Investing in non-communicable disease risk factor control among adolescents worldwide: a modelling study

The FRESHAIR4Life study: Global implementation research on non-communicable disease prevention targeting adolescents' exposure to tobacco and air pollution in disadvantaged populations

The FRESHAIR4Life study aims to reduce the non-communicable disease (NCD) burden by implementing preventive interventions targeting adolescents' exposure to tobacco use and air pollution (AP) worldwide. This paper presents the FRESHAIR4Life methodology and initial rapid review results. The rapid review, using various databases and PubMed, aimed to guide decision-making on risk factor focus, target areas, and populations. It showed variable NCD mortality rates related to tobacco use and AP across the participating countries, with tobacco as the main risk factor in the Kyrgyz Republic, Greece, and Romania, and AP prevailing in Pakistan and Uganda. Adolescent exposure levels, sources, and correlates varied. The study will continue with an in-depth situational analysis to guide the selection, adaptation, and integration of evidence-based interventions into the FRESHAIR4Life prevention package. This package will be implemented, evaluated, assessed for cost-effectiveness, and iteratively refined. The research places a strong emphasis on co-creation, capacity building, and comprehensive communication and dissemination.

Health and economic burden of insufficient physical activity in Saudi Arabia

BACKGROUND

Insufficient physical activity (PA) was estimated to cause 4.8% of deaths and 2.6% of disability-adjusted life-years (DALYs) due to noncommunicable diseases in Saudi Arabia in 2019. While Saudi Arabia is already achieving great improvements, we predict the health and economic burden of insufficient PA up to 2040 to present a case for policy makers to invest more in the uptake of PA.

METHODS

Using a population health model to estimate avoidable health loss, we identified four causes of health loss related to low PA (cardiovascular diseases, diabetes, breast cancer, and colorectal cancer) and estimated the deaths and DALYs from these causes. We projected the expected disease burden until 2040 under alternative assumptions about future PA levels and trends by using three health scenarios: baseline (no change in 2019 PA levels), intervention (81% of the population achieving sufficient PA levels), and ideal (65% of population: moderate PA, 30%: high PA, and 5%: inactive). We applied an "intrinsic value" approach to estimate the economic impact of each scenario.

RESULTS

Overall, we estimate that between 2023 and 2040, about 80,000 to 110,000 deaths from all causes and 2.0 million to 2.9 million DALYs could be avoided by increasing PA levels in Saudi Arabia. The average annual economic loss from insufficient PA is valued at 0.49% to 0.68% of the current gross domestic product, with an average of US$5.4 billion to US$7.6 billion annually till 2040. The most avoidable disease burden and economic losses are expected among males and because of ischemic heart disease.

CONCLUSIONS

This study highlights that low PA levels will have considerable health and economic impacts in Saudi Arabia if people remain inactive and do not start following interventions. There is an urgent need to develop innovative programs and policies to encourage PA among all age and sex groups.

Acceptability and perceived feasibility of the KaziKidz health promotion intervention among educators and caregivers in schools from South Africa: a qualitative descriptive study

BACKGROUND

Despite the uncontested benefits of physical activity, its promotion lags behind in the public health agenda of low- and middle-income countries (LMICs). School-based interventions are promising strategies to foster health during childhood, but evidence of their effectiveness is limited and inconclusive for LMICs. Thus, further investigation is needed on contextual factors associated with intervention implementation in low-resource settings. We studied the acceptability and feasibility of the KaziKidz health promotion intervention and its implementation and make recommendations to improve future adoption and sustainability.

METHODS

KaziKidz was implemented in four primary schools from low-income communities in South Africa in 2019. Semi-structured interviews with four school principals, three focus group interviews with 16 educators, and another three with 16 caregivers were conducted between October and November 2021. Participants were purposively recruited. Interview transcripts were analyzed via thematic analysis using a deductive and reflexive approach.

RESULTS

Three main themes influencing intervention implementation and adoption were identified: (1) prioritizing teachers' needs (2), integrating the program into the school structure, and (3) creating opportunities in the community. Supporting recommendations included: (theme 1) adopting intervention approaches that are inclusive of educators' health and providing them with capacity development and external support; (theme 2) fostering a feeling of ownership and belonging among school stakeholders to adapt interventions to specific resources and needs; and (theme 3) raising community awareness to encourage individuals to claim power over and actively engage with the program.

