Julianne Williams

The epidemiology of cardiovascular disease in the UK 2014

Cardiovascular disease (CVD) presents a significant burden to the UK. This review presents data from nationally representative datasets to provide up-to-date statistics on mortality, prevalence, treatment and costs. Data focus on CVD as a whole, coronary heart disease (International Classification of Diseases (ICD):I20–25) and cerebrovascular disease (ICD:I60–69); however, where available, other cardiovascular conditions are also presented. In 2012, CVD was the most common cause of death in the UK for women (28% of all female deaths), but not for men, where cancer is now the most common cause of death (32% of all male deaths). Mortality from CVD varies widely throughout the UK, with the highest age-standardised CVD death rates in Scotland (347/100 000) and the North of England (320/100 000 in the North West). Prevalence of coronary heart disease is also highest in the North of England (4.5% in the North East) and Scotland (4.3%). Overall, around three times as many men have had a myocardial infarction compared with women. Treatment for CVD is increasing over time, with prescriptions and operations for CVD having substantially increased over the last two decades. The National Health Service in England spent around £6.8 billion on CVD in 2012/2013, the majority of which came from spending on secondary care. Despite significant declines in mortality in the UK, CVD remains a considerable burden, both in terms of health and costs. Both primary and secondary prevention measures are necessary to reduce both the burden of CVD and inequalities in CVD mortality and prevalence.

A systematic review of the influence of the retail food environment around schools on obesity-related outcomes

The high prevalence of childhood obesity has led to questions about the influence of ‘obesogenic’ environments on childrens health. Public health interventions targeting the retail food environment around schools have been proposed, but it is unclear if they are evidence based. This systematic review investigates associations between food outlets near schools and childrens food purchases, consumption and body weight. We conducted a keyword search in 10 databases. Inclusion criteria required papers to be peer reviewed, to measure retailing around schools and to measure obesity‐related outcomes among schoolchildren. Thirty papers were included. This review found very little evidence for an effect of the retail food environment surrounding schools on food purchases and consumption, but some evidence of an effect on body weight. Given the general lack of evidence for association with the mediating variables of food purchases and consumption, and the observational nature of the included studies, it is possible that the effect on body weight is a result of residual confounding. Most of the included studies did not consider individual childrens journeys through the food environment, suggesting that predominant exposure measures may not account for what individual children actually experience. These findings suggest that future interventions targeting the food environment around schools need careful evaluation.

Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review

Summary Background Non-communicable diseases are the leading global cause of death and disproportionately afflict those living in low-income and lower-middle-income countries (LLMICs). The association between socioeconomic status and non-communicable disease behavioural risk factors is well established in high-income countries, but it is not clear how behavioural risk factors are distributed within LLMICs. We aimed to systematically review evidence on the association between socioeconomic status and harmful use of alcohol, tobacco use, unhealthy diets, and physical inactivity within LLMICs. Methods We searched 13 electronic databases, including Embase and MEDLINE, grey literature, and reference lists for primary research published between Jan 1, 1990, and June 30, 2015. We included studies from LLMICs presenting data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. No age or language restrictions were applied. We excluded studies that did not allow comparison between more or less advantaged groups. We used a piloted version of the Cochrane Effective Practice and Organisation of Care Group data collection checklist to extract relevant data at the household and individual level from the included full text studies including study type, methods, outcomes, and results. Due to high heterogeneity, we used a narrative approach for data synthesis. We used descriptive statistics to assess whether the prevalence of each risk factor varied significantly between members of different socioeconomic groups. The study protocol is registered with PROSPERO, number CRD42015026604. Findings After reviewing 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals older than 10 years from 39 LLMICs. Low socioeconomic groups were found to have a significantly higher prevalence of tobacco and alcohol use than did high socioeconomic groups. These groups also consumed less fruit, vegetables, fish, and fibre than those of high socioeconomic status. High socioeconomic groups were found to be less physically active and consume more fats, salt, and processed food than individuals of low socioeconomic status. While the included studies presented clear patterns for tobacco use and physical activity, heterogeneity between dietary outcome measures and a paucity of evidence around harmful alcohol use limit the certainty of these findings. Interpretation Despite significant heterogeneity in exposure and outcome measures, clear evidence shows that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal (SDG) 3.4—reducing premature non-communicable disease mortality by a third by 2030—should leverage their development budgets to address the poverty-health nexus in these settings. Our findings also have significance for health workers serving these populations and policy makers tasked with preventing and controlling the rise of non-communicable diseases. Funding WHO.

