Astrid Ledgaard Holm

Health Impact Assessment of increased cycling to place of work or education in Copenhagen

Objective To quantify the effects of increased cycling on both mortality and morbidity. Design Health Impact Assessment. Setting Cycling to place of work or education in Copenhagen, Denmark. Population Effects were calculated based on the working-age population of Copenhagen. Main outcome measures The primary outcome measure was change in burden of disease (measured as disability-adjusted life years (DALY)) due to changed exposure to the health determinants physical inactivity, air pollution (particulate matter <2.5 μm) and traffic accidents. Results Obtainment of the proposed increase in cycling could reduce the burden of disease in the study population by 19.5 DALY annually. This overall effect comprised a reduction in the burden of disease from health outcomes associated with physical inactivity (76.0 DALY) and an increase in the burden of disease from outcomes associated with air pollution and traffic accidents (5.4 and 51.2 DALY, respectively). Conclusion This study illustrates how quantitative Health Impact Assessment can help clarify potential effects of policies: increased cycling involves opposing effects from different outcomes but with the overall health effect being positive. This result illustrates the importance of designing policies that promote the health benefits and minimise the health risks related to cycling.

Alcohol‐attributed disease burden in four Nordic countries: A comparison using the Global Burden of Disease, Injuries and Risk Factors 2013 study

Abstract Aims (1) To compare alcohol‐attributed disease burden in four Nordic countries 1990–2013, by overall disability‐adjusted life years (DALYs) and separated by premature mortality [years of life lost (YLL)] and health loss to non‐fatal conditions [years lived with disability (YLD)]; (2) to examine whether changes in alcohol consumption informs alcohol‐attributed disease burden; and (3) to compare the distribution of disease burden separated by causes. Design A comparative risk assessment approach. Setting Sweden, Norway, Denmark and Finland. Participants Male and female populations of each country. Measurements Age‐standardized DALYs, YLLs and YLDs per 100 000 with 95% uncertainty intervals (UIs). Findings In Finland, with the highest burden over the study period, overall alcohol‐attributed DALYs were 1616 per 100 000 in 2013, while in Norway, with the lowest burden, corresponding estimates were 634. DALYs in Denmark were 1246 and in Sweden 788. In Denmark and Finland, changes in consumption generally corresponded to changes in disease burden, but not to the same extent in Sweden and Norway. All countries had a similar disease pattern and the majority of DALYs were due to YLLs (62–76%), mainly from alcohol use disorder, cirrhosis, transport injuries, self‐harm and violence. YLDs from alcohol use disorder accounted for 41% and 49% of DALYs in Denmark and Finland compared to 63 and 64% in Norway and Sweden 2013, respectively. Conclusions Finland and Denmark has a higher alcohol‐attributed disease burden than Sweden and Norway in the period 1990–2013. Changes in consumption levels in general corresponded to changes in harm in Finland and Denmark, but not in Sweden and Norway for some years. All countries followed a similar pattern. The majority of disability‐adjusted life years were due to premature mortality. Alcohol use disorder by non‐fatal conditions accounted for a higher proportion of disability‐adjusted life years in Norway and Sweden, compared with Finland and Denmark.

Cost-Effectiveness of Preventive Interventions to Reduce Alcohol Consumption in Denmark

Introduction Excessive alcohol consumption increases the risk of many diseases and injuries, and the Global Burden of Disease 2010 study estimated that 6% of the burden of disease in Denmark is due to alcohol consumption. Alcohol consumption thus places a considerable economic burden on society. Methods We analysed the cost-effectiveness of six interventions aimed at preventing alcohol abuse in the adult Danish population: 30% increased taxation, increased minimum legal drinking age, advertisement bans, limited hours of retail sales, and brief and longer individual interventions. Potential health effects were evaluated as changes in incidence, prevalence and mortality of alcohol-related diseases and injuries. Net costs were calculated as the sum of intervention costs and cost offsets related to treatment of alcohol-related outcomes, based on health care costs from Danish national registers. Cost-effectiveness was evaluated by calculating incremental cost-effectiveness ratios (ICERs) for each intervention. We also created an intervention pathway to determine the optimal sequence of interventions and their combined effects. Results Three of the analysed interventions (advertising bans, limited hours of retail sales and taxation) were cost-saving, and the remaining three interventions were all cost-effective. Net costs varied from € -17 million per year for advertisement ban to € 8 million for longer individual intervention. Effectiveness varied from 115 disability-adjusted life years (DALY) per year for minimum legal drinking age to 2,900 DALY for advertisement ban. The total annual effect if all interventions were implemented would be 7,300 DALY, with a net cost of € -30 million. Conclusion Our results show that interventions targeting the whole population were more effective than individual-focused interventions. A ban on alcohol advertising, limited hours of retail sale and increased taxation had the highest probability of being cost-saving and should thus be first priority for implementation.