CONCLUSIONS

Comprehensive interventions comprising health support, adequate training, and ongoing assistance for educators combined with school-wide and community outreach actions seeking to strengthen program ownership, accountability, and engagement can enhance uptake of school-based interventions and long-term maintenance.

TRIAL REGISTRATION

ISRCTN15648510, registered on 17/04/2020.

Knowledge, attitudes, and practices regarding cardiovascular disease prevention among middle school students in China: a cross-sectional study

Background

The prevalence of cardiovascular disease (CVD) is rapidly increasing globally. With a concerning increase among adolescents due to unhealthy habits, obesity, and hypertension, understanding the current status of knowledge, attitudes, and practices (KAP) related to CVD prevention among middle school students is crucial for developing effective school-based health programs to prevent CVD.

Methods

The analytic cross-sectional survey is used in questionnaires to assess KAP related to CVD prevention among middle school students (N = 17,731) from 50 schools across 16 provinces in China in June-July 2023. The pass rate of KAP scores is categorized as good and poor. Independent predictors of good KAP of CVD prevention are ascertained using a binary logistic regression model.

Results

The study surveyed 8,118 (45.78%) junior high school students and 9,613 (54.22%) high school students. The overall mean [standard deviation (SD)] for the knowledge, attitude, and practice scores were 26.88 (8.12), 53.53 (7.22), and 39.80 (5.96), respectively. The knowledge scores had the lowest pass rate at 56.89%. Only 6.83% of the students know "the definition of blood pressure in adolescents." Attitudes toward health were positive, though the attitude regarding "the danger of prolonged sedentary to cardiovascular health" scored lowest at 73.55%. The practice section had a pass rate of 89.30%; 40.27% of students reported that they spend more than an hour a day on screens. Only one-third of the students would go to bed before 12 o'clock. In univariate analysis, junior high school and high school students differed significantly in knowledge and practice (p < 0.001), but attitude did not differ significantly (p = 0.103).

Conclusion

The majority of students lack sufficient knowledge about CVD. It is also found that socioeconomic background, family environment, and educational levels have an impact on cardiovascular health behaviors among students. Strengthening health education involving students, parents, teachers, and communities is essential to promote health knowledge and practices among adolescents.

Effectiveness of a participatory approach to develop school health interventions in four low resource cities: study protocol of the 'empowering adolescents to lead change using health data' cluster randomised controlled trial

INTRODUCTION

Comprehensive local data on adolescent health are often lacking, particularly in lower resource settings. Furthermore, there are knowledge gaps around which interventions are effective to support healthy behaviours. This study generates health information for students from cities in four middle-income countries to plan, implement and subsequently evaluate a package of interventions to improve health outcomes.

METHODS AND ANALYSIS

We will conduct a cluster randomised controlled trial in schools in Fez, Morocco; Jaipur, India; Saint Catherine Parish, Jamaica; and Sekondi-Takoradi, Ghana. In each city, approximately 30 schools will be randomly selected and assigned to the control or intervention arm. Baseline data collection includes three components. First, a Global School Health Policies and Practices Survey (G-SHPPS) to be completed by principals of all selected schools. Second, a Global School-based Student Health Survey (GSHS) to be administered to a target sample of n=3153 13-17 years old students of randomly selected classes of these schools, including questions on alcohol, tobacco and drug use, diet, hygiene, mental health, physical activity, protective factors, sexual behaviours, violence and injury. Third, a study validating the GSHS physical activity questions against wrist-worn accelerometry in one randomly selected class in each control school (n approximately 300 students per city). Intervention schools will develop a suite of interventions using a participatory approach driven by students and involving parents/guardians, teachers and community stakeholders. Interventions will aim to change existing structures and policies at schools to positively influence students' behaviour, using the collected data and guided by the framework for Making Every School a Health Promoting School. Outcomes will be assessed for differential change after a 2-year follow-up.

