1
|
Uthman OA, Court R, Anjorin S, Enderby J, Al-Khudairy L, Nduka C, Mistry H, Melendez-Torres GJ, Taylor-Phillips S, Clarke A. The potential impact of policies and structural interventions in reducing cardiovascular disease and mortality: a systematic review of simulation-based studies. Health Technol Assess 2023:1-32. [PMID: 38140927 DOI: 10.3310/nmfg0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
Background The aim of the study was to investigate the potential effect of different structural interventions for preventing cardiovascular disease. Methods Medline and EMBASE were searched for peer-reviewed simulation-based studies of structural interventions for prevention of cardiovascular disease. We performed a systematic narrative synthesis. Results A total of 54 studies met the inclusion criteria. Diet, nutrition, tobacco and alcohol control and other programmes are among the policy simulation models explored. Food tax and subsidies, healthy food and lifestyles policies, palm oil tax, processed meat tax, reduction in ultra-processed foods, supplementary nutrition assistance programmes, stricter food policy and subsidised community-supported agriculture were among the diet and nutrition initiatives. Initiatives to reduce tobacco and alcohol use included a smoking ban, a national tobacco control initiative and a tax on alcohol. Others included the NHS Health Check, WHO 25 × 25 and air quality management policy. Future work and limitations There is significant heterogeneity in simulation models, making comparisons of output data impossible. While policy interventions typically include a variety of strategies, none of the models considered possible interrelationships between multiple policies or potential interactions. Research that investigates dose-response interactions between numerous modifications as well as longer-term clinical outcomes can help us better understand the potential impact of policy-level interventions. Conclusions The reviewed studies underscore the potential of structural interventions in addressing cardiovascular diseases. Notably, interventions in areas such as diet, tobacco, and alcohol control demonstrate a prospective decrease in cardiovascular incidents. However, to realize the full potential of such interventions, there is a pressing need for models that consider the interplay and cumulative impacts of multiple policies. Rigorous research into holistic and interconnected interventions will pave the way for more effective policy strategies in the future. Study registration The study is registered as PROSPERO CRD42019154836. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/148/05.
Collapse
Affiliation(s)
- Olalekan A Uthman
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV7 4AL, UK
| | - Rachel Court
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV7 4AL, UK
| | - Seun Anjorin
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV7 4AL, UK
| | - Jodie Enderby
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV7 4AL, UK
| | - Lena Al-Khudairy
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV7 4AL, UK
| | - Chidozie Nduka
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV7 4AL, UK
| | - Hema Mistry
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV7 4AL, UK
| | - G J Melendez-Torres
- Peninsula Technology Assessment Group (PenTAG), College of Medicine and Health, University of Exeter, Exeter, UK
| | - Sian Taylor-Phillips
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV7 4AL, UK
| | - Aileen Clarke
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV7 4AL, UK
| |
Collapse
|
2
|
Huang V, Head A, Hyseni L, O'Flaherty M, Buchan I, Capewell S, Kypridemos C. Identifying best modelling practices for tobacco control policy simulations: a systematic review and a novel quality assessment framework. Tob Control 2023; 32:589-598. [PMID: 35017262 PMCID: PMC10447402 DOI: 10.1136/tobaccocontrol-2021-056825] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/27/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Policy simulation models (PSMs) have been used extensively to shape health policies before real-world implementation and evaluate post-implementation impact. This systematic review aimed to examine best practices, identify common pitfalls in tobacco control PSMs and propose a modelling quality assessment framework. METHODS We searched five databases to identify eligible publications from July 2013 to August 2019. We additionally included papers from Feirman et al for studies before July 2013. Tobacco control PSMs that project tobacco use and tobacco-related outcomes from smoking policies were included. We extracted model inputs, structure and outputs data for models used in two or more included papers. Using our proposed quality assessment framework, we scored these models on population representativeness, policy effectiveness evidence, simulated smoking histories, included smoking-related diseases, exposure-outcome lag time, transparency, sensitivity analysis, validation and equity. FINDINGS We found 146 eligible papers and 25 distinct models. Most models used population data from public or administrative registries, and all performed sensitivity analysis. However, smoking behaviour was commonly modelled into crude categories of smoking status. Eight models only presented overall changes in mortality rather than explicitly considering smoking-related diseases. Only four models reported impacts on health inequalities, and none offered the source code. Overall, the higher scored models achieved higher citation rates. CONCLUSIONS While fragments of good practices were widespread across the reviewed PSMs, only a few included a 'critical mass' of the good practices specified in our quality assessment framework. This framework might, therefore, potentially serve as a benchmark and support sharing of good modelling practices.
