An economic evaluation of salt reduction policies to reduce coronary heart disease in England: a policy modeling study

AbstractObjectivesDietary salt intake has been causally linked to high blood pressure and increased risk of cardiovascular events. Cardiovascular disease causes approximately 35% of total UK deaths, at an estimated annual cost of £30 billion. The World Health Organization and the National Institute for Health and Care Excellence have recommended a reduction in the intake of salt in people's diets. This study evaluated the cost-effectiveness of four population health policies to reduce dietary salt intake on an English population to prevent coronary heart disease (CHD).MethodsThe validated IMPACT CHD model was used to quantify and compare four policies: 1) Change4Life health promotion campaign, 2) front-of-pack traffic light labeling to display salt content, 3) Food Standards Agency working with the food industry to reduce salt (voluntary), and 4) mandatory reformulation to reduce salt in processed foods. The effectiveness of these policies in reducing salt intake, and hence blood pressure, was determined by systematic literature review. The model calculated the reduction in mortality associated with each policy, quantified as life-years gained over 10 years. Policy costs were calculated using evidence from published sources. Health care costs for specific CHD patient groups were estimated. Costs were compared against a “do nothing” baseline.ResultsAll policies resulted in a life-year gain over the baseline. Change4life and labeling each gained approximately 1960 life-years, voluntary reformulation 14,560 life-years, and mandatory reformulation 19,320 life-years. Each policy appeared cost saving, with mandatory reformulation offering the largest cost saving, more than £660 million.ConclusionsAll policies to reduce dietary salt intake could gain life-years and reduce health care expenditure on coronary heart disease

Dynamics of parental work hours, job insecurity, and child wellbeing during middle childhood in Australian dual-income families

This study examines the relationship between parental employment characteristics and child well-being during middle childhood in Australian dual-earner families. Parental employment provides important resources for children’s wellbeing, but may also be associated with variations in parental time availability, parental stress levels and wellbeing, differences in parenting styles and variations in household dynamics. Further, there may be gender differences in how mothers’ and fathers’ employment characteristics relate to child wellbeing, as well as variations by age. Our study contributes to existing research by 1) examining longitudinal data that enables us to examine changes in the association between parental work hours, job insecurity and child wellbeing, within and across parent-child relationships; 2) focusing on dual-employed households to examine the effects of mothers’ and fathers’ employment characteristics on girls’ and boys’ wellbeing; and 3) testing possible mediators in the relationship between parental employment characteristics and child well-being. Drawing on 3 waves of data from two cohorts of the Longitudinal Study of Australian Children (N = 3,216), from 2004 to 2012, we find that mothers who work long hours on average over the study period have children with poorer socio emotional development, while fathers with increasing work hours have children with poorer socio-emotional development. Mothers’ job security is associated with better child development comparing both across mothers and within mothers over time. We find little evidence that these associations are mediated by parenting style or work-family balance, suggesting further research is needed to understand the mechanisms linking parental employment with children’s outcomes

The family life course and health: partnership and fertility histories and physical health trajectories in later life

Life course perspectives suggest that later life health reflects long term social patterns over an individual’s life, in particular the occurrence and timing of key roles and transitions. This has been demonstrated empirically for multiple aspects of fertility and partnership histories, including timing of births and marriage, parity, and the presence and timing of a marital disruption. Most previous studies have, however, addressed particular aspects of fertility or partnership histories singly. We build on this research by examining how a holistic classification of family life course trajectories from age 18-50, incorporating both fertility and partnership histories, is linked to later life physical health for a sample of Australian residents. Our results indicate that long-term family life course trajectories are strongly linked to later life health for men, but only minimally for women. For men, family trajectories characterized by early family formation, no family formation, an early marital disruption, or high fertility, are associated with poorer physical health. Among women, only those who experienced both a disrupted marital history and a high level of fertility were found to be in poorer health

A better understanding of recent coronary heart disease mortality trends and determinants

