M Guzman Castillo

OP74 Estimating the Effect of a Turkish Sugar Sweetened Beverages Tax on Obesity up to year 2031

Background Growing evidence suggests that sugar sweetened beverage (SSB) intake can increase long-term weight gain and hence worsen the ongoing obesity epidemic. A tax on SSBs might offer an effective population wide intervention to reduce the burden of obesity, cardiovascular diseases (CVD) and common cancers. We aimed to estimate the potential impact on obesity of a 10% and 20% tax on SSBs in Turkey. Methods We developed a Markov model for the Turkish population aged 35 years and older. The model follows a closed cohort from year 2011 to 2031. The cohort has the probability of transition to healthy, overweight or obese states or to die from CVD, cancer or other causes. Model inputs were population and death records from Turkish Statistical Institute, overweight and obesity prevalence from Turkish National Chronic Disease Survey, 2011, daily mean SSB intake from Turkish National Diet and Nutrition Survey. We used DISMOD II software to estimate the incidence of overweight and obesity. The effect of tax was calculated using price elasticities obtained from previous published studies. We compared three scenarios: The baseline scenario involved no change in consumption of SSBs. In two additional scenarios, we modelled the effect of a 10% and 20% tax on decreasing SSBs intake. We then modelled the effect of this SSB decrease on BMI and obesity prevalence on the Turkish population. We further calculated the population attributable risk fraction of obesity to estimate the CVD and cancer cases potentially preventable. We also conducted a probabilistic sensitivity analysis to estimate 95% uncertainty intervals (95% UI). Results We forecast that in this closed cohort, by the year 2031, approximately 4,201,100 (4,130,000–4,270,000) men and 5,419,000 (5,305,000–5,537,000) women would be obese. However implementing a 10% SSB tax could result in approximately 21,900 (19,800–29,040) fewer obese men and 13,500 (12,900–15,400) fewer obese women. A 20% tax might result in 41,900 (40,100–48,100) fewer obese men and 24,800 (15,600–28,700) fewer obese women. Overall, a 20% tax could result in a 0.7% reduction in obesity prevalence in the whole cohort. This might result in approximately 29,700 fewer CVD cases and 13,400 fewer obesity related cancer cases by 2031. Conclusion A tax on Sugar Sweetened Beverages in the Turkish population could usefully reduce the prevalence of obesity, cardiovascular disease and common cancers. These findings reinforce the growing evidence of health benefits with SSB taxation policies in diverse countries.

OP25 Dementia prevalence projections to 2030 for England and Wales: IMPACT-Better Ageing Model

Background Dementia is a highly disabling condition causing considerable economic and societal burden worldwide. Predictions of future dementia prevalence need to take into account that, on the one hand, cardiovascular disease risk reduction may result in reduced age-specific dementia incidence but, on the other hand, increased life expectancy may lead to a larger pool of individuals susceptible to dementia. To accurately forecast prevalence of dementia, we modelled simultaneously the two conditions. Methods We developed IMPACT-BAM to model transitions to 2030 in the England and Wales population, aged 35+, through health states of cardiovascular disease, cognitive and functional impairment, and dementia to cardiovascular and non-cardiovascular death. At each iteration of this probabilistic Markov model, age-, sex-, and calendar time-specific transition probabilities (derived from 2002–2012 data of the English Longitudinal Study of Ageing, ELSA) were used to predict prevalence of each health state at the next calendar year. As observed in ELSA, we assumed cardiovascular disease incidence will continue to decline in parallel to cardiovascular mortality. Based on the decline in prevalence of dementia observed in the Rotterdam and Cognitive Function and Ageing Study (CFAS), we inferred a relative reduction of 2% per annum in the incidence of dementia. Validity of the model was established by comparing model estimates for recent years with independent observations. Results Using ELSA 2006 data as input resulted in predicted age and sex-specific prevalence of dementia for 2011 that was consistent with observed prevalence in CFAS 2011, underpinning the validity of IMPACT-BAM model estimates. As of 2015, we estimated 842,000 people aged 65 or older live with dementia in England and Wales, representing a prevalence of 8.15% (95% CI 3.12–14.24) in this age-group. The number (prevalence) of people aged 65 or older living with dementia is expected to rise to 1,045,000 (9.3%)in 2020, 1,216,000 (9.8%) in 2015, and 1,358,000 (9.7%) in 2030. Prevalence of dementia is and will be higher in women than in men: 9.4% (95% CI 3.0–17.6) vs 6.7%, (95% CI 3.3–10.1), respectively in 2015 and 10.4% (95% CI 2.7–26.3) vs 8.9% (95% CI 4.8–16.5) in 2030. Conclusion Despite a projected decline in age-specific dementia incidence, the age-specific prevalence of dementia is likely to rise in the next 15 years, largely due to increasing longevity. We predict a substantial increase in the number of people living with dementia, resulting from rising dementia prevalence compounded by population ageing.

