0.55), 0.40 (0.33-0.49)] and "time constraint" [0.61 (0.51-0.73), 0.78 (0.63-0.96)]. Participants with lower income were more likely to report "price" [lowest vs. highest quartile for women and men, respectively, 1.65 (1.43-1.90), 1.47 (1.26-1.71)] but less likely to report "lack of willpower" [0.71 (0.61-0.82), 0.40 (0.33-0.49)]. Smoking, living situation, nationality and living area showed little or no association.

CONCLUSION

Several barriers to healthy eating were highly prevalent regardless of gender; the most important determinants were age, obesity, education, and income, with different effects per barrier. This requires multifaceted interventions to tackle several barriers simultaneously.

Cardiovascular health in Italy. Ten-year surveillance of cardiovascular diseases and risk factors: Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey 1998-2012

BACKGROUND

Surveillance of and monitoring trends for cardiovascular diseases and risk factors are relevant when we consider that these diseases and conditions are largely preventable. The aim of this paper is to assess time trends of cardiovascular diseases, lifestyles, risk factors and high risk conditions in different socioeconomic levels.

METHODS

Paired but independent population samples of men and women aged 35-74 years located in all 20 Italian regions were examined in 1998-2002 (n = 9612) and in 2008-2012 (n = 8141). Time trends of lifestyles, cardiovascular risk factors, prevalence of high-risk conditions and cardiovascular diseases are shown for two different socioeconomic levels, as assessed by educational level.

RESULTS

Over 10 years, in both genders and socioeconomic classes, the prevalence of smoking decreased (from 32% to 23% in men) as well as mean levels of blood pressure (systolic from 136 mmHg to 133 mmHg in men and from 132 mmHg to 127 mmHg in women), while the prevalence of dyslipidemia and obesity increased reaching 35% and 25% of the population respectively; the prevalence of myocardial infarction remained stable (1.6% in men; about 0.5% in women), that of stroke decreased in men (from 1.2% to 0.7%); the prevalence of diabetes did not change (12% in men; 8% in women). In the low educational class, cardiovascular risk factors and diseases remained unfavourable compared with the high educational class.

CONCLUSIONS

The burden of cardiovascular diseases and their risk factors remain high and require continuous appropriate action at the community and individual levels, as suggested by the European Guidelines for Cardiovascular Prevention.

Neighbourhood socioeconomic status and coronary heart disease in individuals between 40 and 50 years

OBJECTIVE

The incidence of myocardial infarction (MI) has decreased in general but not among younger middle-aged adults. We performed a cohort study of the association between neighbourhood socioeconomic status (SES) at the age of 40 and risk of MI before the age of 50 years.

METHODS

All individuals in Sweden were included in the year of their 40th birthday, if it occurred between 1998 and 2010. National registers were used to categorise neighbourhood SES into high, middle and low, and to retrieve information on incident MI and coronary heart disease (CHD). Cox regression models, adjusted for marital status, education level, immigrant status and region of residence, provided an estimate of the HRs and 95% CIs for MI or CHD.

RESULTS

Out of 587 933 men and 563 719 women, incident MI occurred in 2877 (0.48%) men and 932 (0.17%) women; and CHD occurred in 4400 (0.74%) men and 1756 (0.31%) women during a mean follow-up of 5.5 years. Using individuals living in middle-SES neighbourhoods as referents, living in high-SES neighbourhoods was associated with lower risk of MI in both sexes (HR (95% CI): men: 0.72 (0.64 to 0.82), women: 0.66 (0.53 to 0.81)); living in low-SES neighbourhoods was associated with a higher risk of MI (HR (95% CI): men: 1.31 (1.20 to 1.44), women: 1.28 (1.08 to 1.50)). Similar risk estimates for CHD were found.

CONCLUSIONS

The results of our study suggest an increased risk of MI and CHD among residents from low-SES neighbourhoods and a lower risk in those from high-SES neighbourhoods compared with residents in middle-SES neighbourhoods.

Healthy Lifestyle Interventions to Combat Noncommunicable Disease—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

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.

Healthy lifestyle interventions to combat noncommunicable disease-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

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.

Synthesis and biological evaluation of isoflavone amide derivatives with antihyperlipidemic and preadipocyte antiproliferative activities

A series of isoflavone amides were designed with isoflavone in place of the scaffold of 2-arylbenzoxazole as cholesterol ester transfer protein (CETP) inhibitors. Twelve new compounds were synthesized, and their inhibitory activities of CETP and preadipocyte proliferation were assayed. The hypolipidemic potency of the most effective compound HY-2c was further tested in vivo by hamster. The results indicate that HY-2c exhibited favorable antihyperlipidemic and preadipocyte antiproliferative activities.