Collapse
Affiliation(s)
- Vincy Huang
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Anna Head
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Lirije Hyseni
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Martin O'Flaherty
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Iain Buchan
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Simon Capewell
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Chris Kypridemos
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| |
Collapse
|
3
|
Sozmen K, Ergor G, Sakarya S, Dinc Horasan G, Sahan C, Ekinci B, Arikan A, Sis S, Unal B. Evaluation of Blood Pressure Status and Mortality in Turkey: Findings from Chronic Diseases and Risk Factors Cohort Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1366. [PMID: 37629656 PMCID: PMC10456768 DOI: 10.3390/medicina59081366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/11/2023] [Accepted: 07/23/2023] [Indexed: 08/27/2023]
Abstract
Background and objectives: An important Non-Communicable Disease risk factor, hypertension (HT), is highly prevalent and controlled HT rates are not sufficient which increases the risk of developing premature deaths. The purpose of the study is to evaluate differences in all-cause and cardiovascular-related mortality according to HT status by using national data from Chronic Diseases and Risk Factors Survey in Turkey (2011-2017). Materials and Methods: Cox regression models were used to estimate hazard ratios (HR) for predicting the all-cause and cardiovascular system-related mortalities. Median follow-up period was 6.2 years. Results: Among individuals with HT, 41.8% was untreated, 30.1% received treatment and had controlled blood pressure, and 28.1% were under treatment but had uncontrolled BP levels. The hazard for mortality among treated & uncontrolled hypertensive participants was significantly higher for all-cause (HR = 1.32, 95% CI = 1.06-1.65), cardiovascular (HR = 2.11, 95% CI = 1.46-3.06), heart disease (HR = 2.24, 95% CI = 1.46-3.43), and Coronary Heart Disease mortality (HR = 2.66, 95% CI = 1.56-4.53) compared to normotensive participants. Conclusions: Individuals with HT who were treated but do not have controlled blood pressure in Turkey had a significantly increased risk of Cardiovascular Disease and all-cause mortality. Along with studies investigating the causes of uncontrolled blood pressure despite initiation of treatment, support should be provided to patients in cases of non-adherence to antihypertensive medication or life change recommendations.
Collapse
Affiliation(s)
- Kaan Sozmen
- Department of Public Health, Faculty of Medicine, Izmir Katip Celebi University, Izmir 35620, Türkiye
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
| | - Gul Ergor
- Department of Public Health, Faculty of Medicine, Dokuz Eylul University, Izmir 35340, Türkiye; (G.E.); (C.S.)
| | - Sibel Sakarya
- Department of Public Health, Faculty of Medicine, Koc University, Istanbul 34010, Türkiye
| | - Gonul Dinc Horasan
- Department of Public Health, Faculty of Medicine, Izmir University of Economics, Izmir 35330, Türkiye;
| | - Ceyda Sahan
- Department of Public Health, Faculty of Medicine, Dokuz Eylul University, Izmir 35340, Türkiye; (G.E.); (C.S.)
| | - Banu Ekinci
- Department of Chronic Diseases and Elderly Health, General Directorate of Public Health of Turkey, Ankara 06430, Türkiye; (B.E.); (A.A.); (S.S.)
| | - Ahmet Arikan
- Department of Chronic Diseases and Elderly Health, General Directorate of Public Health of Turkey, Ankara 06430, Türkiye; (B.E.); (A.A.); (S.S.)
| | - Secil Sis
- Department of Chronic Diseases and Elderly Health, General Directorate of Public Health of Turkey, Ankara 06430, Türkiye; (B.E.); (A.A.); (S.S.)