Exploring the opportunities for food and drink purchasing and consumption by teenagers during their journeys between home and school: a feasibility study using a novel method

OBJECTIVE To investigate the feasibility and acceptability of using wearable cameras as a method to capture the opportunities for food and drink purchasing/consumption that young people encounter on their regular journeys to and from school. DESIGN A qualitative study using multiple data-collection methods including wearable cameras, global positioning system units, individual interviews, food and drink purchase and consumption diaries completed by participants over four days, and an audit of food outlets located within an 800 m Euclidean buffer zone around each school. SETTING A community setting. SUBJECTS Twenty-two students (fourteen girls and eight boys) aged 13-15 years recruited from four secondary schools in two counties of England. RESULTS Wearable cameras offered a feasible and acceptable method for collecting food purchase and consumption data when used alongside traditional methods of data collection in a small number of teenagers. We found evidence of participants making deliberate choices about whether or not to purchase/consume food and drink on their journeys. These choices were influenced by priorities over money, friends, journey length, travel mode and ease of access to opportunities for purchase/consumption. Most food and drink items were purchased/consumed within an 800 m Euclidean buffer around school, with items commonly selected being high in energy, fat and sugar. Wearable camera images combined with interviews helped identify unreported items and misreporting errors. CONCLUSIONS Wearable camera images prompt detailed discussion and generate contextually specific information which could offer new insights and understanding around eating behaviour patterns. The feasibility of scaling up the use of these methods requires further empirical work.

Associations between Food Outlets around Schools and BMI among Primary Students in England: A Cross-Classified Multi-Level Analysis

Introduction Researchers and policy-makers are interested in the influence that food retailing around schools may have on child obesity risk. Most previous research comes from North America, uses data aggregated at the school-level and focuses on associations between fast food outlets and school obesity rates. This study examines associations between food retailing and BMI among a large sample of primary school students in Berkshire, England. By controlling for individual, school and home characteristics and stratifying results across the primary school years, we aimed to identify if the food environment around schools had an effect on BMI, independent of socio-economic variables. Methods We measured the densities of fast food outlets and food stores found within schoolchildren’s home and school environments using Geographic Information Systems (GIS) and data from local councils. We linked these data to measures from the 2010/11 National Child Measurement Programme and used a cross-classified multi-level approach to examine associations between food retailing and BMI z-scores. Analyses were stratified among Reception (aged 4-5) and Year 6 (aged 10-11) students to measure associations across the primary school years. Results Our multilevel model had three levels to account for individual (n = 16,956), home neighbourhood (n = 664) and school (n = 268) factors. After controlling for confounders, there were no significant associations between retailing near schools and student BMI, but significant positive associations between fast food outlets in home neighbourhood and BMI z-scores. Year 6 students living in areas with the highest density of fast food outlets had an average BMI z-score that was 0.12 (95% CI: 0.04, 0.20) higher than those living in areas with none. Discussion We found little evidence to suggest that food retailing around schools influences student BMI. There is some evidence to suggest that fast food outlet densities in a child’s home neighbourhood may have an effect on BMI, particularly among girls, but more research is needed to inform effective policies targeting the effects of the retail environment on child obesity.