Integrated preclinical cardiovascular prevention: a new paradigm to face growing challenges of cardiovascular disease

Cardiovascular disease (CVD) still represents the leading cause of mortality and morbidity worldwide. Despite considerable improvements in the prognosis of CVD and the significant reduction of CVD mortality obtained during the past half century, patients developing CVD, even though satisfactorily treated, still carry coronary artery disease and remain at risk for advanced CVD. Thus, the healthcare and socioeconomic burden linked to CVD remains high. As a result, more effective CVD prevention strategies remain crucial. 'Population strategies' and 'high-risk' approaches both have limitations and have often been viewed as alternative solutions. This persistent dualism could be overcome with the promotion of integrated prevention strategies based on a systematic evaluation of the total risk of disease, at both a population and an individual level. New approaches are also needed to reach people earlier in the course of the vascular disease and, possibly, to prevent risk factors and reduce CVD clinical manifestation.

Fruit and vegetable consumption and mortality in Eastern Europe: Longitudinal results from the Health, Alcohol and Psychosocial Factors in Eastern Europe study

BACKGROUND

It is estimated that disease burden due to low fruit and vegetable consumption is higher in Central and Eastern Europe (CEE) and the former Soviet Union (FSU) than any other parts of the world. However, no large scale studies have investigated the association between fruit and vegetable (F&V) intake and mortality in these regions yet.

DESIGN

The Health, Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE) study is a prospective cohort study with participants recruited from the Czech Republic, Poland and Russia.

METHODS

Dietary data was collected using food frequency questionnaire. Mortality data was ascertained through linkage with death registers. Multivariable adjusted hazard ratios were calculated by Cox regression models.

RESULTS

Among 19,333 disease-free participants at baseline, 1314 died over the mean follow-up of 7.1 years. After multivariable adjustment, we found statistically significant inverse association between cohort-specific quartiles of F&V intake and stroke mortality: the highest vs lowest quartile hazard ratio (HR) was 0.52 (95% confidence interval (CI): 0.28-0.98). For total mortality, significant interaction (p = 0.008) between F&V intake and smoking was found. The associations were statistically significant in smokers, with HR 0.70 (0.53-0.91, p for trend: 0.011) for total mortality, and 0.62 (0.40-0.97, p for trend: 0.037) for cardiovascular disease (CVD) mortality. The association was appeared to be mediated by blood pressure, and F&V intake explained a considerable proportion of the mortality differences between the Czech and Russian cohorts.

CONCLUSIONS

Our results suggest that increasing F&V intake may reduce CVD mortality in CEE and FSU, particularly among smokers and hypertensive individuals.

Reducing Cardiovascular and Cancer Risk: How to Address Global Primary Prevention in Clinical Practice

Emerging evidence suggesting the possibility that interventions able to prevent cardiovascular disease (CVD) may also be effective in the prevention of cancer have recently stimulated great interest in the medical community. In particular, data from both experimental and observational studies have demonstrated that aspirin may play a role in preventing different types of cancer. Although the use of aspirin in the secondary prevention of CVD is well established, aspirin in primary prevention is not systematically recommended because the absolute cardiovascular event reduction is similar to the absolute excess in major bleedings. By adding to its cardiovascular prevention benefits, the potential beneficial effect of aspirin in reducing the incidence of mortality and cancer could tip the balance between risks and benefits of aspirin therapy in primary prevention in favor of the latter and broaden the indication for treatment with aspirin in populations at average risk. Prospective and randomized studies are currently investigating the effect of aspirin in prevention of both cancer and CVD; however, clinical efforts at the individual level to promote the use of aspirin in global (or total) primary prevention already could be made on the basis of a balanced evaluation of the benefit/risk ratio.

Quantifying the contribution of statins to the decline in population mean cholesterol by socioeconomic group in England 1991 - 2012: a modelling study

Background

Serum total cholesterol is one of the major targets for cardiovascular disease prevention. Statins are effective for cholesterol control in individual patients. At the population level, however, their contribution to total cholesterol decline remains unclear. The aim of this study was to quantify the contribution of statins to the observed fall in population mean cholesterol levels in England over the past two decades, and explore any differences between socioeconomic groups.

