Mobility Infrastructures and Health: Scoping Review of studies in Europe

Objectives

Movement-friendly environments with infrastructure favouring active mobility are important for promoting physical activity. This scoping literature review aims at identifying the current evidence for links between mobility infrastructures and (a) behaviour regarding active mobility, (b) health outcomes and (c) co-benefits.

Method

This review was conducted in accordance with the PRISMA scoping review guidelines using PubMed and EMBASE databases. Studies included in this review were conducted in Europe, and published between 2000 and March 2023.

Results

146 scientific articles and grey literature reports were identified. Connectivity of sidewalks, walkability, and accessibility of shops, services and work are associated with walking. Cycling is positively associated with cycle-paths, separation of cycling from traffic and proximity to greenspaces, and negatively associated with traffic danger. Increased active transportation has a protective effect on cardiovascular and respiratory health, obesity, fitness, and quality of life. Co-benefits result from the reduction of individual motorized transportation including reduced environmental pollution and projected healthcare expenditure.

Conclusion

Mobility infrastructure combined with social and educational incentives are effective in promoting active travel and reducing future healthcare expenses. A shift to active transportation would increase both individual and community health and decrease greenhouse gas emissions.

Untapped Potential of Unobtrusive Observation for Studying Health Behaviors

Improving the environment is an important upstream intervention to promote population health by influencing health behaviors such as physical activity, smoking, and social distancing. Examples of promising environmental interventions include creating high-quality green spaces, building active transport infrastructure, and implementing urban planning regulations. However, there is little robust evidence to inform policy and decision makers about what kinds of environmental interventions are effective and for which populations. In this viewpoint, we make the case that this evidence gap exists partly because health behavior research is dominated by obtrusive methods that focus on studying individual behavior and that are less suitable for understanding environmental influences. In contrast, unobtrusive observation can assess how behavior varies in different environmental contexts. It thereby provides valuable data relating to how environments affect the behavior of populations, which is often useful knowledge for effectively and equitably tackling population health challenges such as obesity and noncommunicable diseases. Yet despite a long history, unobtrusive observation methods are currently underused in health behavior research. We discuss how developing the use of video technology and automated computer vision techniques can offer a scalable solution for assessing health behaviors, facilitating a more thorough investigation of how environments influence health behaviors. We also reflect on the important ethical challenges associated with unobtrusive observation and the use of these emerging video technologies. By increasing the use of unobtrusive observation alongside other methods, we strongly believe this will improve our understanding of the influences of the environment on health behaviors.

Our Healthy Community Conceptual Framework and Intervention Model for Health Promotion and Disease Prevention in Municipalities

This paper introduces the conceptual framework and intervention model of Our Healthy Community (OHC), a new, coordinated, and integrated approach towards health promotion and disease prevention in municipalities. The model is inspired by systems-based approaches and employs a supersetting approach for engaging stakeholders across sectors in the development and implementation of interventions to increase health and well-being among citizens. The conceptual model includes a combination of a bottom-up approach emphasizing involvement of citizens and other community-based stakeholders combined with a top-down approach emphasizing political, legal, administrative, and technical support from a variety of councils and departments in local municipality government. The model operates bidirectionally: (1) by pushing political and administrative processes to promote the establishment of conducive structural environments for making healthy choices, and (2) by involving citizens and professional stakeholders at all levels in co-creating processes of shaping their own community and municipality. An operational intervention model was further developed by the OHC project while working with the OHC in two Danish municipalities. The operational intervention model of OHC comprises three main phases and key actions to be implemented at the levels of local government and community: (1) Local government: Situational analysis, dialogue, and political priorities; (2) Community: Thematic co-creation among professional stakeholders; and (3) Target area: Intervention development and implementation. The OHC model will provide municipalities with new tools to improve the citizens' health and well-being with available resources. Health promotion and disease prevention interventions are developed, implemented, and anchored in the local community by citizens and local stakeholders at municipal and local community levels using collaboration and partnerships as leverage points.

LDL-cholesterol control in the primary prevention of cardiovascular diseases: An expert opinion for clinicians and health professionals

AIMS

Although adequate clinical management of patients with hypercholesterolemia without a history of known cardiovascular disease is essential for prevention, these subjects are often disregarded. Furthermore, the scientific literature on primary cardiovascular prevention is not as rich as that on secondary prevention; finally, physicians often lack adequate tools for the effective management of subjects in primary prevention and have to face some unsolved relevant issues. This document aims to discuss and review the evidence available on this topic and provide practical guidance.

DATA SYNTHESIS

Available algorithms and risk charts represent the main tool for the assessment of cardiovascular risk in patients in primary prevention. The accuracy of such an estimate can be substantially improved considering the potential contribution of some additional risk factors (C-reactive protein, lipoprotein(a), family history of cardiovascular disease) and conditions (environmental pollution, sleep quality, socioeconomic status, educational level) whose impact on the cardiovascular risk has been better understood in recent years. The availability of non-invasive procedures to evaluate subclinical atherosclerosis may help to identify subjects needing an earlier intervention. Unveiling the presence of these conditions will improve cardiovascular risk estimation, granting a more appropriate intervention.

CONCLUSIONS

The accurate assessment of cardiovascular risk in subjects in primary prevention with the use of algorithms and risk charts together with the evaluation of additional factors will allow physicians to approach each patient with personalized strategies, which should translate into an increased adherence to therapy and, as a consequence, a reduced cardiovascular risk.