| | - Belgin Unal
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
- Department of Public Health, Faculty of Medicine, Dokuz Eylul University, Izmir 35340, Türkiye; (G.E.); (C.S.)
| |
Collapse
|
4
|
Tokgozoglu L, Kayikcioglu M, Ekinci B. The landscape of preventive cardiology in Turkey: Challenges and successes. Am J Prev Cardiol 2021; 6:100184. [PMID: 34327504 PMCID: PMC8315400 DOI: 10.1016/j.ajpc.2021.100184] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/24/2021] [Accepted: 04/04/2021] [Indexed: 12/20/2022] Open
Abstract
Turkey, like many countries, is facing a growing burden of non-communicable disease (NCD)s and is among the countries with high cardiovascular mortality in Europe. Moreover, Turkey currently has the highest rate of premature cardiovascular disease (CVD) in Europe. During the last decades, Turkey made fundamental reforms in the health system to improve the treatment of risk factors to prevent CVD. The most outstanding success was in the area of tobacco control (13.4% decrease in smoking prevalence) and decreasing the salt consumption of the population (from 18 to 9.9 g/day) leading to a significant decrease in CVD mortality from 45% to 36.8% of all deaths. However, obesity and diabetes are increasing rapidly as a result of urbanization, low physical activity and unhealthy eating and the new generation is starting to take up smoking. The increase in cardiometabolic risk factors and aging of the population are expected to increase the number of CVD deaths. All CVD risk factors except smoking are significantly more prevalent in women. In addition, rare disease is a country specific problem with a significant contribution to the high rates of premature CVD in Turkey. Despite major improvements in management in acute coronary syndromes, sustained achievement in guideline recommended goals is suboptimal. In patients with a previous cardiovascular event smoking rate is 25.5%, 80.9% of these patients are overweight (BMI ≥25 kg/m2), 30% obese (BMI ≥30 kg/m2), and LDL‐cholesterol targets of 70 mg/dL are attained in only 18%. Herein, we scrutinize the achievements and challenges of Turkey in establishing a ‘National Heart Health Policy’ aiming to decrease the burden of CVD and its risk factors.
Collapse
Affiliation(s)
- Lale Tokgozoglu
- Department of Cardiology, Hacettepe University Medical Faculty, Ankara, Turkey
| | - Meral Kayikcioglu
- Department of Cardiology, Ege University Medical Faculty, Izmir, Turkey
| | - Banu Ekinci
- Department of Chronic Disease and Elderly Health, Ministry of Health, Ankara, Turkey
| |
Collapse
|
5
|
Cinaroglu S. Oncology services efficiency in the age of pandemic: A jackknife and bootstrap sensitivity analysis for robustness check of DEA scores. J Cancer Policy 2021; 27:100262. [DOI: 10.1016/j.jcpo.2020.100262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/04/2020] [Accepted: 11/18/2020] [Indexed: 01/12/2023]
|
6
|
Schönbach JK, Nusselder W, Lhachimi SK. Substituting polyunsaturated fat for saturated fat: A health impact assessment of a fat tax in seven European countries. PLoS One 2019; 14:e0218464. [PMID: 31291265 PMCID: PMC6619676 DOI: 10.1371/journal.pone.0218464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/03/2019] [Indexed: 01/22/2023] Open
Abstract
There is evidence that replacing saturated fat (SFA) with polyunsaturated fat (PUFA) lowers ischemic heart disease (IHD). In order to improve the population’s diet, the World Health Organization has called for the taxation of foods that are high in SFA. We aimed to assess the potential health gains of a European fat tax by applying the SFA intake reduction that has been observed under the Danish fat tax to six other European countries. For each country, we created a fat tax scenario with a decreased SFA intake and a corresponding increase in PUFA. We compared this fat tax scenario to a reference scenario with no change in SFA intake, and to a guideline scenario with a population-wide SFA intake in line with dietary recommendations. We used DYNAMO-HIA to dynamically project the policy-attributable IHD cases of these three scenarios 10 years into the future. A fat tax would reduce prevalent IHD cases by a minimum of 500 and 300 among males and females in Denmark, respectively, up to a maximum of 5,600 and 4,000 among males and females in the UK. Thereby, the prevented IHD cases under a fat tax scenario would correspond to between 11.0% (in females in the Netherlands) and 29.5% (in females in Italy) of the prevented IHD cases under a guideline scenario, which represents the maximum preventable disease burden. Henceforth, our quantification of beneficial health impacts makes the case for the policy debate on fat taxes.