Methods and Findings

This is a modelling study based on data from the Health Survey for England. We analysed changes in observed mean total cholesterol levels in the adult England population between 1991-92 (baseline) and 2011-12. We then compared the observed changes with a counterfactual ‘no statins’ scenario, where the impact of statins on population total cholesterol was estimated and removed. We estimated uncertainty intervals (UI) using Monte Carlo simulation, where confidence intervals (CI) were impractical. In 2011-12, 13.2% (95% CI: 12.5-14.0%) of the English adult population used statins at least once per week, compared with 1991-92 when the proportion was just 0.5% (95% CI: 0.3-1.0%). Between 1991-92 and 2011-12, mean total cholesterol declined from 5.86 mmol/L (95% CI: 5.82-5.90) to 5.17 mmol/L (95% CI: 5.14-5.20). For 2011-12, mean total cholesterol was lower in more deprived groups. In our ‘no statins’ scenario we predicted a mean total cholesterol of 5.36 mmol/L (95% CI: 5.33-5.40) for 2011-12. Statins were responsible for approximately 33.7% (95% UI: 28.9-38.8%) of the total cholesterol reduction since 1991-92. The statin contribution to cholesterol reduction was greater among the more deprived groups of women, while showing little socio-economic gradient among men.

Conclusions

Our model suggests that statins explained around a third of the substantial falls in total cholesterol observed in England since 1991. Approximately two thirds of the cholesterol decrease can reasonably be attributed non-pharmacological determinants.

Ten-year trends in major lifestyle risk factors using an ongoing population surveillance system in Australia

BACKGROUND

Understanding how risk factors (tobacco, alcohol, physical inactivity, unhealthy diet, high blood pressure, and high cholesterol) change over time is a critical aim of public health. The associations across the social gradient over time are important considerations. Risk factor surveillance systems have a part to play in understanding the epidemiological distribution of the risk factors so as to improve preventive measures and design public health interventions for reducing the burden of disease.

METHODS

Representative, cross-sectional data were collected in South Australia using telephone interviews, conducted on a minimum of 600 randomly selected people (of all ages) each month. Data were collected from January 2004 to December 2013. Unadjusted prevalence over time, the relative percentage change over the 10 years, and the absolute change of the risk factors with sex, age group, and socio-economic status (SES) estimates are presented.

RESULTS

In total 55,548 adults (≥18 years) were interviewed (mean age = 47.8 years, 48.8% male). Decreases were apparent for insufficient physical activity, inadequate fruit and vegetables, smoking, and soft drink consumption of ≥500 ml/day. Increases were found over the 10 years for obesity, high cholesterol, diabetes, and for those with no risk factors. Apparent differences were noticeable by different sex, age, and SES categories. While increases in physical activity and fruit and vegetable consumption and decreases in smoking prevalence and multiple risk factors are to be expected in 2020-2021, the prevalence of obesity, high blood pressure, high cholesterol, and diabetes are expected to increase.

CONCLUSIONS

Public health efforts in increasing the proportion of the population undertaking appropriate risk factor behavior are showing signs of success, with data from 2004 to 2013 showing encouraging trends. Deriving comparable trends over time by key demographics and SES variables provides evidence for policymakers and health planners to encourage interventions aimed at preventing chronic disease.

Reasons for (non)compliance with intervention following identification of 'high-risk' status in the NHS Health Check programme

Background

The Department of Health introduced a risk assessment, management and reduction programme, NHS Health Checks, which aimed to reduce premature morbidity and mortality from cardiovascular diseases for those aged 40–74. Those identified as at increased risk of CVD are offered prophylactic medication and lifestyle advice to reduce their risk. Health gains will only be achieved if patients are compliant with advice/intervention however. This study sought to understand factors that influenced adherence to medication and advice in ‘high-risk’ patients.

Methods

Qualitative data were collected through 29 semi-structured interviews with a purposive sample of individuals who had been identified as at high-risk of CVD. Participants had been offered lifestyle advice, lipid lowering medications and attended at least one annual review.

Results

Findings explore the challenges and experiences confronting ‘high-risk’ individuals when making decisions about engaging with intervention. Key findings explore: statin adherence, as well as adherence to advice about diet, physical activity, alcohol consumption and smoking cessation.

Conclusions

Attention needs to be paid to the way prophylactic medications are prescribed and explained to high-risk patients. Consistent provision of tailored lifestyle advice and access to appropriate services could facilitate sustained changes to factors that increase CVD risk.

