Kremlin Wickramasinghe

Modelling the health impact of environmentally sustainable dietary scenarios in the UK

BACKGROUND/OBJECTIVES:Food is responsible for around one-fifth of all greenhouse gas (GHG) emissions from products consumed in the UK, the largest contributor of which is meat and dairy. The Committee on Climate Change have modelled the impact on GHG emissions of three dietary scenarios for food consumption in the UK. This paper models the impact of the three scenarios on mortality from cardiovascular disease and cancer.SUBJECTS/METHODS:A previously published model (DIETRON) was used. The three scenarios were parameterised by fruit and vegetables, fibre, total fat, saturated fat, monounsaturated fatty acids, polyunsaturated fatty acids, cholesterol and salt using the 2008 Family Food Survey. A Monte Carlo simulation generated 95% credible intervals.RESULTS:Scenario 1 (50% reduction in meat and dairy replaced by fruit, vegetables and cereals: 19% reduction in GHG emissions) resulted in 36 910 (30 192 to 43 592) deaths delayed or averted per year. Scenario 2 (75% reduction in cow and sheep meat replaced by pigs and poultry: 9% reduction in GHG emissions) resulted in 1999 (1739 to 2389) deaths delayed or averted. Scenario 3 (50% reduction in pigs and poultry replaced with fruit, vegetables and cereals: 3% reduction in GHG emissions) resulted in 9297 (7288 to 11 301) deaths delayed or averted.CONCLUSION:Modelled results suggest that public health and climate change dietary goals are in broad alignment with the largest results in both domains occurring when consumption of all meat and dairy products are reduced. Further work in real-life settings is needed to confirm these results.

Quantifying Urbanization as a Risk Factor for Noncommunicable Disease

The aim of this study was to investigate the poorly understood relationship between the process of urbanization and noncommunicable diseases (NCDs) in Sri Lanka using a multicomponent, quantitative measure of urbanicity. NCD prevalence data were taken from the Sri Lankan Diabetes and Cardiovascular Study, comprising a representative sample of people from seven of the nine provinces in Sri Lanka (n = 4,485/5,000; response rate = 89.7%). We constructed a measure of the urban environment for seven areas using a 7-item scale based on data from study clusters to develop an “urbanicity” scale. The items were population size, population density, and access to markets, transportation, communications/media, economic factors, environment/sanitation, health, education, and housing quality. Linear and logistic regression models were constructed to examine the relationship between urbanicity and chronic disease risk factors. Among men, urbanicity was positively associated with physical inactivity (odds ratio [OR] = 3.22; 2.27–4.57), high body mass index (OR = 2.45; 95% CI, 1.88–3.20) and diabetes mellitus (OR = 2.44; 95% CI, 1.66–3.57). Among women, too, urbanicity was positively associated with physical inactivity (OR = 2.29; 95% CI, 1.64–3.21), high body mass index (OR = 2.92; 95% CI, 2.41–3.55), and diabetes mellitus (OR = 2.10; 95% CI, 1.58 – 2.80). There is a clear relationship between urbanicity and common modifiable risk factors for chronic disease in a representative sample of Sri Lankan adults.

Contribution of healthy and unhealthy primary school meals to greenhouse gas emissions in England: linking nutritional data and greenhouse gas emission data of diets

Background/Objectives:School meals represent the largest sector in Government food procurement in the United Kingdom. This paper aims to quantify, simultaneously, the nutritional quality and carbon footprint of meals provided by primary schools in England.Subjects/Methods:The School Food Trust conducted the ‘Primary School Food Survey 2009’ in a nationally representative sample of 139 primary schools in England. The survey included 6690 students who consumed school lunches and 3488 students who brought packed lunches. We estimated the total greenhouse gas emissions (GHGEs) per Kg of the food items contributing to those lunches based on the results of a systematic review of life-cycle analyses.Results:In both school lunches and packed lunches, the ‘meat, fish and alternatives’ group contributed the largest share of GHGEs. The mean GHGE value per school lunch was estimated to be 0.72 (95% uncertainty interval 0.52–1.34) KgCO2e and per packed lunch was 0.70 (0.58–0.94) KgCO2e. The total GHGE due to primary school meals in England per year is 578.1 million KgCO2e (455–892 million).Conclusions:If all children achieved a healthy meal defined by having a low level of salt, free sugars and saturated fat, the total GHGEs from primary school meals would be 441.2 million KgCO2e (384–1192), saving 136.9 million KgCO2e compared with the current total emissions from primary school meals. This paper demonstrates that changes in the primary school food sector can have an impact on UK GHGEs.