ETHICS AND DISSEMINATION

The study was approved by WHO's Research Ethics Review Committee; by the Jodhpur School of Public Health's Institutional Review Board for Jaipur, India; by the Noguchi Memorial Institute for Medical Research Institutional Review Board for Sekondi-Takoradi, Ghana; by the Ministry of Health and Wellness' Advisory Panel on Ethics and Medico-Legal Affairs for St Catherine Parish, Jamaica, and by the Comité d'éthique pour la recherche biomédicale of the Université Mohammed V of Rabat for Fez, Morocco. Findings will be shared through open access publications and conferences.

TRIAL REGISTRATION NUMBER

NCT04963426.

Intervention effects and long-term changes in physical activity and cardiometabolic outcomes among children at risk of noncommunicable diseases in South Africa: a cluster-randomized controlled trial and follow-up analysis

Introduction

Risk factors for noncommunicable diseases such as insufficient physical activity (PA), overweight or hypertension are becoming increasingly predominant among children globally. While school-based interventions are promising preventive strategies, evidence of their long-term effectiveness, especially among vulnerable populations, is scarce. We aim to assess the short-term effects of the physical and health KaziKidz intervention on cardiometabolic risk factors and the long-term, pre-and post-COVID-19 pandemic changes thereof in high-risk children from marginalized communities.

Methods

The intervention was tested in a cluster-randomized controlled trial between January and October 2019 in eight primary schools near Gqeberha, South Africa. Children with overweight, elevated blood pressure, pre-diabetes, and/or borderline dyslipidemia were identified and re-assessed 2 years post-intervention. Study outcomes included accelerometry-measured PA (MVPA), body mass index (BMI), mean arterial pressure (MAP), glucose (HbA1c), and lipid levels (TC to HDL ratio). We conducted mixed regression analyses to assess intervention effects by cardiometabolic risk profile, and Wilcoxon signed-rank tests to evaluate longitudinal changes in the high-risk subpopulation.

Results

We found a significant intervention effect on MVPA during school hours for physically inactive children, and among active as well as inactive girls. In contrast, the intervention lowered HbA1c and TC to HDL ratio only in children with glucose or lipid values within the norm, respectively. At follow-up, the intervention effects were not maintained in at-risk children, who showed a decline in MVPA, and an increase in BMI-for-age, MAP, HbA1c and TC to HDL ratio.

Conclusion

We conclude that schools are key settings in which to promote PA and improve health; however, structural changes are necessary to ensure that effective interventions reach marginalized school populations and achieve sustainable impact.

Economic effects of healthy ageing: functional limitation, forgone wages, and medical and long-term care costs

This study aims to estimate the potential economic benefits of healthy ageing by obtaining estimates of the economic losses generated by functional limitations among middle-aged and older people. Utilising two data sources retrieved from nationally representative samples of the Japanese people, we analysed the association between functional limitation and economic indicators, including labour market outcomes, savings, investment, consumption, and unpaid activities among individuals aged ≥ 60. Using the estimated parameters from our micro-econometric analyses and the official statistics by the Japanese government and a previous study, we calculated the financial costs that can be averted if healthy ageing is achieved as foregone wages and formal medical/long-term care costs incurred by functional limitations. Our micro-econometric analyses found that functional limitation was associated with a 3% point increase in retirement probability, with a stronger association among those aged 60-69. Moreover, functional limitation was linked with higher total health spending and less active involvement in domestic work. Foregone wages generated by functional limitation were estimated to be approximately USD 266.4 million, driven mainly by individuals in their 60s. Long-term care costs, rather than medical care costs, for older people aged ≥ 85 accounted for most of the additional costs, indicating that the estimated medical and long-term costs generated by functional limitations were approximately USD 72.7 billion. Health interventions can yield economic benefits by preventing exits from the labour market due to health issues and reducing medical and long-term care costs.

