P Bhatnagar

The economic burden of ill health due to diet, physical inactivity, smoking, alcohol and obesity in the UK: an update to 2006–07 NHS costs

BACKGROUND Estimates of the economic cost of risk factors for chronic disease to the NHS provide evidence for prioritization of resources for prevention and public health. Previous comparable estimates of the economic costs of poor diet, physical inactivity, smoking, alcohol and overweight/obesity were based on economic data from 1992-93. METHODS Diseases associated with poor diet, physical inactivity, smoking, alcohol and overweight/obesity were identified. Risk factor-specific population attributable fractions for these diseases were applied to disease-specific estimates of the economic cost to the NHS in the UK in 2006-07. RESULTS In 2006-07, poor diet-related ill health cost the NHS in the UK £5.8 billion. The cost of physical inactivity was £0.9 billion. Smoking cost was £3.3 billion, alcohol cost £3.3 billion, overweight and obesity cost £5.1 billion. CONCLUSION The estimates of the economic cost of risk factors for chronic disease presented here are based on recent financial data and are directly comparable. They suggest that poor diet is a behavioural risk factor that has the highest impact on the budget of the NHS, followed by alcohol consumption, smoking and physical inactivity.

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.

Should nutrient profile models be 'category specific' or 'across-the-board'? A comparison of the two systems using diets of British adults.

Background/Objectives:Nutrient profile models have the potential to help promote healthier diets. Some models treat all foods equally (across-the-board), some consider different categories of foods separately (category specific). This paper assesses whether across-the-board or category-specific nutrient profile models are more appropriate tools for improving diets.Subjects/Methods:Adult respondents to a British dietary survey were split into four groups using a diet quality index. Fifteen food categories were identified. A nutrient profile model provided a measure of the healthiness of all foods consumed. The four diet quality groups were compared for differences in (a) the calories consumed from each food category and (b) the healthiness of foods consumed in each category. Evidence of healthier diet quality groups consuming more of healthy food categories than unhealthy diet quality groups supported the adoption of across-the-board nutrient profile models. Evidence of healthier diet quality groups consuming healthier versions of foods within food categories supported adoption of category-specific nutrient profile models.Results:A significantly greater percentage of the healthiest diet quality groups diet consisted of fruit and vegetables (21 vs 16%), fish (3 vs 2%) and breakfast cereals (7 vs 2%), and significantly less meat and meat products (7 vs 14%) than the least healthy diet quality group. The foods from the meat, dairy and cereals categories consumed by the healthy diet quality groups were healthier versions than those consumed by the unhealthy diet quality groups.Conclusions:All other things being equal, nutrient profile models designed to promote an achievable healthy diet should be category specific but with a limited number of categories. However models which use a large number of categories are unhelpful for promoting a healthy diet.

The incidence of all stroke and stroke subtype in the United Kingdom, 1985 to 2008: a systematic review

BackgroundThere is considerable geographic variation in stroke mortality around the United Kingdom (UK). Whether this is due to geographical differences in incidence or case-fatality is unclear. We conducted a systematic review of high-quality studies documenting the incidence of any stroke and stroke subtypes, between 1985 and 2008 in the UK. We aimed to study geographic and temporal trends in relation to equivalent mortality trends.MethodsMEDLINE and EMBASE were searched, reference lists inspected and authors of included papers were contacted. All rates were standardised to the European Standard Population for those over 45, and between 45 and 74 years. Stroke mortality rates for the included areas were then calculated to produce rate ratios of stroke mortality to incidence for each location.ResultsFive papers were included in this review. Geographic variation was narrow but incidence appeared to largely mirror mortality rates for all stroke. For men over 45, incidence (and confidence intervals) per 100,000 ranged from 124 (109-141) in South London, to 185 (164-208) in Scotland. For men, premature (45-74 years) stroke incidence per 100,000 ranged from 79 (67-94) in the North West, to 112 (95-132) in Scotland. Stroke subtype data was more geographically restricted, but did suggest there is no sizeable variation in incidence by subtype around the country. Only one paper, based in South London, had data on temporal trends. This showed that there has been a decline in stroke incidence since the mid 1990 s. This could not be compared to any other locations in this review.ConclusionsGeographic variations in stroke incidence appear to mirror variations in mortality rates. This suggests policies to reduce inequalities in stroke mortality should be directed at risk factor profiles rather than treatment after a first incident event. More high quality stroke incidence data from around the UK are needed before this can be confirmed.

