D Stuckler

Epidemiologic and economic consequences of the global epidemics of obesity and diabetes

Overweight and obesity, the main drivers of type 2 diabetes, have long been regarded as health risks associated with affluence. Over the last decade, profound changes in the quality, quantity and source of food consumed in many developing countries, combined with a decrease in levels of physical activity among the population, have led to an increase in the prevalence of diabetes and its complications. Here, we present quantitative estimates of the epidemiological and economic impact of obesity and diabetes on developing countries. We provide the economic rationale for public policy action. We stress the importance of creating a roadmap to guide the development of comprehensive policies involving governments and private companies, and emphasize the need for experimentation in building the evidence while testing theories.

How will Brexit affect health and health services in the UK? Evaluating three possible scenarios

The process of leaving the European Union (EU) will have profound consequences for health and the National Health Service (NHS) in the UK. In this paper, we use the WHO health system building blocks framework to assess the likely effects of three scenarios we term soft Brexit, hard Brexit, and failed Brexit. We conclude that each scenario poses substantial threats. The workforce of the NHS is heavily reliant on EU staff. Financing of health care for UK citizens in the EU and vice versa is threatened, as is access to some capital funds, while Brexit threatens overall economic performance. Access to pharmaceuticals, technology, blood, and organs for transplant is jeopardised. Information used for international comparisons is threatened, as is service delivery, especially in Northern Ireland. Governance concerns relate to public health, competition and trade law, and research. However, we identified a few potential opportunities for improvement in areas such as competition law and flexibility of training, should the UK Government take them. Overall, a soft version of Brexit would minimise health threats whereas failed Brexit would be the riskiest outcome. Effective parliamentary scrutiny of policy and legal changes will be essential, but the scale of the task risks overwhelming parliament and the civil service.

The Vienna Declaration on Public Health

In 1986 participants at the First International Conference on Health Promotion agreed the landmark Ottawa Charter. The Charter was a powerful response to calls for a new public health movement, setting out a vision and framework for actions to achieve the World Health Organization’s ‘Health for All’ targets by the year 2000 and beyond. It provided the foundation for many subsequent developments, including health in all policies, action on the built environment, community action and empowerment, an emphasis on prevention, and a focus on health equity.nnToday the principles of the Ottawa Charter remain as important as ever. Yet the world in 2016 is very different from that in 1986, and so too have the risks and opportunities for public health. In recognition of these changes, and taking account of other developments such as the 2016 World Federation of Public Health Association’s Global Charter on the Public’s Health,1 the European Public Health Association and its partners have examined how the principles set out in the Ottawa Charter apply …

Inequalities in the use of secondary prevention of cardiovascular disease by socioeconomic status: evidence from the PURE observational study

Summary Background There is little evidence on the use of secondary prevention medicines for cardiovascular disease by socioeconomic groups in countries at different levels of economic development. Methods We assessed use of antiplatelet, cholesterol, and blood-pressure-lowering drugs in 8492 individuals with self-reported cardiovascular disease from 21 countries enrolled in the Prospective Urban Rural Epidemiology (PURE) study. Defining one or more drugs as a minimal level of secondary prevention, wealth-related inequality was measured using the Wagstaff concentration index, scaled from −1 (pro-poor) to 1 (pro-rich), standardised by age and sex. Correlations between inequalities and national health-related indicators were estimated. Findings The proportion of patients with cardiovascular disease on three medications ranged from 0% in South Africa (95% CI 0–1·7), Tanzania (0–3·6), and Zimbabwe (0–5·1), to 49·3% in Canada (44·4–54·3). Proportions receiving at least one drug varied from 2·0% (95% CI 0·5–6·9) in Tanzania to 91·4% (86·6–94·6) in Sweden. There was significant (p<0·05) pro-rich inequality in Saudi Arabia, China, Colombia, India, Pakistan, and Zimbabwe. Pro-poor distributions were observed in Sweden, Brazil, Chile, Poland, and the occupied Palestinian territory. The strongest predictors of inequality were public expenditure on health and overall use of secondary prevention medicines. Interpretation Use of medication for secondary prevention of cardiovascular disease is alarmingly low. In many countries with the lowest use, pro-rich inequality is greatest. Policies associated with an equal or pro-poor distribution include free medications and community health programmes to support adherence to medications. Funding Full funding sources listed at the end of the paper (see Acknowledgments).