Effect of screening and lifestyle counselling on incidence of ischaemic heart disease in general population: Inter99 randomised trial

OBJECTIVE

To investigate the effect of systematic screening for risk factors for ischaemic heart disease followed by repeated lifestyle counselling on the 10 year development of ischaemic heart disease at a population level.

DESIGN

Randomised controlled community based trial.

SETTING

Suburbs of Copenhagen, Denmark.

PARTICIPANTS

59,616 people aged 30-60 years randomised with different age and sex randomisation ratios to an intervention group (n = 11,629) and a control group (n = 47,987).

INTERVENTION

The intervention group was invited for screening, risk assessment, and lifestyle counselling up to four times over a five year period. All participants with an unhealthy lifestyle had individually tailored lifestyle counselling at all visits (at baseline and after one and three years); those at high risk of ischaemic heart disease, according to predefined criteria, were furthermore offered six sessions of group based lifestyle counselling on smoking cessation, diet, and physical activity. After five years all were invited for a final counselling session. Participants were referred to their general practitioner for medical treatment, if relevant. The control group was not invited for screening.

MAIN OUTCOME MEASURES

The primary outcome measure was incidence of ischaemic heart disease in the intervention group compared with the control group. Secondary outcome measures were stroke, combined events (ischaemic heart disease, stroke, or both), and mortality.

RESULTS

6091 (52.4%) people in the intervention group participated at baseline. Among 5978 people eligible at five year follow-up (59 died and 54 emigrated), 4028 (67.4%) attended. A total of 3163 people died in the 10 year follow-up period. Among 58,308 without a history of ischaemic heart disease at baseline, 2782 developed ischaemic heart disease. Among 58,940 without a history of stroke at baseline, 1726 developed stroke. No significant difference was seen between the intervention and control groups in the primary end point (hazard ratio for ischaemic heart disease 1.03, 95% confidence interval 0.94 to 1.13) or in the secondary endpoints (stroke 0.98, 0.87 to 1.11; combined endpoint 1.01, 0.93 to 1.09; total mortality 1.00, 0.91 to 1.09).

CONCLUSION

A community based, individually tailored intervention programme with screening for risk of ischaemic heart disease and repeated lifestyle intervention over five years had no effect on ischaemic heart disease, stroke, or mortality at the population level after 10 years.Trial registration Clinical trials NCT00289237.

Temporal changes in the attitude towards smoking bans in public arenas among adults in the Capital Region of Denmark from 2007 to 2010

AIM

The population's attitude towards smoking bans in public arenas is important for their passing, implementation and compliance. Smoking bans are believed to reduce the social acceptability of smoking, and once people experience them, public support increases--also among pre-ban sceptics. This study aimed to examine the temporal changes in public attitude towards smoking bans in public arenas from 2007 to 2010 and whether these changes differed across educational attainment, smoking status and intention to quit among smokers.

METHODS

Data from two surveys among adults (aged 25-79 years) in 2007 and 2010 in the Capital Region of Denmark (n=36,472/42,504, response rate = 52.3) was linked with data on sex, age and educational attainment from central registers. Age-standardised prevalence of supportive attitude towards smoking bans was estimated. Temporal changes in supportive attitude were explored in workplaces, restaurants and bars using logistic regression models.

RESULTS

The prevalence of supportive attitude towards smoking bans increased significantly in all arenas from 2007 to 2010. Positive temporal changes in supportive attitude towards smoking bans were seen across educational attainment, smoking status and intention to quit smoking in restaurants and across smoking status for smoking bans in workplaces and bars.

CONCLUSIONS

The results of this study show that the public's attitude towards smoking in public arenas has changed after the implementation of a comprehensive smoking ban. This change in attitude can support implementation of future legislation on smoking and may lead to positive changes in smoking norms.

Managing sedentary behavior to reduce the risk of diabetes and cardiovascular disease

Modern human environments are vastly different from those of our forebears. Rapidly advancing technology in transportation, communications, workplaces, and home entertainment confer a wealth of benefits, but increasingly come with costs to human health. Sedentary behavior-too much sitting as distinct from too little physical activity-contributes adversely to cardiometabolic health outcomes and premature mortality. Findings from observational epidemiology have been synthesized in meta-analyses, and evidence is now shifting into the realm of experimental trials with the aim of identifying novel mechanisms and potential causal relationships. We discuss recent observational and experimental evidence that makes a compelling case for reducing and breaking up prolonged sitting time in both the primary prevention and disease management contexts. We also highlight future research needs, the opportunities for developing targeted interventions, and the potential of population-wide initiatives designed to address too much sitting as a health risk.