A conceptual framework for selecting appropriate populations for public health interventions

This article suggests a conceptual framework for choice of target populations for public health interventions. In short, who should benefit? Taking the seminal work of Geoffrey Rose on "individuals at risk" versus the "whole population approach" as a point of departure, we explore later contributions. Frohlich and Potvin introduced the notion of "vulnerable populations" applying relevant social determinants as the defining selection criterion. Other interventions focus on a "physical space" (spatial demarcations) such as a neighborhood as a means to define intervention populations. As an addition to these criteria, we suggest that the life-course perspective entails an alternative means of selecting target populations based on a "temporal" perspective. A focus on the various age phases ranging from fetal life and infancy to old age may guide selection of population segments for targeted public health interventions. Each of the selection criteria has advantages and disadvantages when used for primary, secondary, or tertiary prevention. Thus, the conceptual framework may guide informed decisions in public health planning and research regarding precision prevention versus various approaches to complex community-based interventions.

Design of Smart Aggregates: Toward Rapid Clinical Diagnosis of Hyperlipidemia in Human Blood

Molecular aggregates with environmental responsive properties are desired for their wide practical applications such as bioprobes. Here, a series of smart near-infrared (NIR) luminogens for hyperlipidemia (HLP) diagnosis is reported. The aggregates of these molecules exhibit a twisted intramolecular charge-transfer effect in aqueous media, but aggregation-induced emission in highly viscous media due to the restriction of the intramolecular motion. These aggregates, which can autonomously respond to different environments via switching the aggregation state without changing their chemical structures are described, as "smart aggregates". Intriguingly, these luminogens demonstrate NIR-II and NIR-III luminescence with ultralarge Stokes shifts (>950 nm). Both in vitro detection and in vivo imaging of HLP can be realized in a mouse model. Linear relationships exist between the emission intensity and multiple pathological parameters in blood samples of HLP patients. Thus, the design of smart aggregate facilitates rapid and accurate detection of HLP and provides a promising attempt in aggregate science.

EAPC Core Curriculum for Preventive Cardiology

Preventive cardiology encompasses the whole spectrum of cardiovascular disease (CVD) prevention, at individual and population level, through all stages of life. This includes promotion of cardiovascular (CV) health, management of individuals at risk of developing CVD, and management of patients with established CVD, through interdisciplinary care in different settings. Preventive cardiology addresses all aspects of CV health in the context of the social determinants of health, including physical activity, exercise, sports, nutrition, weight management, smoking cessation, psychosocial factors and behavioural change, environmental, genetic and biological risk factors, and CV protective medications. This is the first European Core Curriculum for Preventive Cardiology, which will help to standardize, structure, deliver, and evaluate training in preventive cardiology across Europe. It will be the basis for dedicated fellowship programmes and a European Society of Preventive Cardiology (EAPC) subspecialty certification for cardiologists, with the intention to improve quality and outcome in CVD prevention.

Evaluating community-driven cardiovascular health policy changes in the United States using agent-based modeling

Comprehensive smoke-free policy is a strategy to prevent cardiovascular disease (CVD) at a population-level; however, evaluating their long-term outcomes is difficult. This study used an agent-based model to estimate long-term impacts of a comprehensive smoke-free policy, as it was implemented in two communities, Arlington and Mesquite, Texas. The model predicted the percentage of myocardial infarction (MI), stroke, and diabetes in the population 10 and 20 years following policy adoption. In Arlington, the percentage of the population with these conditions each decreased by approximately 0.5% over 20 years; in Mesquite, the percentage of the population with diabetes, myocardial infarction (MI), and stroke decreased by 1.1%, 0.6%, and 0.3%, respectively, after 20 years. The results were statistically significant (p < 0.001). As an evaluation strategy, agent-based modeling can help researchers and practitioners estimate the potential long-term effects of policies and garner intervention support for implementation.

Chemical and Sensory Evaluation of Balady Bread Supplemented with Watermelon Rinds Flour and its Anti-Hyperlipidemic Effect in Male Albina Rats

&lt;b&gt;Background and Objective:&lt;/b&gt; Watermelon is a good source of minerals, vitamins and dietary fibers. It has been considered a health benefits effect due to the high amount of antioxidants and phytonutrients such as phenolics, flavonoids, phytosterols and other medicinal compounds which decrease the risk of cardiovascular, diabetes and cancer. This research was carried out to study the effect of wheat flour (WF) supplemented with different levels of watermelon rinds flour (WRF) on the chemical and organoleptic properties of balady bread. Furthermore, the effect of prepared bread on reducing blood lipids of hyperlipidemic rats. &lt;b&gt;Materials and Methods:&lt;/b&gt; Wheat flour (WF) has been supplemented with different levels (5, 10, 15 and 20%) of watermelon rinds flour (WRF). The chemical and organoleptic properties of balady bread and the anti-hyperlipidemic effect of prepared bread on hyperlipidemic rats were evaluated. &lt;b&gt;Results:&lt;/b&gt; The results indicated that incorporation of WRF in balady bread wheat flour increased the fibre, ash and minerals content of prepared bread. While carbohydrates content and energy value were decreased by increasing the WRF substitution levels. Organoleptic evaluation tests showed that up to 15% of WF could be replaced with WRF in balady bread and still more acceptable bread compared with control bread samples. In addition, rats fed on a hyperlipidemic diet containing balady bread fortified with WRF showed a significant decrease (p<0.05) in the triglyceride (TG), total cholesterol (TC), High-Density Lipoprotein Cholesterol (HDL-C), Low-Density Lipoprotein Cholesterol (LDL-C) and Very-Low-Density Lipoprotein Cholesterol (V-LDL) level by increasing the amounts of simultaneous supplementation with WRF 5-15% in the formulated balady bread compared to control samples. &lt;b&gt;Conclusion:&lt;/b&gt; The research recommended that the 15% replacement of WRF gave good quality properties and lead to reducing body weight and serum lipid profile of hyperlipidemic rats.