Assessment of health impacts of decreased smoking prevalence in Copenhagen: Application of the DYNAMO-HIA model

Aims: Tobacco smoking is among the leading risk factors for chronic disease and early death in developed countries, including Denmark, where smoking causes 14% of the disease burden. In Denmark, many public health interventions, including smoking prevention, are undertaken by the municipalities, but models to estimate potential health effects of local interventions are lacking. The aim of the current study was to model the effects of decreased smoking prevalence in Copenhagen, Denmark. Methods: The DYNAMO-HIA model was applied to the population of Copenhagen, by using health survey data and data from Danish population registers. We modelled the effects of four intervention scenarios aimed at different target groups, compared to a reference scenario. The potential effects of each scenario were modelled until 2040. Results: A combined scenario affecting both initiation rates among youth, and cessation and re-initiation rates among adults, which reduced the smoking prevalence to 4% by 2025, would have large beneficial effects on incidence and prevalence of smoking-related diseases and mortality. Health benefits could also be obtained through interventions targeting only cessation or re-initiation rates, whereas an intervention targeting only initiation among youth had marginal effects on morbidity and mortality within the modelled time frame. Conclusions: By modifying the DYNAMO-HIA model, we were able to estimate the potential health effects of four interventions to reduce smoking prevalence in the population of Copenhagen. The effect of the interventions on future public health depended on population subgroup(s) targeted, duration of implementation and intervention reach.

The health benefits of selective taxation as an economic instrument in relation to IHD and nutrition-related cancers.

OBJECTIVE The present study aimed to estimate the health benefits of selective taxation of healthy and unhealthy food commodities in relation to CVD and nutrition-related cancers. DESIGN The potential health effects of a selective taxation scenario were estimated as changes in the burden of disease, measured by disability-adjusted life years, from health outcomes affected by the changes in food intake. The change in burden of a disease was calculated as the change in incidence of the disease due to a modified exposure level, using the potential impact fraction. Estimates of relative risk for the associations between various foods and relevant diseases were found through a literature search and used in the calculation of potential impact fractions. SETTING The study was based in Denmark, estimating the health effects of a Danish selective taxation scenario. SUBJECTS The potential health effects of selective taxation were modelled for the adult Danish population. RESULTS Halving the rate of value-added tax on fruit and vegetables and increasing the tax on fats would result in moderate reductions in the burden of disease from IHD, ischaemic stroke, and colorectal, lung and breast cancer (0·4–2·4 % change). The largest effect could be obtained through increased intake of fruit and vegetables (0·9–2·4 %). CONCLUSIONS Applying selective taxation to healthy and unhealthy foods can moderately reduce the burden of disease in the Danish population.

Job mobility and health in the Danish workforce

Aims: The globalized economy has stimulated mobility in the labour market in many countries and Denmark has one of the highest rates of mobility between workplaces among the OECD countries. This raises the question of the potential health effects of mobility and the effect of disease on mobility. Methods: This study was register-based with a longitudinal design using data on the entire Danish population in 1992–2006. The data included mobility between employers and workplaces and seven different diseases based on admissions to hospital and drug prescriptions. Results: After adjusting for relevant confounders, an exposure–response relationship was seen between mobility and the incidence of ischaemic heart disease, stroke, duodenal ulcer, anxiety/depression and, most strongly, with alcohol-related disorders. The effects were not very strong, however, with odds ratios varying from 1.2 to 1.6. As expected, no effect was seen for colorectal cancer. We also found an effect of both somatic and mental disorders on mobility, but not for the two cancer types. Mobility did not seem to prevent being out of the labour force after diagnosis. Conclusions: Frequent mobility in the labour market increases the risk of cardiovascular disease, common mental disorders and alcohol-related disorders and these diagnoses also seem to increase the risk of subsequent mobility.