Tobacco Smoking Among School Children in Colombo District, Sri Lanka:

Tobacco smoking is an important problem among schoolchildren. The authors studied the patterns of tobacco smoking among schoolchildren in Colombo, Sri Lanka, using a self-administered questionnaire. Multistaged stratified random sampling was used to select 6000 students. Response rate was 90.7% (5446), out of which 53.4% were males. Prevalence rates for males and females, respectively, were as follows: having smoked at least 1 complete cigarette: 27.0% and 13.3%, smoked more than 100 cigarettes: 2.3% and 0.3%, daily smoking: 1.8% and 0.2%. Mean age of starting to smoke was 14.16 years. The tobacco products most used were cigarettes (91.5%) and bidis (3.8%). In univariate analysis, male gender, parental smoking, studying non-science subjects, peer smoking, and participating in sports were significantly associated with smoking of at least 1 complete cigarette (P < .05). In multivariate analysis, the most significant correlates were having close friends (odds ratio = 3.29, confidence interval = 2.47-4.37) or parents who smoked (odds ratio = 1.86, confidence interval = 1.28-2.71). Female smoking has increased from previously reported values. These high-risk groups can be targets for preventive programs.

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.

Defining sustainable diets by comparing greenhouse gas emissions from different food groups: a systematic review

Abstract Background Many physical and biological systems are changing because of anthropogenic global warming, but many effects of climate change can be avoided, reduced, or delayed by mitigation. The UK Climate Change Act 2008 sets a target to cut the total annual greenhouse gas emissions (GHGE) by 80% by 2050, with an interim target of a reduction of 34% by 2020, compared with 1990 levels. UK food production and consumption is responsible for up to 18–30% of the total GHGE. Therefore, defining sustainable healthy diets is important to cut down GHGE from food. We have adequate information on nutrients in food, but we do not have robust data on GHGEs of individual food groups. Methods This systematic review estimated GHGE values (mean and range) for all the food groups in a commonly used food frequency questionnaire (FFQ). Eight medical and geographical databases were searched from 1995 to 2012 to identify lifecycle assessment (LCA) studies of food. Full papers or reports of selected studies were obtained. If they estimated the GHGE (individual gases or the total global warming potential [GWP]) per functional unit (eg, kilogram or tonne of meat, litre of milk) of any food group by LCA they were included. If studies assessed only emissions per land area or per farm they were excluded. We selected studies that described these components and authors were contacted if these components were not explained in the full report. Studies were not excluded if authors did not respond or were not available in English language. GWP per kg of food, in kg of carbon dioxide equivalence over 100 years (KgCO 2 e), was recorded from each study with details about farming methods, location, and the boundaries of lifecycle. The initial search identified 14 096 hits. 126 were selected after screening titles and abstracts and a further 42 papers were added by searching organisational websites and databases. Quality assessors were masked. Findings Beef (mean 28·00, range 8·10–156·00) and lamb (15·52, 0·67–56·70) had the highest GWP values per kg and bread (–0·56, 0·25–0·93), fruits (–0·53, 0·06–1·37), and potatoes (–0·21, 0·13–0·48) were among the lowest values. The mean GWP for 1 kg of fruit juice was 2·92 KgCO 2 e. Whether organically and locally produced foods always have less GWP than non-organic foods and imported foods, respectively, is unclear. The GHGE values for organic products such as pork, chicken, eggs, potatoes, and tomatoes were higher than those for these foods when non-organically produced. The boundary of the LCA considered by the authors contributed substantially to variance in the results. Variation in results is due to a wide range of production systems, locations, and different system boundaries used in LCA studies. Therefore, the final estimates are not directly comparable and ranges overlap between food groups. GHGE is not the only indicator to measure the sustainability of food. However, GHGE was used in this study because it is the most commonly used indicator and government targets are set to measure the reduction in GHGE. Interpretation Organic foods and locally produced foods do not always produce fewer GHGEs. Little consistency in LCA methods makes direct comparisons of estimates difficult. Future LCA food studies should make efforts to follow a uniform approach, to include common definition of stages in the lifecycle and inclusion of similar activities always under each category of food. These GHGE estimates are for common food groups in a FFQ and could be combined with existing nutrition databases to address questions around sustainable healthy diets. These findings will be used to quantify the GHGE changes of different dietary scenarios in the UK to achieve GHGE reduction targets. Funding British Heart Foundation.

Use of illicit substances among schoolchildren in Colombo District, Sri Lanka

ABSTRACT Objective: This study aimed to understand the usage patterns and correlates of illicit drug use among schoolchildren in Colombo district, Sri Lanka. Methods: A cross-sectional study was carried out among grade 10 and 12 students using a self-administered questionnaire. Results: From the 6000 students selected, 5353(89.22%) responded. Betel chewing with tobacco was seen in 28.48% males and 10.44% females. Substances such as Barbul, Madana Modaka, and cough syrups that are not established as illicit drugs were used as psychoactive substances. Ingredients of some of these compounds are not fully understood or regulated. Prevalence of cannabis use was 3.85% in males and 0.24% in females. Studying nonscience subjects for Advanced Level, doing sports, low academic performance, and peer smoking significantly increased the odds of using one or more substances (P < .05). Conclusions: Many types of illicit substances were used by schoolchildren. More strategies to prevent further aggravation of these behaviors are needed. Constituents of some compounds are not understood and need further evaluation. Recognized high-risk groups can be targets for preventive and cessation programs.