OP71 Comparing coronary mortality reductions by shifting the population blood pressure distribution versus improved management of hypertensive patients: modelling study

Background Blood pressure reduction is an important target for the prevention of coronary heart disease (CHD). In 1982, Rose proposed that small population-wide reductions in blood pressure, through public health measures to reduce salt intake, might deliver larger reductions in CHD mortality than by treating hypertensive patients. We aimed to estimate the potential for each strategy to reduce future CHD deaths in England and Wales. Methods We used the Stock of Health (SoH) model, where each individual is born with a 100% stock which then depreciates year-by-year, reflecting fixed and modifiable risk factors. A CHD death occurs when the individual’s CHD’s SoH falls below a critical point. Births, deaths and risk factor distributions were obtained from the Office of National Statistics and the Health Survey for England. Model parameters were calibrated using data from the US Cardiovascular Lifetime Risk Pooling Project. We modelled ten policy scenarios: population-wide, individual-based and combination strategies. The population-wide strategies were: a systolic blood pressure (SBP) reduction of 0.1 mmHg achieved by health promotion media strategies (Pop1), a 1.3 mmHg reduction achieved by mandatory salt reformulation (Pop2) and an attainable goal where SBP levels fall to those observed in the US population (Pop3). The individual-based strategies assumed that in currently uncontrolled hypertensive patients, control was then achieved in 30% (Indi1) and 50% (Indi2) of them. Results We forecast that approximately 467,200 CHD (95% CI 466,900–467,600) deaths may occur between 2013 and 2030. By controlling 30% and 50% of hypertensive patients, we predict approximately 3800 (3200–4300) and 6200 (5700–6800) fewer deaths respectively. Conversely, we predict approximately 1300 (800–1900) fewer deaths by health promotion; some 16,400 (15,800–16,900) fewer deaths by mandatory reformulation and approximately 25,400 (24,900–25,900) fewer deaths by gradual SBP declines to US levels. Combining Pop1 and Indi1 might achieve approximately 5100 (4500–5600) fewer deaths in 2030; whereas combining Pop1 and Indi2 could achieve some 7500 (2000–13,000) fewer deaths. Combining Pop2 and Indi1 might prevent approximately 19,700 (19,200–20,300) deaths; while combining Pop2 and Indi2 could prevent or postpone some 21,900 (21,400–22,400) deaths by 2030. Conclusion Both population-wide salt reduction policies and individual-based treatment strategies could substantially reduce CHD deaths in England and Wales. Even greater reductions in mortality might be achieved by reducing SBP to US levels. However, there is no clear single successful intervention, but both types of strategies are needed to maximise our chances of controlling the burden of mortality attributable to blood pressure.

OP16 Utilising a Novel Framework to Assess Public Health Nutrition Actions Across 30 European Countries (EuroHeart II Project)