Lifestyle management to prevent atherosclerotic cardiovascular disease: evidence and challenges

Lifestyle management is the cornerstone of both primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) and the importance of lifestyle management is emphasised by all major guidelines. Despite this, actual implementation of lifestyle management is poor. Lifestyle modification includes smoking cessation, weight loss, dietary change, increasing physical inactivity, and stress management. This review summarises evidence-based opportunities and challenges for healthcare professionals to promote healthy lifestyles at an individual level for the prevention of ASCVD.

Risk-factors associated with extremely high cardiovascular risk of mid- and long-term mortality following myocardial infarction: Analysis of the Hyperlipidaemia Therapy in tERtiary Cardiological cEnTer (TERCET) registry

BACKGROUND AND AIMS

Risk-factor identification and risk stratification are prerequisites to the effective primary and secondary prevention of cardiovascular disease (CVD). Patients at the highest risk benefit the most from the intensive risk-factor reduction. However, the high-risk patients' group is heterogeneous, and it is increasingly recognised that there is an 'extreme-risk' category of patients who may require particularly close attention and intensive therapeutic approach. The aim of this study was to identify subgroups of patients at the highest risk of death following myocardial infarction (MI) that might be considered as those at extremely high CVD risk.

METHODS

We used data from 19,582 participants of the Hyperlipidaemia Therapy in tERtiary Cardiological cEnTer (TERCET) Registry (NCT03065543) of patients with ischaemic heart disease in Poland from 2006 to present. Characteristics of 13,052 patients with chronic coronary syndromes (CCS) were compared with those of 4295 patients with myocardial infarction (STEMI and NSTEMI). Multivariable logistic regression with stepwise backward elimination was used to identify risk factors associated with mortality in the 12-36 months following the index hospitalisation.

RESULTS

The mortality rates were significantly higher in patients after MI than in patients with CCS. In the multivariable analysis, the risk factors most strongly associated with 12-month mortality in patients after MI were left ventricular ejection fraction (LVEF) lower than 35% (hazard ratio [HR] 3.83, 95% confidence interval [CI] 3.14-4.67), age >75 years (HR 1.91, 95%CI 1.55-2.35), multivessel coronary artery disease (HR 1.61, 95%CI 1.30-1.99), atrial fibrillation (HR 1.53, 95%CI 1.21-1.94) diabetes mellitus (HR 1.35, 95%CI 1.11-1.64) and increased LDL-C (HR per 1 mmol/l 1.09, 95%CI 1.01-1.19) or creatinine levels (HR per 10 μmol/L 1.04, 95% CI 1.04-1.05). The risk factors that influenced mortality after 24-36 months were consistent with those after 12 months, with additional low haemoglobin (20-25% risk increase per 1 mmol reduction) and chronic obstructive pulmonary disease (65% risk increase after 36 months).

CONCLUSIONS

In our large, single-center real-world analysis, we identified the patients with the highest risk of death who could probably benefit the most from the most intensive therapy, and hence should be considered to be an 'extreme risk' population.

Small-diameter polyurethane vascular graft with high strength and excellent compliance

In this study, a polyurethane vascular graft with excellent strength and compliance for clinical application was designed and fabricated by preparing three small-diameter vascular graft layers via the textile techniques of wet spinning and knitting. The polyurethane filament that was fabricated by wet spinning formed the inner layer. The polyurethane tubular fabric was used as the middle layer. The outer layer was prepared by spraying polyurethane solution. The three layers of the polyurethane vascular graft have uniform wall thickness, high strength, excellent compliance, and good puncture resistance compared with clinical poly(ethylene terephthalate) (PET) and expanded polytetrafluoroethylene (ePTFE) vascular graft. Therefore, these layers can have potential clinical applications in the replacement of the conventional artificial vascular graft prepared from PET and ePTFE.

A Preliminary Study on the Effect of Psyllium Husk Ethanolic Extract on Hyperlipidemia, Hyperglycemia, and Oxidative Stress Induced by Triton X-100 Injection in Rats

The aim of this study is to assess the efficiency of psyllium husk ethanolic extract (PHEE) on Triton X-100 induced hyperlipidemic rats by studying the changes in hepatic and pancreatic function and histopathology. Forty male albino rats (bodyweight 175-188 g) were grouped randomly into four sets with ten rats. The experimental groups included: (1) control group (CON); (2) Triton X-100 induced hyperlipidemic group-rats were intraperitoneally injected with a single dose of Triton X-100 (100 mg/kg body weight) on the 21st day of Trial onset; (3) PHEE group-PHEE was orally administered (100 mg/kg body weight dissolved in 1 mL of distilled water) by gastric tube from the first day of the experiment until the fortieth day, once daily, (PHEE); (4) PHEE +Triton group, which received PHEE orally with the induction of hyperlipidemia. Treating hyperlipidemic rats with PHEE showed a decrease in the total serum lipids, triglyceride (TG), total cholesterol (TC), atherogenic index (AI), and malondialdehyde (MDA) with an increase in superoxide dismutase (SOD) and catalase (CAT) activities. PHEE administration alleviated the negative impact of Triton on the serum levels of glucose, insulin, glycated hemoglobin (HbA1c), homeostatic model assessment for insulin resistance (HOMA IR index), leptin hormone, Alanine Aminotransferase (ALT), Aspartate Aminotransferase (AST), Gamma-Glutamyl Transferase (GGT) and proteinogram. The Triton-induced hyperlipidemic rats showed extensive histopathological changes in the liver and pancreas, which were alleviated with PHEE administration. It could be concluded that PHEE has potent effects against hyperlipidemia, hyperglycemia, and oxidative stress due to its biologically active constituents detected by GC-MS analysis. This study's findings may help develop a novel trial against the effects of hyperlipidemia in the future.