Food Outlet Access and the Healthiness of Food Available ‘On-Demand’ via Meal Delivery Apps in New Zealand

Access to unhealthy commodities is a key factor determining consumption, and therefore influences the prevalence of non-communicable diseases. Recently, there has been an increase in the availability of food ‘on-demand’ via meal delivery apps (MDAs). However, the public health and equity impacts of this shift are not yet well understood. This study focused on three MDAs in New Zealand and aimed to answer (1) what is the health profile of the foods being offered on-demand, (2) how many food outlets are available and does this differ by physical access or neighbourhood demographics and (3) does the health profile of foods offered differ by physical access or neighbourhood demographics? A dataset was created by sampling a set of street addresses across a range of demographic variables, and recording the menu items and number of available outlets offered to each address. Machine learning was utilised to evaluate the healthiness of menu items, and we examined if healthiness and the number of available outlets varied by neighbourhood demographics. Over 75% of menu items offered by all MDAs were unhealthy and approximately 30% of all menu items across the three MDAs scored at the lowest level of healthiness. Statistically significant differences by demographics were identified in one of the three MDAs in this study, which suggested that the proportion of unhealthy foods offered was highest in areas with the greatest socioeconomic deprivation and those with a higher proportion of Māori population. Policy and regulatory approaches need to adapt to this novel mode of access to unhealthy foods, to mitigate public health consequences and the effects on population groups already more vulnerable to non-communicable diseases.

Prevalence of multiple non-communicable diseases risk factors among adolescents in 140 countries: A population-based study

BACKGROUND

Modifiable non-communicable disease (NCD) risk factors are becoming increasingly common among adolescents, with clustering of these risk factors in individuals of particular concern. The aim of this study was to assess global status of clustering of common modifiable NCD risk factors among adolescents.

METHODS

We used latest available data from nationally representative survey for 140 countries, namely the Global School-based Student Health Survey, the Health Behaviour in School-Aged Children and the longitudinal study of Australian Children. Weighted mean estimates of prevalence with corresponding 95% confidence intervals of nine NCD risk factors - physical inactivity, sedentary behaviour, insufficient fruits and vegetable consumption, carbonated soft drink consumption, fast food consumption, tobacco use, alcohol consumption and overweight/obesity - were calculated by country, region and sex.

FINDINGS

Over 487,565 adolescents, aged 11-17 years, were included in this study. According to trend analysis, prevalence of four or more NCD risk factors increased gradually over time. Prevalence of four or more NCD risk factors was 14.8% in 2003-2007 and increased to 44% in 2013-2017, an approximately three-fold increase (44.0%). Similar trends were also observed for three and two risk factors. Large variation between countries in the prevalence of adolescents with four or more risk factors was found in all regions. The country level range was higher in the South-East Asia Region (minimum Sri Lanka = 8%, maximum Myanmar = 84%) than Western Pacific Region (minimum China = 3%, maximum Niue = 72%), European Region (minimum Sweden = 13.9%, maximum Ireland = 66.0%), African Region (minimum Senegal = 0.8%, maximum Uganda = 82.1%) and Eastern Mediterranean Region (minimum Libya = 0.2%, maximum Lebanon = 80.2%). Insufficient vegetable consumption, insufficient fruit consumption and physically inactivity were three of the four most prevalent risk factors in all regions.

INTERPRETATION

Our results suggest a high prevalence of four or more NCD risk factors in adolescents globally, although variation was found between countries. Results from our study indicate that efforts to reduce adolescent NCD risk factors and the associated health burden need to be improved. These findings can assist policy makers to target the rollout of country- specific interventions.

FUNDING

None.

The global return on investment from preventing and treating adolescent mental disorders and suicide: a modelling study

INTRODUCTION

Despite the high burden of mental disorders among adolescents and the potentially lifelong consequences of these conditions, access to mental health services remains insufficient for adolescents in low-income and middle-income countries. We conducted an economic modelling study to quantify the potential costs and benefits of mental health interventions to prevent or treat anxiety, depression, bipolar disorder, and suicide among adolescents.

METHODS

We developed a Markov model that followed cohorts of adolescents (ages 10-19) from 36 countries to assess the impact of addressing anxiety, depression, bipolar disorder, and suicide during adolescence on health and non-health outcomes through their lives. We estimated the costs of interventions using an ingredients-based approach and modelled impacts on education and employment and the resulting economic, morbidity, and mortality benefits.