Collapse
Affiliation(s)
- Johanna-Katharina Schönbach
- Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany
- Research Group for Evidence-Based Public Health, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Germany
- * E-mail:
| | - Wilma Nusselder
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Stefan K. Lhachimi
- Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany
- Research Group for Evidence-Based Public Health, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Germany
| |
Collapse
|
7
|
Erdem Y, Akpolat T, Derici Ü, Şengül Ş, Ertürk Ş, Ulusoy Ş, Altun B, Arıcı M. Dietary Sources of High Sodium Intake in Turkey: SALTURK II. Nutrients 2017; 9:nu9090933. [PMID: 28837102 PMCID: PMC5622693 DOI: 10.3390/nu9090933] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/09/2017] [Accepted: 08/16/2017] [Indexed: 01/28/2023] Open
Abstract
Previous research has shown daily salt intakes in Turkey to be far above the recommended limits. Knowing the sources of dietary salt could form a basis for preventive strategies aimed towards salt reduction. This study aimed to investigate dietary sources of salt in Turkey. A sub-group (n = 657) was selected from the PatenT2 study population, which represented the urban and rural areas of 4 major cities (Ankara, Istanbul, Izmir, and Konya). A questionnaire inquiring about sociodemographic characteristics, medical histories, detailed histories of diet, and salt consumption was completed. Participants were asked to collect a 24-h urine sample and to record their food intake (dietary recall) on the same day. Of 925 participants selected, 657 (71%) provided accurate 24-h urine collections, based on creatinine excretion data. The mean daily 24-h urinary sodium excretion was 252.0 ± 92.2 mmol/day, equal to daily salt intake of 14.8 ± 5.4 g. Of the 657 participants with accurate 24-h urine collections, 464 (70%) provided fully completed dietary recalls. Among these 464 participants, there was a significant difference between the 24-h urinary sodium excretion-based salt intake estimation (14.5 ± 5.1 g/day) and the dietary recall-based salt intake estimation (12.0 ± 7.0 g/day) (p < 0.001). On the other hand, a positive correlation was obtained between the dietary recall-based daily salt intake and 24-h urinary sodium excretion-based daily salt intake (r = 0.277, p < 0.001). Bread was the main source of salt (34%) followed by salt added during cooking and preparing food before serving (30%), salt from various processed foods (21%), and salt added at the table during food consumption (11%). Conclusively, this study confirmed a very high salt intake of the adult population in four major cities in Turkey. The present findings support the emerging salt reduction strategy in Turkey by promoting lower salt content in baked bread, and less salt use in habitual food preparation and during food consumption in the home.
Collapse
Affiliation(s)
- Yunus Erdem
- Department of Internal Medicine, Division of Nephrology, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey.
| | - Tekin Akpolat
- Department of Internal Medicine, Division of Nephrology, Istinye University Liv Hospital, Istanbul 34510, Turkey.
| | - Ülver Derici
- Department of Internal Medicine, Division of Nephrology, Gazi University Faculty of Medicine, Ankara 06560, Turkey.
| | - Şule Şengül
- Department of Internal Medicine, Division of Nephrology, Ankara University Faculty of Medicine, Ankara 06100, Turkey.
| | - Şehsuvar Ertürk
- Department of Internal Medicine, Division of Nephrology, Ankara University Faculty of Medicine, Ankara 06100, Turkey.
| | - Şükrü Ulusoy
- Department of Internal Medicine, Karadeniz Teknik University Faculty of Medicine, Trabzon 61080, Turkey.
| | - Bülent Altun
- Department of Internal Medicine, Division of Nephrology, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey.