Prognostic benefit from an early invasive strategy in patients with non-ST elevation acute coronary syndrome (NSTEACS): evaluation of the new risk stratification in the NSTEACS European guidelines

OBJECTIVES

The objective of our work is to evaluate the prognostic benefit of an early invasive strategy in patients with high-risk NSTACS according to the recommendations of the 2020 clinical practice guidelines during long-term follow-up.

METHODS

This retrospective observational study included 6454 consecutive NSTEACS patients. We analyze the effects of early coronary angiography (< 24 h) in patients with: (a) GRACE risk score > 140 and (b) patients with "established NSTEMI" (non ST-segment elevation myocardial infarction defined by an increase in troponins) or dynamic ST-T-segment changes with a GRACE risk score < 140.

RESULTS

From 2003 to 2017, 6454 patients with "new high-risk NSTEACS" were admitted, and 6031 (93.45%) of these underwent coronary angiography. After inverse probability of treatment weighting, the long-term cumulative probability of being free of all-cause mortality, cardiovascular mortality and MACE differed significantly due to an early coronary intervention in patients with NSTEACS and GRACE > 140 [HR 0.62 (IC 95% 0.57-0.67), HR 0.62 (IC 95% 0.56-0.68), HR 0.57 (IC 95% 0.53-0.61), respectively]. In patients with NSTEACS and GRACE < 140 with established NSTEMI or ST/T-segment changes, the benefit of the early invasive strategy is only observed in the reduction of MACE [HR 0.62 (IC 95% 0.56-0.68)], but not for total mortality [HR 0.96 (IC 95% 0.78-1.2)] and cardiovascular mortality [HR 0.96 (IC 95% 0.75-1.24)].

CONCLUSIONS

An early invasive management is associated with reduced all-cause mortality, cardiovascular mortality and MACE in NSTEACS with high GRACE risk score. However, this benefit is less evident in the subgroup of patients with a GRACE score < 140 with established NSTEMI or ST/T-segment changes.

Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension

High blood pressure is one of the most important risk factors for ischaemic heart disease, stroke, other cardiovascular diseases, chronic kidney disease and dementia. Mean blood pressure and the prevalence of raised blood pressure have declined substantially in high-income regions since at least the 1970s. By contrast, blood pressure has risen in East, South and Southeast Asia, Oceania and sub-Saharan Africa. Given these trends, the prevalence of hypertension is now higher in low-income and middle-income countries than in high-income countries. In 2015, an estimated 8.5 million deaths were attributable to systolic blood pressure >115 mmHg, 88% of which were in low-income and middle-income countries. Measures such as increasing the availability and affordability of fresh fruits and vegetables, lowering the sodium content of packaged and prepared food and staples such as bread, and improving the availability of dietary salt substitutes can help lower blood pressure in the entire population. The use and effectiveness of hypertension treatment vary substantially across countries. Factors influencing this variation include a country's financial resources, the extent of health insurance and health facilities, how frequently people interact with physicians and non-physician health personnel, whether a clear and widely adopted clinical guideline exists and the availability of medicines. Scaling up treatment coverage and improving its community effectiveness can substantially reduce the health burden of hypertension.

Improved Performance of Bacterial Nanocellulose Conduits by the Introduction of Silk Fibroin Nanoparticles and Heparin for Small-Caliber Vascular Graft Applications

Bacterial nanocellulose (BNC) is a promising material for small-caliber artificial blood vessels, although promoting its anticoagulant properties with more rapid endothelialization would improve long-term patency. Silk fibroin nanoparticles (SFNP) were introduced into the luminal wall surface of BNC conduits both with and without heparin (Hep) through pressurization followed by fixation. Hep was introduced in two ways: (1) embedded within SF nanoparticles to form SF-HepNPs for construction of the BNC-SF-HepNP conduit and (2) chemically grafted onto BNC and BNC-SFNP to form BNC-Hep and BNC-SFNP-Hep conduits. Fourier transform infrared spectroscopy confirmed the formation of SF-HepNPs, although they did not incorporate into the fibrillar network due to their large size. Hep was successfully grafted onto BNC and BNC-SFNP, verified by toluidine blue staining. The hemocompatibility and cytocompatibility of the five samples (BNC, BNC-SFNP, BNC-SF-HepNP, BNC-Hep, and BNC-SFNP-Hep conduits) were compared in vitro. The heparinized BNC-Hep and BNC-SFNP-Hep conduits improved the anticoagulant properties, and BNC-SFNP-Hep promoted human umbilical vein endothelial cell proliferation but also controlled excessive human arterial smooth muscle cell proliferation, assisting rapid endothelialization and improving lumen patency. No significant inflammatory reaction or material degradation was observed after subcutaneous implantation for 4 weeks. Autogenous tissues were observed around the conduits, and cells infiltrated into the edges of all samples, the BNC-SFNP conduit causing the deepest infiltration, providing an appropriate microenvironment for angiogenesis when used in small-caliber blood vessel applications. Few inflammatory cells were found around the BNC-Hep and BNC-SFNP-Hep conduits. Thus, the anticoagulant properties of the BNC-SFNP-Hep conduit and its stimulation of endothelialization suggest that it has great potential in clinical applications as a small-caliber artificial blood vessel.