Barriers to healthy dietary choice amongst students in Sri Lanka as perceived by school principals and staff

Summary Sri Lanka has experienced a massive demographic, environmental, economic and social transition in recent decades. Over this period of time the country has undergone rapid urbanization leading to accompanying shifts in lifestyle and it suffers a double burden of under- and over-nutrition. Current programmes in the country focus on improving the dietary behaviour of secondary school students. The purpose of this study was to investigate principals perceptions on barriers to healthy dietary choice among pupils within a socio-ecological framework. Focus groups (n = 11) were carried out with school principals and staff (n = 55) in two rural districts of Sri Lanka. Principals identified a number of barriers to healthy dietary choice by students, which could be found at a number of levels of influence of a socio-ecological framework: (i) structural level barriers included educational and agricultural policies, (ii) living and working level barriers included employment opportunities and local food production, (iii) social and community level barriers included traditions and social/cultural beliefs and (iv) individual level barriers included knowledge and preference. Findings from this study suggest that the barriers to healthy dietary choice amongst secondary school students in Sri Lanka occur at many levels supporting the use of multifactorial programmes to promote healthy eating. Only from understanding these barriers and finding ways to counter them can we hope to reduce the double burden of under- and over-nutrition the country is currently suffering.

Evaluation of research on interventions aligned to WHO ‘Best Buys’ for NCDs in low-income and lower-middle-income countries: a systematic review from 1990 to 2015

Background Non-communicable diseases (NCDs) are the leading cause of death and disability worldwide, with low-income and middle-income countries experiencing a disproportionately high burden. Since 2010 WHO has promoted 24 highly cost-effective interventions for NCDs, dubbed ‘best buys’. It is unclear whether these interventions have been evaluated in low-income and lower-middle-income countries (LLMICs). Aim To systematically review research on interventions aligned to WHO ‘best buys’ for NCDs in LLMICs. Methods We searched 13 major databases and included papers conducted in the 83 World Bank-defined LLMICs, published between 1 January 1990 and 5 February 2015. Two reviewers independently screened papers and assessed risk of bias. We adopted a narrative approach to data synthesis. The primary outcomes were NCD-related mortality and morbidity, and risk factor prevalence. Results We identified 2672 records, of which 36 were included (608 940 participants). No studies on ‘best buys’ were found in 89% of LLMICs. Nineteen of the 36 studies reported on the effectiveness of tobacco-related ‘best buys’, presenting good evidence for group interventions in reducing tobacco use but weaker evidence for interventions targeting individuals. There were fewer studies on smoking bans, warning labels and mass media campaigns, and no studies on taxes or marketing restrictions. There was supportive evidence that cervical screening and hepatitis B immunisation prevent cancer in LLMICs. A single randomised controlled trial supported polypharmacy for cardiovascular disease. Fourteen of the ‘best buy’ interventions did not have any good evidence for effectiveness in LLMICs. Conclusions We found studies on only 11 of the 24 interventions aligned with the WHO ‘best buys’ from LLMIC settings. Most LLMICs have not conducted research on these interventions in their populations. LLMICs should take action to implement and evaluate ‘best buys’ in their national context, based on national priorities, and starting with interventions with the strongest evidence base.

Poverty and risk factors for non-communicable diseases in developing countries: a systematic review

Abstract Background The association between poverty and health is highly context-specific; in high-income countries, low socioeconomic status is associated with use of tobacco and alcohol, physical inactivity, and poor diet. We lack good quality epidemiological evidence from developing countries, especially from low and lower middle-income countries (LLMICs). This systematic review sought to fill this gap. Methods We conducted a comprehensive literature search for primary research published between Jan 1, 1990, and June 30, 2015, using 13 electronic databases, including Embase and Medline, as well as a grey literature review and hand searching of references. Two reviewers independently screened papers retrieved from 13 databases with a search devised by an experienced medical librarian combining MeSH terms and synonyms for non-communicable diseases, behavioural risk factors, poverty, and the 84 LLMICs defined by the World Bank. We included studies from LLMICs that presented data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. We performed narrative data synthesis. Findings After review of 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals aged more than 10 years from 39 LLMICs. Most studies found that, compared with high socioeconomic groups, lower status groups had a high prevalence of tobacco and alcohol use (odds ratios up to 18·8 and 3·5, respectively). Most studies also found that lower socioeconomic groups consumed less fruit, vegetables, fish, and fibre (odds ratios negligible to 12·9, depending on context). Higher socioeconomic groups were up to 4·4 times less physically active and consumed more fats, salt, and processed food; however, these dietary studies tended to be smaller with wide confidence intervals. Interpretation Despite variation in exposure and outcome measures, there is clear evidence that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal 3.4—reducing premature mortality from non-communicable diseases by a third by 2030—should leverage their development budgets to address the poverty–health nexus in these settings. Our findings are also important for health workers serving these populations, and for policymakers tasked with preventing and controlling the rise of non-communicable diseases. Funding None.