RESULTS

Implementing the selected interventions offers a return on investment of 23.6 and a cost of $102.9 per disability adjusted life year (DALY) averted over 80 years. The high return on investment and low cost per DALY averted is observed across regions and country income levels, with the highest return on investment arising from treating mild depression with group-based cognitive behavioural therapy, prevention of suicide attempts among high-risk adolescents, and universal prevention of combined anxiety and depression in low-income and lower-middle income countries.

CONCLUSIONS

The high return on investment and low cost per DALY averted suggests the importance and value of addressing mental disorders among adolescents worldwide. Intervening to prevent and treat these mental disorders even only during adolescence can have lifelong health and economic benefits.

Prevention and Management of High-Burden Noncommunicable Diseases in School-Age Children: A Systematic Review

BACKGROUND AND OBJECTIVES

Noncommunicable diseases (NCDs) are chronic conditions requiring health care, education, social and community services, addressing prevention, treatment, and management. This review aimed to summarize and synthesize the available evidence on interventions from systematic reviews of high-burden NCDs and risk factors among school-aged children.

METHODS

The following databases were used for this research: Medline, Embase, The Cochrane Library, and the Campbell library. The search dates were from 2000 to 2021. We included systematic reviews that synthesized studies to evaluate intervention effectiveness in children aged 5 to 19 years globally. Two reviewers independently extracted data and assessed methodological quality of included reviews using the AMSTAR 2 tool.

RESULTS

Fifty studies were included. Asthma had the highest number of eligible reviews (n = 19). Of the reviews reporting the delivery platform, 27% (n = 16) reported outpatient settings, 13% (n = 8) home and community-based respectively, and 8% (n = 5) school-based platforms. Included reviews primarily (69%) reported high-income country data. This may limit the results' generalizability for school-aged children and adolescents in low- and middle- income countries.

CONCLUSIONS

School-aged children and adolescents affected by NCDs require access to quality care, treatment, and support to effectively manage their diseases into adulthood. Strengthening research and the capacity of countries, especially low- and middle- income countries, for early screening, risk education and management of disease are crucial for NCD prevention and control.

NCD Countdown 2030: efficient pathways and strategic investments to accelerate progress towards the Sustainable Development Goal target 3.4 in low-income and middle-income countries

Most countries have made little progress in achieving the Sustainable Development Goal (SDG) target 3.4, which calls for a reduction in premature mortality from non-communicable diseases (NCDs) by a third from 2015 to 2030. In this Health Policy paper, we synthesise the evidence related to interventions that can reduce premature mortality from the major NCDs over the next decade and that are feasible to implement in countries at all levels of income. Our recommendations are intended as generic guidance to help 123 low-income and middle-income countries meet SDG target 3.4; country-level applications require additional analyses and consideration of the local implementation and utilisation context. Protecting current investments and scaling up these interventions is especially crucial in the context of COVID-19-related health system disruptions. We show how cost-effectiveness data and other information can be used to define locally tailored packages of interventions to accelerate rates of decline in NCD mortality. Under realistic implementation constraints, most countries could achieve (or almost achieve) the NCD target using a combination of these interventions; the greatest gains would be for cardiovascular disease mortality. Implementing the most efficient package of interventions in each world region would require, on average, an additional US$18 billion annually over 2023-30; this investment could avert 39 million deaths and generate an average net economic benefit of $2·7 trillion, or $390 per capita. Although specific clinical intervention pathways would vary across countries and regions, policies to reduce behavioural risks, such as tobacco smoking, harmful use of alcohol, and excess sodium intake, would be relevant in nearly every country, accounting for nearly two-thirds of the health gains of any locally tailored NCD package. By 2030, ministries of health would need to contribute about 20% of their budgets to high-priority NCD interventions. Our report concludes with a discussion of financing and health system implementation considerations and reflections on the NCD agenda beyond the SDG target 3.4 and beyond the SDG period.