Effectiveness and Feasibility of Taxing Salt and Foods High in Sodium: A Systematic Review of the Evidence

Diets high in salt are a leading risk for death and disability globally. Taxing unhealthy food is an effective means of influencing what people eat and improving population health. Although there is a growing body of evidence on taxing products high in sugar, and unhealthy foods more broadly, there is limited knowledge or experience of using fiscal measures to reduce salt consumption. We searched peer-reviewed databases [MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and the Cochrane Database of Systematic Reviews] and gray literature for studies published between January 2000 and October 2019. Studies were included if they provided information on the impact on salt consumption of: taxes on salt; taxes on foods high in salt, and taxes on unhealthy foods defined to include foods high in salt. Studies were excluded if their definition of unhealthy foods did not specify high salt or sodium. We found 18 relevant studies, including 15 studies reporting the effects of salt taxes through modeling (8), real-world evaluation (4), experimental design (2), or review of cost-effectiveness (1); 6 studies providing information relevant to country implementation of salt taxes; and 2 studies reporting stakeholder perceptions toward salt taxation. Although there is some evidence on the potential effectiveness and cost-effectiveness of salt taxation, especially from modeling studies, uptake of salt taxation is limited in practice. Some modeling studies suggested that food taxes can have unintended outcomes such as reduced consumption of healthy foods, or increased consumption of unhealthy, untaxed substitutes. In contrast, modeling studies that combined taxes for unhealthy foods with subsidies found that the benefits were increased. Modeling suggests that taxing all foods based on their salt content is likely to have more impact than taxing specific products high in salt given that salt is pervasive in the food chain. However, the limited experience we found suggests that policy-makers favor taxing specific products.

Taxation of the fat content of foods for reducing their consumption and preventing obesity or other adverse health outcomes

BACKGROUND

Overweight and obesity are increasing worldwide and are considered to be a major public health issue of the 21st century. Introducing taxation of the fat content in foods is considered a potentially powerful policy tool to reduce consumption of foods high in fat or saturated fat, or both.

OBJECTIVES

To assess the effects of taxation of the fat content in food on consumption of total fat and saturated fat, energy intake, overweight, obesity, and other adverse health outcomes in the general population.

SEARCH METHODS

We searched CENTRAL, Cochrane Database of Systematic Reviews, MEDLINE, Embase, and 15 other databases and trial registers on 12 September 2019. We handsearched the reference lists of all records of included studies, searched websites of international organizations and institutions (14 October 2019), and contacted review advisory group members to identify planned, ongoing, or unpublished studies (26 February 2020).

SELECTION CRITERIA

In line with Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria, we included the following study types: randomized controlled trials (RCTs), cluster-randomized controlled trials (cRCTs), non-randomized controlled trials (nRCTs), controlled before-after (CBA) studies, and interrupted time series studies. We included studies that evaluated the effects of taxes on the fat content in foods. Such a tax could be expressed as sales, excise, or special value added tax (VAT) on the final product or an intermediary product. Eligible interventions were taxation at any level, with no restriction on the duration or the implementation level (i.e. local, regional, national, or multinational). Eligible study populations were children (zero to 17 years) and adults (18 years or older) from any country and setting. We excluded studies that focused on specific subgroups only (e.g. people receiving pharmaceutical intervention; people undergoing a surgical intervention; ill people who are overweight or obese as a side effect, such as those with thyroiditis and depression; and people with chronic illness). Primary outcomes were total fat consumption, consumption of saturated fat, energy intake through fat, energy intake through saturated fat, total energy intake, and incidence/prevalence of overweight or obesity. We did not exclude studies based on country, setting, comparison, or population.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for all phases of the review. Risk of bias of the included studies was assessed using the criteria of Cochrane's 'Risk of bias' tool and the EPOC Group's guidance. Results of the review are summarized narratively and the certainty of the evidence was assessed using the GRADE approach. These steps were done by two review authors, independently.

MAIN RESULTS

We identified 23,281 records from searching electronic databases and 1173 records from other sources, leading to a total of 24,454 records. Two studies met the criteria for inclusion in the review. Both included studies investigated the effect the Danish tax on saturated fat contained in selected food items between 2011 and 2012. Both studies used an interrupted time series design. Neither included study had a parallel control group from another geographic area. The included studies investigated an unbalanced panel of approximately 2000 households in Denmark and the sales data from a specific Danish supermarket chain (1293 stores). Therefore, the included studies did not address individual participants, and no restriction regarding age, sex, and socioeconomic characteristics were defined. We judged the overall risk of bias of the two included studies as unclear. For the outcome total consumption of fat, a reduction of 41.8 grams per week per person in a household (P < 0.001) was estimated. For the consumption of saturated fat, one study reported a reduction of 4.2% from minced beef sales, a reduction of 5.8% from cream sales, and an increase of 0.5% to sour cream sales (no measures of statistical precision were reported for these estimates). These estimates are based on a restricted number of food types and derived from sales data; they do not measure individual intake. Moreover, these estimates do not account for other relevant sources of fat intake (e.g. packaged or processed food) or other food outlets (e.g. restaurants or cafeterias); hence, we judged the evidence on the effect of taxation on total fat consumption or saturated fat consumption to be very uncertain. We did not identify evidence on the effect of the intervention on energy intake or the incidence or prevalence of overweight or obesity.

AUTHORS' CONCLUSIONS

Given the very low quality of the evidence currently available, we are unable to reliably establish whether a tax on total fat or saturated fat is effective or ineffective in reducing consumption of total fat or saturated fat. There is currently no evidence on the effect of a tax on total fat or saturated fat on total energy intake or energy intake through saturated fat or total fat, or preventing the incidence or reducing the prevalence of overweight or obesity.

Simulations of future cardiometabolic disease and life expectancy under counterfactual obesity reduction scenarios

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HIAs provide simulations of future disease levels related to an array of obesity scenarios.

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In a relatively lean population, obesity still contribute to a substantial reduction in life expectancy.

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Large reductions in diabetes and multi-morbidity is estimated as an effect of reducing obesity.

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Incremental increase in future stroke and IHD cases is expected.