Background EuroHeart II is a European programme designed to inform cardiovascular health strategies across Europe. Our project examines the role of food policies in cardiovascular disease prevention, including the development and piloting of a novel conceptual framework for categorising public health nutrition policies. Methods We conducted a mapping exercise to identify and categorise public health nutrition policy actions across 30 European countries using a novel framework. The framework was based on the traditional marketing “4Ps” approach: Price, Product, Promotion and Place (the “marketing mix”). A database was created to summarise public health nutrition policy for 30 European countries (EU 27 plus Iceland, Norway and Switzerland). National policies were classified according to Price (taxes, subsidises, other economic incentives); Product (reformulation, new healthier products); Place (schools, workplaces, community settings); and Promotion (advertising to children/general population, food labelling and health education initiatives). Results Dialogue, recommendations and nutrition guidelines are now widespread across Europe. Information and education campaigns are also widespread. These include campaigns covering the general population, and campaigns targeting schools, the workplace or communities. Subsidies for fruit in schools are almost universal through the EU School Fruit Scheme, but implementation differs across the 30 countries. New EU legislation supports limited, back of pack food labelling. Some countries have also implemented national legislation requiring more detailed label information about the nutritional value of foods (e.g. Finland). However, the presentation and information vary widely. Voluntary reformulation of foods is common, especially for salt, sugar and total fat (e.g. salt reduction in the UK). However, mandatory reformulation of products to reduce saturated fat and salt are still limited to trans fat bans in Austria, Denmark, Iceland and Switzerland. Legislation/regulation affecting salt, sugar, fat and fruit and vegetable consumption is uncommon, although several countries have legal requirements regarding the maximum salt content in certain foods (Belgium, Bulgaria, Finland, Greece, Latvia, Lithuania, Netherlands, Portugal, Romania, Slovak Republic, Slovenia and Wales). Taxes to promote healthy nutrition are currently used infrequently. However, Finland, France, Hungary and Portugal have implemented ‘sugar taxes’ on sugary foods and sugar-sweetened beverages. Hungary and Portugal also tax salty products. Conclusion The diverse public health nutrition activities across 30 European countries might initially appear complex and bewildering. However, the “4Ps” framework offers a potentially structured and comprehensive categorisation of these diverse interventions. National food policies in Europe are currently at very different stages of development and implementation. However, exemplar countries might include Denmark, Finland, Hungary, Iceland, the UK and Portugal.

OP15 Identifying the most effective public health nutrition policies: The views of policy-makers and thought-leaders across 14 EU countries

Background EuroHeart 2 is a European research programme led by the European Heart Network and European Society of Cardiology (http://www.ehnheart.org/euroheart-ii.html). One aspect of the project aimed to identify the most effective public health nutrition policies, in order to inform future evidence-based strategies to promote cardiovascular health. We interviewed senior policy-makers and thought-leaders in 14 diverse EU countries to elicit their views on a very wide range of possible nutrition strategies covering the entire public health policy spectrum aimed at improving approaches to public health nutrition. Methods We first mapped national nutrition policies across 30 European countries. We then identified contacted and recruited potential participants in 14 diverse countries. Policy-makers, thought-leaders and others active in the field of public health nutrition at the national level were interviewed. Questions were first developed and piloted with senior stakeholders in the UK. The interviews were conducted in English, either by person, telephone or Skype. The interviews typically lasted between 45 and 60 minutes. The interviews were transcribed and entered into NVIVO software. The Framework approach was used to analyse the transcripts. Results We conducted 66 interviews in 14 countries across Europe. The interviews enabled more up to date and accurate information than was provided on websites or in reports. Responses revealed important differences between official lists of food policies and their actual implementation “on the ground”. European countries are at very different stages of addressing public health nutrition issues. Most are promoting dialogue, recommendations and guidelines (often considered an early part of the policy process). Voluntary reformulation of foods is also common, especially for salt, sugar and total fat. However, legislation regulation or fiscal interventions targeting salt, sugar, fat or fruit and vegetable consumption are still uncommon. Many interviewees expressed a preference for regulation and fiscal interventions and generally believed they were more effective, albeit politically more challenging. Conversely, information-based interventions were often seen as being more politically feasible. Conclusion Public health nutrition policies in Europe represent a complex, dynamic and rapidly changing arena. Encouragingly, the majority of countries are engaged in activities intended to increase consumption of health food, and decrease the intake of junk food and sugary drinks. Exemplar countries demonstrating notable progress might include Finland, Norway, Iceland, Hungary, the UK and Portugal. However, most countries fall well short of optimal activities. Implementation of potentially powerful nutrition policies remains frustratingly patchy across Europe.

