Will Cardiovascular Disease Prevention Widen Health Inequalities?

Simon Capewell and Hilary Graham review different population strategies for preventing cardiovascular disease and conclude that screening and treating high-risk individuals may be ineffective and widen social inequalities

Bringing prevention to the population: an important role for cardiologists in policy-making.

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Food for thought? Potential conflicts of interest in academic experts advising government and charities on dietary policies

Abstract Background A conflict of interest (CoI) can occur between public duty and private interest, in which a public official’s private-capacity interest could improperly influence the performance of their official duties and responsibilities. The most tangible and commonly considered CoI are financial. However, CoI can also arise due to other types of influence including interpersonal relationships, career progression, or ideology. CoI thus exist in academia, business, government and non-governmental organisations. However, public knowledge of CoI is currently limited due to a lack of information. The mechanisms of managing potential conflicts of interest also remain unclear due to a lack of guidelines. We therefore examined the independence of academic experts and how well potential CoI are identified and addressed in four government and non-governmental organisations in the UK responsible for the development of food policy. Methods Policy analysis. We developed an analytical framework to explore CoI in high-level UK food policy advice, using four case studies. Two government policy-making bodies: Department of Health ‘Obesity Review Group’ (ORG), ‘Scientific Advisory Committee on Nutrition’ (SACN) and two charities: ‘Action on Sugar’ (AoS), & ‘Heart of Mersey’ (HoM). Information was obtained from publicly available sources and declarations. We developed a five point ordinal scale based upon the ideology of the Nolan Principles of Public Life. Group members were individually categorised on the ordinal ConScale from “0”, (complete independence from the food and drink industry) to “4”, (employed by the food and drink industry or a representative organisation). Results CoI involving various industries have long been evident in policy making, academia and clinical practice. Suggested approaches for managing CoI could be categorised as “deny”, “describe”, or “diminish”. Declared CoI were common in the ORG and SACN. 4 out of 28 ORG members were direct industry employees. In SACN 11 out of 17 members declared industry advisory roles or industry research funding. The two charities appeared to have equally strong academic expertise but fewer conflicts. No HoM members declared CoI. 5 out of 21 AoS members declared links with industry, mainly pharmaceutical companies. We were unable to obtain information on conflicts for some individuals. Conclusions Conflicts of interest are unavoidable but potentially manageable. Government organisations responsible for policy development and implementation must institutionalize an approach to identify (disclose) and manage (mitigate or eliminate) perceived and actual CoI to improve public confidence in government decision-making relevant to food policy

Why choice of metric matters in public health analyses: a case study of the attribution of credit for the decline in coronary heart disease mortality in the US and other populations

RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are.Abstract Background Reasons for the widespread declines in coronary heart disease (CHD) mortality in high income countries are controversial. Here we explore how the type of metric chosen for the analyses of these declines affects the answer obtained. Methods The analyses we reviewed were performed using IMPACT, a large Excel based model of the determinants of temporal change in mortality from CHD. Assessments of the decline in CHD mortality in the USA between 1980 and 2000 served as the central case study. Results Analyses based in the metric of number of deaths prevented attributed about half the decline to treatments (including preventive medications) and half to favourable shifts in risk factors. However, when mortality change was expressed in the metric of life-years-gained, the share attributed to risk factor change rose to 65%. This happened because risk factor changes were modelled as slowing disease progression, such that the hypothetical deaths averted resulted in longer average remaining lifetimes gained than the deaths averted by better treatments. This result was robust to a range of plausible assumptions on the relative effect sizes of changes in treatments and risk factors. Conclusions Time-based metrics (such as life years) are generally preferable because they direct attention to the changes in the natural history of disease that are produced by changes in key health determinants. The life-years attached to each death averted will also weight deaths in a way that better reflects social preferences.Peer Reviewe

Return on investment of public health interventions : a systematic review

BACKGROUND: Public sector austerity measures in many high-income countries mean that public health budgets are reducing year on year. To help inform the potential impact of these proposed disinvestments in public health, we set out to determine the return on investment (ROI) from a range of existing public health interventions. METHODS: We conducted systematic searches on all relevant databases (including MEDLINE; EMBASE; CINAHL; AMED; PubMed, Cochrane and Scopus) to identify studies that calculated a ROI or cost-benefit ratio (CBR) for public health interventions in high-income countries. RESULTS: We identified 2957 titles, and included 52 studies. The median ROI for public health interventions was 14.3 to 1, and median CBR was 8.3. The median ROI for all 29 local public health interventions was 4.1 to 1, and median CBR was 10.3. Even larger benefits were reported in 28 studies analysing nationwide public health interventions; the median ROI was 27.2, and median CBR was 17.5. CONCLUSIONS: This systematic review suggests that local and national public health interventions are highly cost-saving. Cuts to public health budgets in high income countries therefore represent a false economy, and are likely to generate billions of pounds of additional costs to health services and the wider economy

The role of the food industry in health: lessons from tobacco?

IntroductionIn this review, we highlight poor diet as the biggest risk factor for non-communicable diseases. We examine the denial tactics used by the food industry, how they reflect the tactics previously used by the tobacco industry, and how campaigners can use this knowledge to achieve future public health successes.Sources of dataData sources are wide ranging, notably publications relating to public health, obesity and processed food, the effectiveness hierarchy and food industry denialism tactics.Areas of agreementGlobal burden of disease analyses consistently demonstrate that poor diet produces a bigger burden of non-communicable disease than tobacco, alcohol and inactivity put together. The lessons learnt from the tobacco control experience of successfully fighting the tobacco industry can be applied to other industries including processed food and sugary drinks.Areas of controversyTackling obesity and poor diet is a more complex issue than tobacco. Food industries continue to promote weak or ineffective policies such as voluntary reformulation, and resist regulation and taxation. However, the UK food industry now faces increasing pressure from professionals, public and politicians to accept reformulation and taxes, or face more stringent measures.Growing points and areas timely for developing researchThe rise in childhood and adult obesity needs to be arrested and then reversed. Unhealthy processed food and sugary drinks are a major contributing factor. There is increasing interest in the tactics being used by the food industry to resist change. Advocacy and activism will be essential to counter these denialism tactics and ensure that scientific evidence is translated into effective regulation and taxation