The aim of this study was to provide decision makers with an assessment of potential future health effects of interventions against overweight and obesity (OWOB). By means of the DYNAMO-HIA tool we conducted a health impact assessment simulating future prevented disease (ischemic heart disease (IHD), diabetes, stroke, and multi morbidity) incidence, prevalence and life expectancy (LE) related to a scenario where OWOB is reduced by 25% and a scenario where obesity is eliminated. The study covered projected number of persons living in Copenhagen, Denmark during year 2014–2040 (n 2040 = 742,129). Reducing the proportion of men/women with OWOB with 25% will increase population LE by 2.4/1.2 months and at the same time decrease LE with diabetes by 3.1/2.2 months. As a result of eliminating obesity, total LE will increase by 6.0/3.6 months and LE with diabetes will decrease with 9.8/10.3 months for men/women. We found no important effects on LE with IHD and stroke. This illustrates that the positive effects of lowering OWOB levels on IHD and stroke incidence is offset due to increasing total LE. Although the population of Copenhagen is relatively lean, reducing obesity levels will result in significant benefits for population cardiometabolic health status and LE. Future public health prevention programs may use the results as reference data for potential impact of reductions in OWOB.

Explaining Mechanisms That Influence Smoke-Free Implementation at the Local Level: A Realist Review of Smoking Bans

INTRODUCTION

While studies have been undertaken to understand the adoption of outdoor and indoor smoking bans, not much is known about why implementation of smoke-free (SF) environments differs at local levels. As most European countries remain at the level of indoor bans, we aim to translate existing evidence into practical recommendations on how to improve SF (outdoor) implementation within European municipalities.

METHODS

We applied six methodological steps of a realist review consistent with the RAMESES publication standards for realist syntheses. Literature search was conducted in PubMed/MEDLINE and Web of Science. In total, 3829 references were screened, of which 43 were synthesized. Studies dating from 2004 to 2015 with rigor evidence of SF implementation at the local level were selected. Implementation outcomes were SF enforcement, monitoring, nonsmoking compliance, and public support in cities.

RESULTS

The explanatory realist framework links four innovation stages with three context-mechanism-outcome (CMO)configurations. We identified "triggering trust," "increasing priorities," and "limiting opposing interests" as underlying mechanisms, when (1) establishing, (2) developing, (3) contesting, and (4) implementing local smoking bans. The CMO propositions (CMOs) support practical recommendations, such as (1) providing authorities with local data when establishing and developing bans, (2) developing long-term strategies and implementing state-funded SF programs to prioritize sustained enforcement, and (3) limiting opposing interests through the use of the child protection frame.

CONCLUSIONS

This is the first realist review on the implementation of SF enviroments at the local level. The process-oriented theory explains how and why CMOs determine SF development in cities and municipalities from planning until implementation.

IMPLICATIONS

In 2015, only 16% of the world's population lived under the jurisdiction of comprehensive SF laws. The findings of this realist review are useful to implement WHO goals of the Framework Convention on Tobacco Control (FCTC) and specifically SF environments at more local levels and to adjust them to specific contextual circumstances. This paper unpacks three mechanisms that could be triggered by SF strategies developed at local levels and that can result in improved policy implementation. Such evidence is needed to enhance SF strategies at the level of cities and municipalities and to achieve WHO "Healthy Cities Network" objectives.

What are effective policies for promoting physical activity? A systematic review of reviews

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There is a growing need for evidence on the effectiveness of different policies to promote physical activity.

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We conducted a systematic literature review to collate the available evidence.

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We identified 57 reviews with evidence on 53 types of physical activity policies from 7 areas.

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There is a solid evidence base for the effectiveness of school-based and some infrastructural policies.

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The evidence for other (e.g. economic) policies remains insufficient.

The importance of policy for promoting physical activity (PA) is increasingly recognized by academics, and there is a push by national governments and international institutions for PA policy development and monitoring. However, our knowledge about which policies are actually effective to promote PA remains limited. This article summarizes the currently available evidence by reviewing existing reviews on the subject.

Building on results from a previous scoping review on different types of PA-related evidence, we ran searches for combinations of the terms “physical activity”, “evidence”, “effect”, “review”, and “policy” in six different databases (PubMed, Scopus, SportDiscus, PsycInfo, ERIC, and IBSS). We used EPPI Reviewer 4 to further process the results and conduct an in-depth analysis.

We identified 57 reviews providing evidence on 53 types of policies and seven broader groups of policies. Reviews fell into four main categories: 1) setting- and target group-specific; 2) urban design, environment and transport; 3) economic instruments; and 4) broad-range perspective. Results indicate that there is solid evidence for policy effectiveness in some areas (esp. school-based and infrastructural policies) but that the evidence in other areas is insufficient (esp. for economic policies).

The available evidence provides some guidance for policy-makers regarding which policies can currently be recommended as effective. However, results also highlight some broader epistemological issues deriving from the current research. This includes the conflation of PA policies and PA interventions, the lack of appropriate tools for benchmarking individual policies, and the need to critically revisit research methodologies for collating evidence on policies.

Impact of the consumption tax rate increase on out-of-hospital cardiac arrest in Japan: an interrupted time series analysis

OBJECTIVES

The Japanese government increased the consumption tax rate from 5% to 8% on 1 April 2014. The impact of this policy on the incidence of out-of-hospital cardiac arrest (OHCA) is unknown. Thus, we aimed to evaluate a potential association between the consumption tax rate increase and OHCA.

DESIGN

An interrupted time series design.

SETTING

National registry data for all cases of OHCA in Japan.

PARTICIPANTS

All OHCA cases of presumed cardiac origin in Japan between January 2005 and December 2016.

PRIMARY OUTCOME MEASURE

We used a quasiexperimental design with interrupted time series analysis to investigate whether the consumption tax rate increase was associated with changes in OHCA trends after adjusting for baseline trends. The effective date of the consumption tax rate increase (1 April 2014) was used to split the OHCA data into categories of before and after the change.