Trends in the epidemiology of cardiovascular disease in the UK

Cardiovascular disease (CVD) mortality in the UK is declining; however, CVD burden comes not only from deaths, but also from those living with the disease. This review uses national datasets with multiple years of data to present secular trends in mortality, morbidity, and treatment for all CVD and specific subtypes within the UK. We produced all-ages and premature age-standardised mortality rates by gender, standardised to the 2013 European Standard Population, using data from the national statistics agencies of the UK. We obtained data on hospital admissions from the National Health Service records, using the main diagnosis. Prevalence data come from the Quality and Outcome Framework and national surveys. Total CVD mortality declined by 68% between 1980 and 2013 in the UK. Similar decreases were seen for coronary heart disease and stroke. Coronary heart disease prevalence has remained constant at around 3% in England and 4% in Scotland, Wales, and Northern Ireland. Hospital admissions for all CVD increased by over 46 000 between 2010/2011 and 2013/2014, with more than 36 500 of these increased admissions for men. Hospital admission trends vary by country and CVD condition. CVD prescriptions and operations have increased over the last decade. CVD mortality has declined notably for both men and women while hospital admissions have increased. CVD prevalence shows little evidence of change. This review highlights that improvements in the burden of CVD have not occurred equally between the four constituent countries of the UK, or between men and women.

Generational differences in the physical activity of UK South Asians: a systematic review.

BackgroundSouth Asians are some of the least active people in the UK, but we know very little about how physical activity varies within and between different UK South Asian groups. There is much socio-economic and cultural heterogeneity among UK Indians, Pakistanis and Bangladeshis, and the same approaches to increasing physical activity may not be appropriate for all people of these ethnic groups. We report on the variation in physical activity behaviour prevalence in quantitative studies and the variations in attitudes, motivations and barriers to physical activity among South Asians in qualitative papers.MethodsWe performed systematic searches in MEDLINE, Embase and Psychinfo for papers written in English and published between 1990 and 2014. We also attempted to search literature not published in peer-review journals (the ‘grey’ literature). We reported data for the quantitative observational studies and synthesised themes from the qualitative literature according to age-group. We assessed the quality of studies using a National Institute of Health and Clinical Excellence tool.ResultsWe included 29 quantitative papers and 17 qualitative papers. Thirteen papers reported on physical activity prevalence in South Asian children, with the majority comparing them to White British children. Four papers reported on adult second-generation South Asians and the rest reported on South Asian adults in general. Second-generation South Asians were more active than the first-generation but were still less active than the White British. There were no high quality qualitative studies on second-generation South Asian adults, but there were some studies on South Asian children. The adult studies indicated that the second-generation might have a more favourable attitude towards physical activity than the first-generation.ConclusionsThere is clear variation in physical activity levels among UK South Asians. Second-generation South Asians appear to be more physically active than the first-generation, but still less active than the White British. More qualitative research is needed to understand why, but there are indications that second-generation South Asians have a more positive attitude towards physical activity than the first-generation. Different strategies to increase physical activity may be needed for different generations of UK South Asians.

The physical activity profiles of South Asian ethnic groups in England

Background To identify what types of activity contribute to overall physical activity in South Asian ethnic groups and how these vary according to sex and age. We used the White British ethnic group as a comparison. Methods Self-reported physical activity was measured in the Health Survey for England 1999 and 2004, a nationally representative, cross-sectional survey that boosted ethnic minority samples in these years. We merged the two survey years and analysed data from 19 476 adults. The proportions of total physical activity achieved through walking, housework, sports and DIY activity were calculated. We stratified by sex and age group and used analysis of variances to examine differences between ethnic groups, adjusted for the socioeconomic status. Results There was a significant difference between ethnic groups for the contributions of all physical activity domains for those aged below 55 years, with the exception of walking. In women aged 16–34 years, there was no significant difference in the contribution of walking to total physical activity (p=0.38). In the 35–54 age group, Bangladeshi males have the highest proportion of total activity from walking (30%). In those aged over 55 years, the proportion of activity from sports was the lowest in all South Asian ethnic groups for both sexes. Conclusions UK South Asians are more active in some ways that differ, by age and sex, from White British, but are similarly active in other ways. These results can be used to develop targeted population level interventions for increasing physical activity levels in adult UK South Asian populations.