Prevalence of Excessive Weight and Underweight and Its Associated Knowledge and Lifestyle Behaviors among Urban Private School-Going Adolescents in New Delhi

With rapid urbanization and the Indian nutrition transition, Indian adolescents face a high risk of developing an energy imbalance. This study aims to assess the prevalence of excessive weight, underweight, and associated knowledge and lifestyle behaviors among private school-going adolescents in Delhi. A cross-sectional study was conducted in students (6th–7th grades) of eight randomly selected private schools in Delhi, India in 2019. A self-administered survey was used to assess students’ dietary-and-physical-activity-related knowledge and behavior. Anthropometric measurements (height, weight, and waist circumference) were also conducted. Out of 1567 participants, 7.2% were underweight, 61.3% normal, and 31.5% excess in weight. Underweight was associated with significantly more eating whilst studying for exams (relative risk ratio (RRR) 1.7 (1.0–2.9)). Excessive weight was associated with less incorrect knowledge on behaviors causing overweight (RRR 0.7 (0.5–0.9)), more often reading nutritional labels of packed food items (RRR 0.6 (0.4–0.9)), and less frequent vegetable-intake (RRR 0.7 (0.4–0.9)). Underweight students showed more suboptimal knowledge and unhealthy behaviors, whilst students with excessive weight showed more correct knowledge and healthy behaviors. This study highlights the immediate need for effective health-promoting interventions focused on the importance of healthy lifestyle at least in underweight adolescents.

Knowledge, attitude, and behaviours on diet, physical activity, and tobacco use among school students: A cross-sectional study in two Indian states

Background: Non-communicable diseases (NCDs) are escalating in India and can be attributed to behavioural risk factors such as unhealthy diet, physical inactivity and tobacco use that began in early years. Understanding adolescents' knowledge, attitudes and behaviours (KAB) related to NCD risk factors would inform the development of school-based health programmes to prevent NCDs. Methods: Sixth-grade students (n=1026) in 20 schools (10 private, 10 public) from two Indian cities (n=667 from Pune; n=359 from Bengaluru) participated in a KAB survey in 2019. Differences in KAB by gender, school type within cities were investigated. Results: Knowledge about the harms of tobacco use was higher than knowledge about a healthy diet and importance of physical activity. Only a small proportion of students did not eat breakfast (8.7%) or fruits (11.3%) daily. Only 33.4% of students read nutrition labels before choosing their food. Moderate-to-vigorous physical activity of less than an hour per day was reported by 42.5% of students. Approximately one-third of students had ever tried smoking tobacco (30.1%), smokeless tobacco (30.5%), and e-cigarettes (32.4%). Differences in these behaviours by gender and school type showed that both boys, girls and students of private and public schools are vulnerable. Conclusions: The study findings highlight that knowledge is low for thematic areas like diet and physical activity. While knowledge of tobacco related harms is better but the prevalence of ever tobacco use was found to be high. Socio-demographic factors such as school type and gender had a varying effect on various KAB indicators. There is a need to strengthen health education activities by developing context-specific health intervention materials by engaging school children, their parents, teachers, and communities to promote healthy behaviours among adolescents. Need to augment school health programmes in India with a differential approach based on the issues, specific to school type and city.

Knowledge, attitude, and behaviours on diet, physical activity, and tobacco use among school students: A cross-sectional study in two Indian states

Background: Non-communicable diseases (NCDs) are escalating in India and can be attributed to behavioural risk factors such as unhealthy diet, physical inactivity and tobacco use that began in early years. Understanding adolescents' knowledge, attitudes and behaviours (KAB) related to NCD risk factors would inform the development of school-based health programmes to prevent NCDs. Methods: Sixth-grade students (n=1026) in 20 schools (10 private, 10 public) from two Indian cities (n=667 from Pune; n=359 from Bengaluru) participated in a KAB survey in 2019. Differences in KAB by gender, school type within cities were investigated. Results: Knowledge about the harms of tobacco use was higher than knowledge about a healthy diet and the importance of physical activity. Only a small proportion of students did not eat breakfast (8.7%) or fruits (11.3%) daily. Only 33.4% of students read nutrition labels before choosing their food. Moderate-to-vigorous physical activity of less than an hour per day was reported by 42.5% of students. Approximately one-third of students had ever tried smoking tobacco (30.1%), smokeless tobacco (30.5%), and e-cigarettes (32.4%). Differences in these behaviours by gender and school type showed that both boys, girls and students of private and public schools are vulnerable. Conclusions: The findings highlight that knowledge is low for thematic areas like diet and physical activity. Low knowledge can be attributed to unfavourable behaviours like lack of reading nutrition labels and indulgence in sedentary activities. To protect India's young population (adolescents), there is a need to amplify health education activities and context-specific health intervention materials for them by engaging parents and communities. Thus, these programmes should be incorporated into the curriculum as part of the regular teaching, as they may induce positive changes in their knowledge and behaviours. In India, school health programmes should dedicate significant time to health promotion and NCD risk prevention.