RESULTS

In total, 808 055 OHCAs of presumed cardiac origin were reported during the study period. Prior to the consumption tax rate increase, the mean monthly OHCA rate was 5.12 cases per 100 000 population (mean monthly count: 5483.45). After adjusting for underlying trends, there was a substantial step change in the incidence of OHCAs (relative risk (RR): 0.921; 95% CI 0.889 to 0.955).

CONCLUSIONS

The implementation of the consumption tax rate increase was associated with a significant decrease in the incidence of OHCAs in Japan.

The Church Challenge: A community-based multilevel cluster randomized controlled trial to improve blood pressure and wellness in African American churches in Flint, Michigan

Chronic disease carries high morbidity and mortality in the United States, with large racial and ethnic disparities observed in chronic disease. Physical activity and healthy food are vital for chronic disease prevention yet challenging to access in economically distressed areas. Public health prevention efforts have become particularly prominent within faith-based organizations over the last three decades. This manuscript describes the protocol of the Church Challenge, a multilevel cluster-randomized controlled nutrition and physical activity trial across 24 churches to reduce blood pressure by 6 mmHg among 576 residents in Flint, MI. The Church Challenge was developed using community-based participatory approaches and is rooted in a church-based program developed by and for primarily African-American Flint church congregations. This three-level intervention addresses health at the community (level 3), church (level 2), and individual (level 1) to reduce blood pressure, reduce chronic disease risk, and promote health equity and wellbeing in Flint. Churches are randomized in a 1:1 ratio to a 16-week physical activity and nutrition program or a 4-session health and wellness workshop. Flint is not a unique community but has a history of traumatic community wide events; even now, the public health infrastructure continues to be a challenge and distract residents from focusing on their health. This trial is highly significant and innovative because it uses a combination of evidence-based practices simultaneously supporting health behavior change for individuals and their faith organizations, and evaluates multilevel efforts to sustain long-term health promotion activities in vulnerable communities like Flint.

Retinal and choroidal vasculature changes associated with chronic kidney disease

PURPOSE

Retinal and choroidal microvascular changes can be related to renal impairment in hypertension and chronic kidney disease (CKD). The study examines the association between retinochoroidal parameters and renal impairment in hypertensive, non-diabetic patients.

METHODS

This is a cross-sectional study on Caucasian patients with systemic arterial hypertension with different levels of renal function. All subjects were studied by blood chemistry, urine examination, microalbuminuria and blood pressure. Complete eye examination was completed with swept source optical coherence tomography (SS-OCT) and optical coherence tomography angiography (OCTA) scans of macular region. Patients were divided in groups: LowGFR and HighGFR and CKD- and CKD+, according to the value of glomerular filtrate (GFR) and albuminuria. LowGFR and CKD+ groups included patients with clinical kidney impairment.

RESULTS

One hundred and twenty eyes of 120 hypertensive patients were evaluated. The mean retinal thickness was thinner in CKD+ versus CKD- group (p < 0.009). LowGFR and CKD+ groups showed thinner choroidal values than HighGFR (p < 0.02) and CKD- (p < 0.001) groups. OCTA showed lower density in LowGFR than in HighGFR group (p < 0.001) and in CKD+ versus CKD- group (p < 0.001). Albuminuria was inversely related to choroidal and retinal thickness measures (p < 0.001) and to the indices of superficial parafoveal (p < 0.05) and foveal (p < 0.05) vascular densities.

CONCLUSIONS

CKD is associated with retinal thinning, eGFR and decreasing renal function with progressive reduction of choroidal and retinal vascular density. SS-OCT and OCTA documented close association between CKD and reduction of both choroidal thickness and paracentral retinal vascular density in hypertensive patients.

Early revascularization and long-term mortality in high-risk patients with non-ST-elevation myocardial infarction. The CARDIOCHUS-HUSJ registry

INTRODUCTION AND OBJECTIVES

This study sought to analyze the association of early coronary angiography with all-cause mortality and cardiovascular mortality in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) using a large contemporary cohort of patients with NSTEACS from 2 Spanish tertiary hospitals.

METHODS

This retrospective observational study included 5673 consecutive NSTEACS patients from 2 Spanish hospitals between 2005 and 2016. We performed propensity score matching to obtain a well-balanced subset of patients with the same probability of undergoing an early strategy, resulting in 3780 patients. Survival analyses were performed by Cox regression models once proportional risk test were verified.

RESULTS

Among the study participants, only 2087 patients (40.9%) underwent early invasive coronary angiography. The median follow-up was 59.0 months [interquartile range, 25.0-80.0 months]. All-cause mortality was 19.0%, cardiovascular mortality was 12.8%, and 51.1% patients experienced at least 1 major cardiovascular adverse event in the follow-up. After propensity score matching, the early strategy was associated with significantly lower mortality (hazard ratio: 0.79; 95% confidence interval 0.62-0.98) in high-risk NSTEACS patients. The darly strategy showed a nonsignificant inverse tendency in patients with GRACE score <140.

CONCLUSIONS

In high-risk (GRACE score≥ 140) NSTEACS patients in a contemporary real-world registry, early coronary angiography (first 24hours after hospital admission) may be associated with reduced all-cause mortality and cardiovascular mortality at long-term follow-up.