Prevalence of behavioural cardiovascular disease risk factors in UK-born ethnic minorities: a systematic review for public health guidance

Abstract Background Some behavioural cardiovascular risk factors are known to be high in ethnic minority groups in the UK. In 2011, about half of all Indians, Pakistanis, Bangladeshis, and black Caribbeans living in the UK were born in the UK; however, little is known about whether the prevalence of cardiovascular risk factors differs between overseas-born and UK-born ethnic minorities. We aimed to investigate the prevalence of behavioural cardiovascular risk factors in UK-born ethnic groups. A common explanation for ethnic differences in health behaviours is socioeconomic factors; therefore, we also looked to see if the reasons behind any differences within and between UK-born ethnic groups had been explored. A main aim was also to assess the quality of reports on this topic. Methods We searched Medline, Embase, and PubMed for observational quantitative manuscripts. Selected manuscripts were those published between 1990 and 2012 and reporting on UK-born adult populations of black Caribbeans, black Africans, Indians, Pakistanis, or Bangladeshis, either alone or in comparison with another subgroup of the population. Manuscripts had to report on the prevalence of dietary factors, alcohol use, tobacco use, physical activity, or obesity. The titles and abstracts of manuscripts were screened and then the selected manuscripts were read in full. References of all manuscripts read in full were searched for further manuscripts. Exclusion of reports of poor quality is conventional, which might introduce biases into the results. Because one of the aims of this review was to assess the quality of the manuscripts, manuscripts of all quality were retained in the review and assessed using a quality appraisal instrument from the report on the methods used to develop the National Institute for Health and Care Excellence Public Health guidance. Quality assessors were not masked. Findings 124 manuscripts were identified through the search strategy after duplicates were removed. 23 manuscripts were read in full and ten studies were included in the review. The included manuscripts showed some evidence of a different prevalence of behavioural cardiovascular risk factors in the UK-born ethnic groups when compared with migrants and the white British ethnic group (appendix). In Indian women, the prevalence of smoking was 3·3% in the first generation but 10·2% in the second generation. Physical activity levels were higher in the second generation for all ethnic groups included; however, levels were still lower than in the general population. Compared with the general population, one manuscript suggested higher intakes of fried foods in UK-born ethnic minority participants (33·4% of UK-born Pakistanis eating fried food three or more times a week compared with 18·4% from the white group), but lower levels of alcohol intake and tobacco use. Some manuscripts attempted to minimise their risk of bias; however, underpowered samples and failure to adjust for important confounding variables limited the generalisability of their results. Because most manuscripts did not include socioeconomic factors in their regression models, we could not assess the contribution of this to differences in risk factors. Interpretation This review revealed some evidence of a different profile of cardiovascular risk factors in UK-born ethnic minorities, as compared with the migrant generation, although explanations for these differences are inadequate. Research with theoretical approaches and adequate sample sizes is needed to firmly establish any differences in prevalence between generations of ethnic minorities. As far as we are aware, this is the first manuscript to review and assess the quality of studies that examine the prevalence of cardiovascular behavioural risk factors in UK-born ethnic minorities. A limitation of this study is that the title and abstract screening was done by one person, although the final selection of manuscripts was agreed by all authors. Funding The main authors are funded by the British Heart Foundation.

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.

Turning the tide on NCDs by engaging the next generation

www.thelancet.com Vol 390 October 21, 2017 1829 7 Dart AB, Martens PJ, Rigatto C, Brownell MD, Dean HJ, Sellers EA. Earlier onset of complications in youth with type 2 diabetes. Diabetes Care 2014; 37: 436–43. 8 Huynh E, Rand D, McNeill C, et al. Beating diabetes together: a mixed-methods analysis of a feasibility study of intensive lifestyle intervention for youth with type 2 diabetes. Can J Diabetes 2015; 39: 484–90. 9 Petit-Zeman S, Firkins L, Scadding JW. The James Lind Alliance: tackling research mismatches. Lancet 2010; 376: 667–69. 10 Berkowitz RI, Marcus MD, Anderson BJ, et al. Adherence to a lifestyle program for youth with type 2 diabetes and its association with treatment outcome in the TODAY clinical trial. Pediatr Diabetes 2017; published online June 30. DOI:10.1111/ pedi.12555. actively engage adolescents with type 2 diabetes and their family members in the design of novel approaches to care. Empirical testing of patient-centred interventions that move beyond diet and exercise are warranted, considering the low efficacy of existing therapeutic options and low adherence rates to self-management behaviours among adolescents living with type 2 diabetes.