A conceptual framework for investigating the impacts of international trade and investment agreements on noncommunicable disease risk factors

We developed a conceptual framework exploring pathways between trade and investment and noncommunicable disease (NCD) outcomes. Despite increased knowledge of the relevance of social and structural determinants of health, the discourse on NCD prevention has been dominated by individualizing paradigms targeted at lifestyle interventions. We situate individual risk factors, alongside key social determinants of health, as being conditioned and constrained by trade and investment policy, with the aim of creating a more comprehensive approach to investigations of the health impacts of trade and investment agreements, and to encourage upstream approaches to combating rising rates of NCDs. To develop the framework we employed causal chain analysis, a technique which sequences the immediate causes, underlying causes, and root causes of an outcome; and realist review, a type of literature review focussed on explaining the underlying mechanisms connecting two events. The results explore how facilitating trade in goods can increase flows of affordable unhealthy imports; while potentially altering revenues for public service provision and reshaping domestic economies and labour markets-both of which distribute and redistribute resources for healthy lifestyles. The facilitation of cross-border trade in services and investment can drive foreign investment in unhealthy commodities, which in turn, influences consumption of these products; while altering accessibility to pharmaceuticals that may mediate NCDs outcomes that result from increased consumption. Furthermore, trade and investment provisions that influence the policy-making process, set international standards, and restrict policy-space, may alter a states propensity for regulating unhealthy commodities and the efficacy of those regulations. It is the hope that the development of this conceptual framework will encourage capacity and inclination among a greater number of researchers to investigate a more comprehensive range of potential health impacts of trade and investment agreements to generate an extensive and robust evidence-base to guide future policy actions in this area.

Complexity and conflicts of interest statements: a case-study of emails exchanged between Coca-Cola and the principal investigators of the International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE)

Statements on conflicts of interest provide important information for readers of scientific papers. There is now compelling evidence from several fields that papers reporting funding from organizations that have an interest in the results often generate different findings from those that do not report such funding. We describe the findings of an analysis of correspondence between representatives of a major soft drinks company and scientists researching childhood obesity. Although the studies report no influence by the funder, the correspondence describes detailed exchanges on the study design, presentation of results and acknowledgement of funding. This raises important questions about the meaning of standard statements on conflicts of interest.

Constructing a Housing Precariousness Measure for Europe

There are concerns that the recovery from the Great Recession in Europe has left growing numbers of people facing precarious housing situations. Yet, to our knowledge, there is no comparative measure of housing precariousness in contrast to an extensive body of work on labour market precariousness. Here, we draw on a comparative survey of 31 European countries from the 2012 wave of European Union Survey of Income and Living Conditions to develop a novel housing precariousness measure. We integrate four dimensions of housing precariousness: security, affordability, quality and access to services, into a scale ranging from 0 (not at all precarious) to 4 (most precarious). Over half of the European population report at least one element of housing precariousness; 14.7u2009 percent report two dimensions and 2.8u2009 percent three or more (equivalent to ~15u2009 million people). Eastern European and small island nations have relatively greater precariousness scores. Worse precariousness tends to be more severe among the young, unemployed, single and those with low educational attainment or who live in rented homes and is associated with poor self-reported health. Future research is needed to strengthen surveillance of housing precariousness as well as to understand what policies and programmes can help alleviate it.

The Impact of U.S. Free Trade Agreements on Calorie Availability and Obesity: A Natural Experiment in Canada

Introduction Globalization via free trade and investment agreements is often implicated in the obesity pandemic. Concerns center on how free trade and investment agreements increase population exposure to unhealthy, high-calorie diets, but existing studies preclude causal conclusions. Few studies of free trade and investment agreements and diets isolated their impact from confounding changes, and none examined any effect on caloric intake, despite its critical role in the etiology of obesity. This study addresses these limitations by analyzing a unique natural experiment arising from the exceptional circumstances surrounding the implementation of the 1989 Canada–U.S. Free Trade Agreement. Methods Data from the UN (2017) were analyzed using fixed-effects regression models and the synthetic control method to estimate the impact of the Canada–U.S. Free Trade Agreement on calorie availability in Canada, 1978–2006, and coinciding increases in U.S. exports and investment in Canada’s food and beverage sector. The impact of changes to calorie availability on body weights was then modeled. Results Calorie availability increased by ≅170 kilocalories per capita per day in Canada after the Canada–U.S. Free Trade Agreement. There was a coinciding rise in U.S. trade and investment in the Canadian food and beverage sector. This rise in calorie availability is estimated to account for an average weight gain of between 1.8 kg and 12.2 kg in the Canadian population, depending on sex and physical activity levels. Conclusions The Canada–U.S. Free Trade Agreement was associated with a substantial rise in calorie availability in Canada. U.S. free trade and investment agreements can contribute to rising obesity and related diseases by pushing up caloric intake.