| | - Mustafa Arıcı
- Department of Internal Medicine, Division of Nephrology, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey.
| |
Collapse
|
8
|
Vasara E, Marakis G, Breda J, Skepastianos P, Hassapidou M, Kafatos A, Rodopaios N, Koulouri AA, Cappuccio FP. Sodium and Potassium Intake in Healthy Adults in Thessaloniki Greater Metropolitan Area-The Salt Intake in Northern Greece (SING) Study. Nutrients 2017; 9:E417. [PMID: 28441726 PMCID: PMC5409756 DOI: 10.3390/nu9040417] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 04/06/2017] [Accepted: 04/20/2017] [Indexed: 12/14/2022] Open
Abstract
A reduction in population sodium (as salt) consumption is a global health priority, as well as one of the most cost-effective strategies to reduce the burden of cardiovascular disease. High potassium intake is also recommended to reduce cardiovascular disease. To establish effective policies for setting targets and monitoring effectiveness within each country, the current level of consumption should be known. Greece lacks data on actual sodium and potassium intake. The aim of the present study was therefore to assess dietary salt (using sodium as biomarker) and potassium intakes in a sample of healthy adults in northern Greece, and to determine whether adherence to a Mediterranean diet is related to different sodium intakes or sodium-to-potassium ratio. A cross-sectional survey was carried out in the Thessaloniki greater metropolitan area (northern Greece) (n = 252, aged 18-75 years, 45.2% males). Participants' dietary sodium and potassium intakes were determined by 24-hour urinary sodium and potassium excretions. In addition, we estimated their adherence to Mediterranean diet by the use of an 11-item MedDietScore (range 0-55). The mean sodium excretion was 175 (SD 72) mmol/day, equivalent to 4220 (1745) mg of sodium or 10.7 (4.4) g of salt per day, and the potassium excretion was 65 (25) mmol/day, equivalent to 3303 (1247) mg per day. Men had higher sodium and potassium excretions compared to women. Only 5.6% of the sample had salt intake <5 g/day, which is the target intake recommended by the World Health Organization. Mean sodium-to-potassium excretion ratio was 2.82 (1.07). There was no significant difference in salt or potassium intake or their ratio across MedDietScore quartiles. No significant relationships were found between salt intake and adherence to a Mediterranean diet, suggesting that the perception of the health benefits of the Mediterranean diet does not hold when referring to salt consumption. These results suggest the need for a larger, nation-wide survey on salt intake in Greece and underline the importance of continuation of salt reduction initiatives in Greece.
Collapse
Affiliation(s)
- Eleni Vasara
- Laboratory of Animal Physiology, Department of Zoology, School of Biology, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece.
| | - Georgios Marakis
- Nutrition Policy and Research Directorate, Hellenic Food Authority, 124 Kifisias Av. & 2 Iatridou Str., Athens 11526, Greece.
| | - Joao Breda
- Division of Noncommunicable Diseases and Promoting Health through the Life-Course, WHO Regional Office for Europe, Copenhagen DK-2100, Denmark.
| | - Petros Skepastianos
- Department of Medical Laboratory Studies, Alexander Technological and Educational Institute of Thessaloniki, Sindos, Thessaloniki 57400, Greece.
| | - Maria Hassapidou
- Department of Nutrition and Dietetics, Alexander Technological and Educational Institute of Thessaloniki, Sindos, Thessaloniki 57400, Greece.
| | - Anthony Kafatos
- Department of Social Medicine, Preventive Medicine and Nutrition Clinic, Medical School, University of Crete, Heraklion 71003, Crete, Greece.
| | - Nikolaos Rodopaios
- Department of Social Medicine, Preventive Medicine and Nutrition Clinic, Medical School, University of Crete, Heraklion 71003, Crete, Greece.
| | - Alexandra A Koulouri
- Department of Social Medicine, Preventive Medicine and Nutrition Clinic, Medical School, University of Crete, Heraklion 71003, Crete, Greece.
| | - Francesco P Cappuccio
- Division of Health Sciences (Mental Health & Wellbeing), Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK.
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, CV2 2DX, UK.
| |
Collapse
|