P1-93 Trends in the burden of cardiovascular diseases in the UK, 1961 to 2011

Introduction Mortality from cardiovascular disease (CVD) has dramatically reduced over the past 50 years in the UK. While this trend should be celebrated, it is important to consider mortality alongside trends in morbidity to gain a full understanding of how healthcare resources and prevention schemes should be directed. This paper reported trends in mortality, incidence and prevalence of coronary heart disease (CHD), stroke, heart attack, angina and heart failure over the past 50 years. Methods Mortality data were provided by the UK national statistics agencies. For morbidity data we reviewed the peer-reviewed and grey literature for comparable estimates from different time points over the last 50 years. Results Around half of the UK population died from CVD in the 1960s; by 2009 this had dropped to a third. CHD mortality rates have remained 30%–40% higher in Scotland than in England since 1961. Incidence rates for heart attack have decreased since the 1960s, while survival has improved; prevalence in those over 75 has increased by around 40% since the mid-1990s. Over the past 20 years heart failure incidence decreased by over a third in Scotland. Between 1970 and 1991, prevalence of angina nearly tripled for men over 75 and has continued to rise. Conclusion Mortality from CVD has declined over the past 50 years, but striking geographic inequalities have remained. Incidence of two major CVD conditions have declined, but continuing increases in prevalence and an ageing population mean that the burden of CVD is still a major issue for the UK.

A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries

Background Non-communicable diseases (NCDs) are the leading cause of death globally. Eighty-two percent of premature NCD deaths occur within low- and lower middle-income countries (LLMICs). Research to date, largely drawn from high-income countries, suggests that disadvantaged and marginalized groups have a higher NCD burden, but there has been a dearth of research studying this relationship within LLMICs. The purpose of this systematic review is to map the literature on evidence from LLMICs on the socio-economic status (SES) gradient of four particular NCDs: cardiovascular disease, cancer, diabetes, and chronic respiratory diseases. Methods We conducted a comprehensive literature search for primary research published between 1 January 1990 and 27 April 2015 using six bibliographic databases and web resources. We included studies that reported SES and morbidity or mortality from cardiovascular disease, cancer, diabetes and chronic respiratory diseases within LLMICs. Results Fifty-seven studies from 17 LLMICs met our inclusion criteria. Fourteen of the 18 papers that reported significant associations between cancer and SES suggested that low SES groups had the highest cancer risk. Eleven of 15 papers reporting significant relationships between CVD and SES suggested that low SES groups have higher risk. In contrast, seven of 12 papers reporting significant findings related to diabetes found that higher SES groups had higher diabetes risk. We identified just three studies on the relationship between chronic respiratory diseases and SES; none of them reported significant findings. Conclusions Only 17 of the 84 LLMICs were represented, highlighting the need for more research on NCDs within these countries. The majority of studies were medium to high quality cross-sectional studies. When we restricted our analyses to high quality studies only, for both cancer and cardiovascular disease more than half of studies found a significantly higher risk for those of lower SES. The opposite was true for diabetes, whilst there was a paucity of high quality research on chronic respiratory disease. Development programmes must consider health alongside other aims and NCD prevention interventions must target all members of the population. Systematic review registration number Prospero: CRD42015020169.

Building Noncommunicable Disease Research Capacity in the South Asian Region The ASCEND Program

The Asian Collaboration for Excellence in Noncommunicable Disease Research (ASCEND) Program is delighted that this supplementary issue of the Asia-Pacific Journal of Public Health has come to fruition. This special edition of the journal features research articles from a number of the research trainees from the ASCEND program, a noncommunicable disease (NCD) research training and mentoring program for earlyand mid-career researchers from India, Malaysia, and Sri Lanka, which has been established by funding from the Fogarty International Center, United States National Institutes of Health1 since 2010. As noted by Mehta2 in his commentary piece in this same issue, NCDs including cardiovascular disease (CVD), diabetes, chronic respiratory diseases, and cancers now account for the highest burden of disease and mortality in both the developing and developed world. Alarmingly, rates of NCDs such as CVD, diabetes, mental health disorders, and cancers are continuing to rise, particularly in lowand middleincome countries (LMICs), including in South Asia. Too little research has been undertaken in LMICs about how to implement programs and policies that can improve health, prevent chronic conditions, and also help improve their management. This improved evidence base needs to take account of the many special issues and challenges that confront low and middle income countries in addressing the prevention and control of NCDs. Often, there are health system challenges, a lack of health professionals and most importantly, a lack of a health research workforce to undertake the research to develop an evidence base that considers the enablers of and barriers to effective implementation in the local context. The ASCEND Program strives to build this evidence-base by strengthening NCD research capacity across Asia, providing high-quality research training and building a regional network of NCD researchers and research institutions with a special focus on prevention and more “upstream” determinants of health and interventions. The program has also focused on the new field of implementation science as applied to public health interventions and programs. To date, it has provided training to 50 young researchers from university and research institutions within participating countries and it has also established a diverse network of regional collaborators from government, nongovernment and other organizations as well as researchers from a number of other countries.