PP09 Assessing the Potential Effect of Healthy Eating Policy Interventions on Socioeconomic Inequalities: Systematic Review

Background Cardiovascular disease (CVD) is one of the main contributors to health inequalities. CVD primary prevention includes potentially powerful interventions to promote healthy eating. However, might some dietary interventions actually widen the heath gap between rich and poor, thus leading to intervention-generated inequalities? Objective To systematically review the evidence for differential socio-economic effects associated with healthy eating policy interventions. Methods We initially searched two bibliographic databases (MEDLINE & Psycinfo) using a piloted search strategy. Results from further databases and additional sources will be reported in the final review. Search results were screened independently by two reviewers. We included evaluations of policy interventions to promote healthier diets, (defined as the reduced intake of salt, sugar, trans fats, saturated fat, total fat, or total calories, or increased consumption of fruit and vegetables). All quantitative studies were eligible for inclusion. Studies were only included if quantitative results were presented by socio-economic group (SEG), defined by income, education level, ethnicity, or occupational status. Extracted data were categorised with a modified version of the 4Ps marketing framework: Price, Product, Place and Promotion, with a 5th “P” labelled “Personal”, relating to person-based health education. Based on preliminary findings included studies were synthesised as a narrative review due to their heterogeneous nature. Results We identified 14,449 studies in the initial search and reviewed 47 full text papers. Following screening, only 14 articles met the inclusion criteria. Preliminary results analysed using the “5 P’s” framework suggest that some food policy interventions may generate socio-economic differentials. Price interventions showed the greatest potential to reduce health inequalities (3 of 5 studies). Conversely, Personal interventions tended to widen inequalities (3 of 4 studies showed preferential outcomes in higher SEGs). Results relating to Place interventions were mixed, with 2 school-based studies reporting a preferential outcome in higher SEGs, and 1 work-based study reporting a preferential outcome in lower SEGs. Evidence for Product and Promotion interventions appears sparse, with only 1 study found for each category. However, both reporting preferential outcomes in higher SEGs. Conclusion Interventions categorised by the “5 P’s” show differential effects on healthy eating outcomes by SEG, with interventions categorised as Personal appearing the most likely to increase health inequalities. However the vast majority of studies retrieved did not explore differential effects by socio-economic group. Future policies aimed at improving population health should be routinely evaluated for their potential impact on health inequalities.

PPO1 Predicting Future Coronary Heart Disease Mortality trends in England and Wales in 2020: a Bayesian age Period Cohort Approach

Background Although Coronary Heart Disease (CHD) death rates have halved since the 1970s, CHD remains a major cause of mortality in the UK. Furthermore, population ageing plus recent increases in obesity and diabetes may soon increase total CHD deaths. Future CHD mortality predictions are thus potentially problematic. Our aim was therefore to explore future projections of CHD mortality in England & Wales under conventional but contrasting assumptions. Methods In SCENARIO 1, we assumed a conventional counterfactual, that recent CHD mortality rates (ONS, ICD10 codes I20-I25) in 2006 would persist unchanged. The future number of deaths was then calculated by projecting those rates into 2020 population estimates. In SCENARIO 2, we assumed that recent changes in CHD mortality rates would continue. We used a well-established hierarchical Bayesian Age Period Cohort (APC) model, which works under the assumption that variability in incidence data can be explained by age, period and cohort effects. We fitted this model to observed CHD mortality rate trends from 1982 to 2006. We then used the model to predict mortality rates in 2020, and then these rates applied to the 2020 population to compute future deaths. Results In SCENARIO 1 by assuming that 2006 mortality rates would continue at that level to 2020, the number of CHD deaths would substantially increase: +49% in men and +25% women (104,500 total CHD deaths in 2020). In SCENARIO 2, assuming recent trends continued, the APC model suggested that number of deaths would decrease by -48% (95% CI -25%, -64% in men); and -59% (-39%, -73%) in women (36,425 total deaths in 2020, despite a predicted slowing of the mortality decline in groups aged 35-64 years). Conclusion The decline in CHD mortality has been reasonably continuous since 1982, and there is little reason to believe it will soon abruptly halt, (the dubious underlying assumption of a commonly used mortality counterfactual). By contrast, the Bayesian APC model offers a far more plausible prediction of future trends by simultaneously considering age, period and cohort effects. Therefore, despite population ageing, the number of CHD deaths will most likely halve again between 2006 and 2020. However, CHD mortality rates elsewhere have previously shifted rapidly due to changes in population risk factors. There is thus no room for complacency.