Alcohol-attributed disease burden in four Nordic countries: a comparison using the Global Burden of Disease, Injuries and Risk Factors 2013 study

Abstract Aims (1) To compare alcohol‐attributed disease burden in four Nordic countries 1990–2013, by overall disability‐adjusted life years (DALYs) and separated by premature mortality [years of life lost (YLL)] and health loss to non‐fatal conditions [years lived with disability (YLD)]; (2) to examine whether changes in alcohol consumption informs alcohol‐attributed disease burden; and (3) to compare the distribution of disease burden separated by causes. Design A comparative risk assessment approach. Setting Sweden, Norway, Denmark and Finland. Participants Male and female populations of each country. Measurements Age‐standardized DALYs, YLLs and YLDs per 100 000 with 95% uncertainty intervals (UIs). Findings In Finland, with the highest burden over the study period, overall alcohol‐attributed DALYs were 1616 per 100 000 in 2013, while in Norway, with the lowest burden, corresponding estimates were 634. DALYs in Denmark were 1246 and in Sweden 788. In Denmark and Finland, changes in consumption generally corresponded to changes in disease burden, but not to the same extent in Sweden and Norway. All countries had a similar disease pattern and the majority of DALYs were due to YLLs (62–76%), mainly from alcohol use disorder, cirrhosis, transport injuries, self‐harm and violence. YLDs from alcohol use disorder accounted for 41% and 49% of DALYs in Denmark and Finland compared to 63 and 64% in Norway and Sweden 2013, respectively. Conclusions Finland and Denmark has a higher alcohol‐attributed disease burden than Sweden and Norway in the period 1990–2013. Changes in consumption levels in general corresponded to changes in harm in Finland and Denmark, but not in Sweden and Norway for some years. All countries followed a similar pattern. The majority of disability‐adjusted life years were due to premature mortality. Alcohol use disorder by non‐fatal conditions accounted for a higher proportion of disability‐adjusted life years in Norway and Sweden, compared with Finland and Denmark.

Alcohol-attributed disease burden in four Nordic countries

Abstract Aims (1) To compare alcohol‐attributed disease burden in four Nordic countries 1990–2013, by overall disability‐adjusted life years (DALYs) and separated by premature mortality [years of life lost (YLL)] and health loss to non‐fatal conditions [years lived with disability (YLD)]; (2) to examine whether changes in alcohol consumption informs alcohol‐attributed disease burden; and (3) to compare the distribution of disease burden separated by causes. Design A comparative risk assessment approach. Setting Sweden, Norway, Denmark and Finland. Participants Male and female populations of each country. Measurements Age‐standardized DALYs, YLLs and YLDs per 100 000 with 95% uncertainty intervals (UIs). Findings In Finland, with the highest burden over the study period, overall alcohol‐attributed DALYs were 1616 per 100 000 in 2013, while in Norway, with the lowest burden, corresponding estimates were 634. DALYs in Denmark were 1246 and in Sweden 788. In Denmark and Finland, changes in consumption generally corresponded to changes in disease burden, but not to the same extent in Sweden and Norway. All countries had a similar disease pattern and the majority of DALYs were due to YLLs (62–76%), mainly from alcohol use disorder, cirrhosis, transport injuries, self‐harm and violence. YLDs from alcohol use disorder accounted for 41% and 49% of DALYs in Denmark and Finland compared to 63 and 64% in Norway and Sweden 2013, respectively. Conclusions Finland and Denmark has a higher alcohol‐attributed disease burden than Sweden and Norway in the period 1990–2013. Changes in consumption levels in general corresponded to changes in harm in Finland and Denmark, but not in Sweden and Norway for some years. All countries followed a similar pattern. The majority of disability‐adjusted life years were due to premature mortality. Alcohol use disorder by non‐fatal conditions accounted for a higher proportion of disability‐adjusted life years in Norway and Sweden, compared with Finland and Denmark.