The interplay of Western diet and binge drinking on the onset, progression, and outlook of liver disease

Non-alcoholic fatty liver disease and alcoholic liver disease, the two most prevalent liver diseases worldwide, share a common pathology but have largely been considered disparate diseases. Liver diseases are widely underestimated, but their prevalence is increasing worldwide. The Western diet (high-fat, high-sugar) and binge drinking (rapid consumption of alcohol in a short period of time) are two highly prevalent features of standard life in the United States, and both are linked to the development and progression of liver disease. Yet, few studies have been conducted to elucidate their potential interactions. Data shows binge drinking is on the rise in several age groups, and poor dietary trends continue to be prevalent. This review serves to summarize the sparse findings on the hepatic consequences of the combination of binge drinking and consuming a Western diet, while also drawing conclusions on potential future impacts. The data suggest the potential for a looming liver disease epidemic, indicating that more research on its progression as well as its prevention is needed on this critical topic.

Proactive prevention: Act now to disrupt the impending non-communicable disease crisis in low-burden populations

Non-communicable disease (NCD) prevention efforts have traditionally targeted high-risk and high-burden populations. We propose an alteration in prevention efforts to also include emphasis and focus on low-risk populations, predominantly younger individuals and low-prevalence populations. We refer to this approach as "proactive prevention." This emphasis is based on the priority to put in place policies, programs, and infrastructure that can disrupt the epidemiological transition to develop NCDs among these groups, thereby averting future NCD crises. Proactive prevention strategies can be classified, and their implementation prioritized, based on a 2-dimensional assessment: impact and feasibility. Thus, potential interventions can be categorized into a 2-by-2 matrix: high impact/high feasibility, high impact/low feasibility, low impact/high feasibility, and low impact/low feasibility. We propose that high impact/high feasibility interventions are ready to be implemented (act), while high impact/low feasibility interventions require efforts to foster buy-in first. Low impact/high feasibility interventions need to be changed to improve their impact while low impact/low feasibility might be best re-designed in the context of limited resources. Using this framework, policy makers, public health experts, and other stakeholders can more effectively prioritize and leverage limited resources in an effort to slow or prevent the evolving global NCD crisis.

Distributional equity as a consideration in economic and modelling evaluations of health taxes: A systematic review

PURPOSE/SETTING

The extent to which distributional equity is incorporated into evaluations of the (potential or observed) impact of health taxes is unclear. This systematic review of economic and modelling evaluations investigating taxation on tobacco, sugar-sweetened-beverages (SSBs), or alcohol aims to assess the proportion that have considered distributional impact by income or socioeconomic group. Secondary aims included summarising the reported distributional impacts, for both costs and health benefits.

FINDINGS

Of 4656 search results, 69 studies were included. The majority were economic analyses with epidemiological modelling, with studies on SSB taxes being of the highest quality. Tobacco was most commonly investigated tax, with 37 evaluations. Of these, 12 (32 %) considered distributional equity, with six (27 %) of 22 included SSB evaluations doing the same, and none for alcohol. A tobacco tax favoured lowerincome groups in the distribution of costs in all identified evaluations and for health benefits in nine out of 12 evaluations (75 %). For SSBs, four evaluations (67 %) found costs to favour low-income groups, with three (50 %) for health benefits.

CONCLUSIONS

Despite recommendations, evaluations of health taxes do not routinely consider the distributional impact of both costs and health benefits. Evaluations for alcohol taxation are particularly weak in this regard. Where investigated, the majority of evidence found tobacco taxation to favour low-income groups, whereas the limited evidence for SSBs is mixed.