Health and Wealth in the United States and England—Two Very Different Countries With Similar Findings

Although superficially they have much in common, health and social policy in the United States and England differ greatly. England provides universal health coverage; notwithstanding the achievements of the Affordable Care Act, the United States does not. England has retained strong social safety nets. Welfare in the United States is much less generous and, although those reaching 65 years can look forward to a range of benefits, support for the young is much less generous. But what do these differences mean for the health of those living in each country? Makaroun and colleagues1 ask this question in the accompanying article. They are not the first to do so. We know that deaths from causes amenable to medical care are more frequent in the United States, which is unsurprising given problems with access to care in the American health care system. Health inequalities, at least as measured by income or education, also seem to be wider in the United States.2 However, Makaroun and colleagues1 add a new perspective, examining the role of wealth inequalities on health outcomes in the 2 countries. Their findings are both alarming and surprising. First, they showed that the differences between those in the most and least wealthy quintiles were enormous; in the younger groups (aged between 54 and 65 years) those in the wealthiest quintile had 231 times as much value in assets as the least wealthy in the United States, whereas the gap was slightly narrower, at 180 times, in England. The corresponding figures were 163 times more in the United States and 115 times more in England among the older group (aged 66-76 years). Second, they showed that greater wealth was consistently associated with improved health outcomes in both countries. In the younger sample, those in the least wealthy quintile were over 3 times as likely to die in the subsequent 10 years than those in wealthiest quintile. This difference narrowed slightly when adjusted for other factors, such as race, education, and sex, but, arguably, while the effect of adjustment is of interest to epidemiologists, it is the unadjusted figure that matters most for the individuals concerned. The difference in probability of dying between the most and least wealthy was slightly narrower among those aged between 66 and 76 years, but was still more than 2-fold. Similar findings were obtained when comparing patterns of disability. What can we take from these findings? First, they remind us of the importance of addressing wealth inequalities. In the data sets used in the study, the degree of inequality of wealth was much greater than for income. Wealth inequalities had been narrowing during the first part of the 20th century but are now widening markedly across successive generations in England3 and between races in the United States.4 Second, although we already know that wealth inequalities have an impact on health, by showing similar health inequalities in quite different social and health care system contexts, this study adds considerably to what we already know about why wealth impacts health. Unsurprisingly, ownership of assets, especially those such as property that can generate unearned income, can insulate individuals against economic shocks. Yet this is only part of the story. Even without the prospect of unearned income, assets can be protective. A European study5 found that those facing problems paying rent experienced worsening health while those facing similar problems paying mortgages on properties they owned did not. And simply knowing that the value of one’s assets has increased may benefit health. A British study6 found that home owners whose property increased in value during a property boom experienced better health and fewer chronic conditions than those whose property did not, findings attributed to resulting lower work intensity and healthier leisure choices. Third, the empirical evidence presented here strengthens the case for policies on health inequalities that address the unequal distribution of wealth. These can be justified as a matter of fairness. Many of the most wealthy have become so not by their own efforts but by the play of chance, for example by owning assets in the right place at the right time or by inheriting wealth from family members. Fourth, they confirm that, as with income and education, health varies over the entire range of wealth. This strengthens the case against welfare policies that only target the very poor rather than those that seek to help everyone while doing most for those lower down the wealth scale. This approach is termed progressive universalism and has the added benefit of convincing the middle classes that, although they may pay for the poor through their taxes, they also get something back. This reduces the tendency to view welfare as “us” paying for “them,” which tends to undermine solidarity, especially when many of the recipients are identifiably different, for example because of skin color or dress. Fifth, the finding that inequalities are similar in each country, despite their very different health and social systems, is very important. As noted by the authors, reaching age 65 years is a major milestone for Americans. An earlier comparison of the United States and England demonstrated how important it is for health outcomes, showing how death rates from many chronic disorders among Americans younger than 65 years were much higher than in England, but the gap narrowed after that age. In contrast, in England cancer survival declined at older ages, thought to reflect implicit age rationing in a cash limited system.7 In contrast, it remains high even at old age in the United States. The study by Makaroun and colleagues1 suggests that, despite these different systems, the impact on inRelated article Health and Wealth in the United States and England Invited Commentary

Impact of welfare benefit sanctioning on food insecurity: a dynamic cross-area study of food bank usage in the UK.

Since 2009, the UK has witnessed marked increases in the rate of sanctions applied to unemployment insurance claimants, as part of a wider agenda of austerity and welfare reform. In 2013, over one million sanctions were applied, stopping benefit payments for a minimum of four weeks and potentially leaving people facing economic hardship and driving them to use food banks. Here we explore whether sanctioning is associated with food bank use by linking data from The Trussell Trust Foodbank Network with records on sanctioning rates across 259 local authorities in the UK. After accounting for local authority differences and time trends, the rate of adults fed by food banks rose by an additional 3.36 adults per 100,000 (95% CI: 1.71 to 5.01) as the rate of sanctioning increased by 10 per 100,000 adults. The availability of food distribution sites affected how tightly sanctioning and food bank usage were associated (p < 0.001); in areas with few distribution sites, rising sanctions led to smaller increases in food bank usage. In conclusion, sanctioning is closely linked with rising food bank usage, but the impact of sanctioning on household food insecurity is not fully reflected in available data.