Project SoL-A Community-Based, Multi-Component Health Promotion Intervention to Improve Eating Habits and Physical Activity among Danish Families with Young Children. Part 1: Intervention Development and Implementation

Project SoL was implemented over a period of four years from 2012–2015 with the aim to promote healthy eating and physical activity among families with children aged 3–8 years, living in selected communities in two Danish municipalities. This was done by applying the supersetting approach to implement complex multi-component interventions in a participatory, coordinated, and integrated manner in childcare centres, schools, and supermarkets in three local communities, as well as in local media during a 19-month period in the Regional Municipality of Bornholm, which served as the intervention site. The matching municipality of Odsherred served as a control site based on its similarity to Bornholm regarding several socio-demographic and health indicators. The present paper describes the design of Project SoL as well as the processes of developing and implementing its complex interventions. Moreover, the theoretical and conceptual framework of the project is described together with its organisational structure, concrete activities, and sustainability measures. The paper discusses some of the key lessons learned related to participatory development and the implementation of a multi-component intervention. The paper concludes that coordinated and integrated health promotion activities that are implemented together with multiple stakeholders and across multiple settings in the local community are much more powerful than individual activities carried out in single settings. The supersetting approach was a useful conceptual framework for developing and implementing a complex multi-component health promotion intervention and for fostering ownership and sustainability of the intervention in the local community. The research and evaluation approach of the project is described in a separate paper (Part 2).

ACC/AHA guidelines superior to ESC/EAS guidelines for primary prevention with statins in non-diabetic Europeans: the Copenhagen General Population Study

Aim

We compared the 2013 American College of Cardiology/American Heart Association (ACC/AHA) and the 2016 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines on prevention of atherosclerotic cardiovascular disease (ASCVD) using different risk prediction models [US Pooled Cohort Equations (US-PCE for any ASCVD) and European Systematic COronary Risk Evaluation system (European-SCORE for fatal ASCVD)] and different statin eligibility criteria.

Methods and results

We examined 44 889 individuals aged 40-75 recruited in 2003-09 in the Copenhagen General Population Study, all free of ASCVD, diabetes, and statin use at baseline. We detected 2217 any ASCVD events and 199 fatal ASCVD events through 2014. The predicted-to-observed event ratio was 1.2 using US-PCE for any ASCVD and 5.0 using European-SCORE for fatal ASCVD. The US-PCE, but not the European-SCORE, was well-calibrated around decision thresholds for statin therapy. For a Class I recommendation, 42% of individuals qualified for statins using the ACC/AHA guidelines vs. 6% with the ESC/EAS guidelines. Using ACC/AHA- vs. ESC/EAS-defined statin eligibility led to a substantial gain in sensitivity (+62% for any ASCVD and +76% for fatal ASCVD) with a smaller loss in specificity (-35% for any ASCVD and -36% for fatal ASCVD). Similar differences between the ACC/AHA and ESC/EAS guidelines were found for men and women separately, and for Class IIa recommendations. The sensitivity and specificity of a US-PCE risk of 5% were similar to those of a European-SCORE risk of 1.4%, whereas a US-PCE risk of 7.5% was similar to a European-SCORE risk of 2.4%.

Conclusions

The ACC/AHA guidelines were superior to the ESC/EAS guidelines for primary prevention of ASCVD, that is, for accurately assigning statin therapy to those who would benefit.

Daily Consumption of Virgin Coconut Oil Increases High-Density Lipoprotein Cholesterol Levels in Healthy Volunteers: A Randomized Crossover Trial

This open-label, randomized, controlled, crossover trial assessed the effect of daily virgin coconut oil (VCO) consumption on plasma lipoproteins levels and adverse events. The study population was 35 healthy Thai volunteers, aged 18-25. At entry, participants were randomly allocated to receive either (i) 15 mL VCO or (ii) 15 mL 2% carboxymethylcellulose (CMC) solution (as control), twice daily, for 8 weeks. After 8 weeks, participants had an 8-week washout period and then crossed over to take the alternative regimen for 8 weeks. Plasma lipoproteins levels were measured in participants at baseline, week-8, week-16, and week-24 follow-up visits. Results. Of 32 volunteers with complete follow-up (16 males and 16 females), daily VCO intake significantly increased high-density lipoprotein cholesterol by 5.72 mg/dL (p = 0.001) compared to the control regimen. However, there was no difference in the change in total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels between the two regimens. Mild diarrhea was reported by some volunteers when taking VCO, but no serious adverse events were reported. Conclusion. Daily consumption of 30 mL VCO in young healthy adults significantly increased high-density lipoprotein cholesterol. No major safety issues of taking VCO daily for 8 weeks were reported.

[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.

[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.

Fifteen-year trends in the prevalence of barriers to healthy eating in a high-income country

Background: Despite increasing levels of education and income in the Swiss population over time and greater food diversity due to globalization, adherence to dietary guidelines has remained persistently low. This may be because of barriers to healthy eating hampering adherence, but whether these barriers have evolved in prevalence over time has never been assessed, to our knowledge.Objective: We assessed 15-y trends in the prevalence of self-reported barriers to healthy eating in Switzerland overall and according to sex, age, education, and income.Design: We used data from 4 national Swiss Health Surveys conducted between 1997 and 2012 (52,238 participants aged ≥18 y, 55% women), applying multivariable-adjusted logistic regression models to assess trends in prevalence of 6 barriers to healthy eating (taste, price, daily habits, time, lack of willpower, and limited options).Results: The prevalence of 3 barriers exhibited an increasing trend until 2007, followed by a decrease in 2012 (from 44% in 1997 to 50% in 2007 and then to 44% in 2012 for taste, from 40% to 52% and then to 39% for price, and from 29% to 34% and then to 32% for time; quadratic P-trend < 0.0001). Limited options decreased slightly until 2007 (35-33%) and then sharply by 2012 (18%) (linear P-trend < 0.0001). Daily habits remained relatively stable across time from 42% in 1997 to 38% in 2012 (linear P-trend < 0.0001). Conversely, lack of willpower decreased steadily over time from 26% in 1997 to 21% in 2012 (linear P-trend < 0.0001). Trends were similar for all barriers irrespective of sex, age, education, and income.Conclusion: Between 1997 and 2012, barriers to healthy eating remained highly prevalent (≥20%) in the Swiss population and evolved similarly irrespective of age, sex, education, and income.

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.