Participant Experience Using GPS Devices in a Food Environment and Nutrition Study

ABSTRACT Global Positioning Systems (GPS) have emerged as potentially useful tools for research on the spatial contexts of food purchases and consumption, but limited studies have assessed users’ experiences using GPS to track diet behaviors in free-living settings. This was a pilot study conducted in Seattle, Washington, in the fall of 2011. Ten university students (8 female, 2 male, mean age = 27.9, SD = 4.8) tracked their food purchases and consumption over 3 days using a Wintec WBT 202 GPS device and traditional paper-based methods. We compared the frequency of reports using these methods and assessed the participants’ experiences via interviews and product evaluation questionnaires. For most participants, the GPS method captured more records than the paper-based methods. Users appreciated the device’s compact size and the simplicity of its design but frequently complained about the device’s short battery life, problems carrying the device, difficulty maintaining satellite connections, and problems remembering to use the device. This study highlights the importance of investigating participant experiences with technologies before deploying them on a larger scale. A number of key characteristics should be considered in the development of such devices to optimize the user’s experience without sacrificing accuracy of the data collected.

Influence of the retail food environment around schools on obesity-related outcomes: a systematic review

Abstract Background Soaring childhood obesity rates have led to questions about the influence of obesogenic environments on childrens health. Public health interventions that target the retail food environment around schools have been proposed, but whether these interventions are evidence based is unclear. Methods We examined associations between the retail food environment near schools and food purchasing, consumption, and bodyweight of students. We catalogued and critiqued the methods and results of studies analysing these associations and sought to assess the quality of evidence within the publications. We undertook a keyword search of several databases and sources of grey literature, including Medline, Embase, Web of Science, and the Cochrane Public Health Group specialised register. Inclusion criteria required studies to be published in a peer-reviewed journal between January, 1981, and October, 2012, provide at least one measurement of food retailing surrounding schools, and include outcome data for school children aged 5–18 years. Two researchers independently reviewed papers and blindly assessed the quality of the study using a modified checklist that covered study design and reporting. Methodological heterogeneity precluded meta-analysis, so we used a semiquantitative method in which we categorised papers according to their outcomes and identified whether or not the outcome was significantly (p Findings 21 studies met our inclusion criteria. All followed a cross-sectional study design. 19 described the food environment with geographical-system-information-based measures (eg, the density or proximity of food outlets within a buffer zone around the school) and two characterised the food environment using qualitative data. Outcome measures varied considerably. Only one study examined effects on food purchasing behaviour. Far more common were studies examining effects on the consumption of fruit and vegetables and of foods high in fat, sugar, or salt, or the effects on bodyweight. The one study that examined the associations between food outlets and food purchases showed a significant correlation between the proximity of fast food outlets and the number of fast food purchases. Five papers assessed associations between food outlets around schools and the consumption of fruits and vegetables. 34 relations were assessed, half of which showed a positive correlation. Only one of these results was significant (p Interpretation This review of the scientific literature found very little evidence for an effect of the retail food environment surrounding schools on food purchases and consumption patterns, but some evidence of an effect on bodyweight. Given the general lack of evidence for association with the mediating variables of food purchasing and food consumption, and the observational nature of the studies included in this review, it is possible that this finding is a result of residual confounding. The methods for the studies varied, but many contained worrying limitations; for example, most studies measured exposure at the level of the school and only one study considered childrens actual journeys through the food environment. Better studies are required to inform effective public health policies. Funding British Heart Foundation, NHS Berkshire.