Ecologic correlations of selected food groups with disease incidence and mortality in Switzerland

BACKGROUND

There is little information regarding the impact of diet on disease incidence and mortality in Switzerland. We assessed ecologic correlations between food availability and disease.

METHODS

In this ecologic study for the period 1970-2009, food availability was measured using the food balance sheets of the Food and Agriculture Organization of the United Nations. Standardized mortality rates (SMRs) were obtained from the Swiss Federal Office of Statistics. Cancer incidence data were obtained from the World Health Organization Health For All database and the Vaud Cancer Registry. Associations between food availability and mortality/incidence were assessed at lags 0, 5, 10, and 15 years by multivariate regression adjusted for total caloric intake.

RESULTS

Alcoholic beverages and fruit availability were positively associated, and fish availability was inversely associated, with SMRs for cardiovascular diseases. Animal products, meat, and animal fats were positively associated with the SMR for ischemic heart disease only. For cancer, the results of analysis using SMRs and incidence rates were contradictory. Alcoholic beverages and fruits were positively associated with SMRs for all cancer but inversely associated with all-cancer incidence rates. Similar findings were obtained for all other foods except vegetables, which were weakly inversely associated with SMRs and incidence rates. Use of a 15-year lag reversed the associations with animal and vegetal products, weakened the association with alcohol and fruits, and strengthened the association with fish.

CONCLUSIONS

Ecologic associations between food availability and disease vary considerably on the basis of whether mortality or incidence rates are used in the analysis. Great care is thus necessary when interpreting our results.

Traffic-related air pollution and noise and children's blood pressure: results from the PIAMA birth cohort study

AIMS

Elevation of a child's blood pressure may cause possible health risks in later life. There is evidence for adverse effects of exposure to air pollution and noise on blood pressure in adults. Little is known about these associations in children. We investigated the associations of air pollution and noise exposure with blood pressure in 12-year-olds.

METHODS

Blood pressure was measured at age 12 years in 1432 participants of the PIAMA birth cohort study. Annual average exposure to traffic-related air pollution [NO2, mass concentrations of particulate matter with diameters of less than 2.5 µm (PM2.5) and less than 10 µm (PM10), and PM2.5 absorbance] at the participants' home and school addresses at the time of blood pressure measurements was estimated by land-use regression models. Air pollution exposure on the days preceding blood pressure measurements was estimated from routine air monitoring data. Long-term noise exposure was assessed by linking addresses to modelled equivalent road traffic noise levels. Associations of exposures with blood pressure were analysed by linear regression. Effects are presented for an interquartile range increase in exposure.

RESULTS

Long-term exposure to NO2 and PM2.5 absorbance were associated with increased diastolic blood pressure, in children who lived at the same address since birth [adjusted mean difference (95% confidence interval) [mmHg] 0.83 (0.06 to 1.61) and 0.75 (-0.08 to 1.58), respectively], but not with systolic blood pressure. We found no association of blood pressure with short-term air pollution or noise exposure.

CONCLUSIONS

Long-term exposure to traffic-related air pollution may increase diastolic blood pressure in children.

Association between neighbourhood green space and sedentary leisure time in a Danish population

Aim: Sedentary behaviour is a risk factor for diabetes, cardiovascular disease etc., independently of level of physical activity. Availability of recreational green space is associated with physical activity, but is unknown in relation to sedentary behaviour. The aim of this study is to examine the association between availability of green space and sedentary leisure time in a Danish population. Methods: The study was based on a random sample of 49,806 adults aged 16 + who answered a questionnaire in 2010, including sedentary leisure time. Objective measures of density green were calculated for each respondent using Geographical Information System (GIS). A multilevel regression analysis, taking neighbourhood and individual factors into account, was performed. Results: 65% of the respondents were sedentary in leisure time for more than 3h/day. We found that poor availability of forest and recreational facilities in the neighbourhood is associated with more sedentary leisure time; OR: 1.11 (95% CL: 1.04–1.19), after adjusting for individual, and neighbourhood, level characteristics. Conclusions: Among adult inhabitants, sedentary leisure time of more than 3h/day was more frequent in neighbourhoods with less green surroundings. Intervention efforts may benefit from emphasising the importance of having recreations options in residential areas to provide alternatives to sedentary activities.