Introduction Coronary heart disease (CHD) is one of the leading global causes of morbidity and mortality. The underlying biological mechanisms are well understood, and a host of causal risk factors for the disease have been identified, mainly related to diet, smoking and physical activity. Evidence-based treatments for the disease are also available, reducing mortality and improving quality of life. The decline in CHD mortality rates observed in most developed countries since the 1960s represents a most remarkable epidemiological phenomenon. However, this decline is not universal, and may now be in jeopardy. Thus, the mortality decline has recently plateaued in young adults in the United States. Furthermore, the absolute burden of disease is set to increase mainly because of an increasingly ageing population, and will represent a heavy burden to high, middle and low income countries alike. Furthermore, CHD incidence may rise in future because of recent adverse trends in major CHD risk factors, namely the worldwide increases in obesity and diabetes prevalence observed since the 1980s. Moreover, new technology and improved treatments are decreasing case fatality in CHD patients, increasing life expectancy and thus expanding the pool of patients surviving with clinically apparent disease. Finally, and crucially, important socioeconomic inequalities persist, perhaps reflecting disease determinants. The complex interplay of these factors and potential changes over time together suggest that the CHD epidemic may still be evolving. Further attention is therefore essential. The analysis of time trends in disease specific mortality can thus potentially help us to understand the population dynamic of diseases such as CHD, warn about key changes and perhaps offer some novel insights for better prevention and control. However, most previous analyses have been focused on age-adjusted rates that might conceal important differences by age or by socioeconomic status, which might provide further understanding of trend drivers. Aims and objectives: My aim is to study recent coronary heart disease mortality time trends in different countries, in order to better understand the current state of the CHD epidemic. Furthermore, I will analyze the relative importance of CHD treatments and risk factors as drivers of the mortality trends. Finally, I will consider the Public Health implications of my findings. My objectives therefore are: 1. To summarize our current understanding of Coronary Heart Disease (CHD) causation 2. To describe recent CHD mortality time trends focusing on age and gender specific trends by identifying periods with similar rate of change in diverse populations (England & Wales, the Netherlands, Poland and Australia). 3. To describe recent CHD mortality time trends by Socio-Economic Status in England and Scotland. 4. To quantify the role of risk factors and evidence-based treatments as drivers of the CHD mortality trends, first using a modelling approach in Poland, and then in England while also considering socioeconomic factors. 5. To consider the public health policy implications of dynamic trends in coronary heart disease mortality. Methods CHD mortality trends were analysed using the joinpoint regression approach. Widely used in cancer epidemiology, but rarely in CHD, this method explores trend data to find points in time (“joinpoints”) that define segments where the trend has a constant pace of change. The key strength of this technique is objectivity- (it avoids the detection of potentially biased patterns when trends are described using time intervals defined subjectively by the researcher). Joinpoint avoids this potential bias by essentially removing the observer from the selection process, instead using a formal and objective exploration of the time-series data. My analysis therefore focused on age-adjusted rates, then age and gender specific rates. The analysis for Scotland and England also considered socio-economic status (using area-based measures of material deprivation). The contributions of risk factors and treatments to the observed CHJD mortality trends in Poland were studied using the IMPACT model, a comprehensive, population-based model of CHD epidemiology. The model goal is to quantify the decline in coronary heart disease deaths in the Polish population between 1991 and 2005 which might be explained by risk factor changes and by treatments. The model is comprehensive, incorporating all usual treatments for coronary heart disease and heart failure plus all major cardiovascular risk factors, including smoking, blood pressure, cholesterol, diabetes, obesity and physical activity. Similar analyses but also exploring the socio-economic differences were conducted in England, using a modified IMPACT model (IMPACTsec). That was used to estimate the contribution of risk factors and evidence based treatments to the observed decline in mortality in England between 2000 and 2007, for each quintile of the index of multiple deprivation. Results Age-adjusted trends in England and Wales, Scotland, Australia and the Netherlands conceal important recent age specific patterns. In these countries, the age-adjusted rates show continuing declines; however, among young adults a recent period of slowing down of the rate of decline in CHD mortality has been observed. Furthermore, trends are very dynamic, and the patterns can change surprisingly quickly. In the Netherlands, the sustained period of minimal change in young adults was followed by a period of further decline. Poland offers a strikingly different example of trend dynamism. After a period of constant increase, Poland showed a sudden, sharp decline in CHD mortality rates within a period of a very few years. This decline occurred in all age and gender groups, and still continues. The recent mortality trends are probably attributable more to changes in risk factors rather than medical treatments. For example, using the IMPACT model to study the decline phase of the Polish CHD epidemic, approximately 55% of the observed fall in mortality might be attributed to changes in risk factors, and only about a third to evidence based therapies. Because of the social patterning of risk factors levels, further insights on the role of risk factors as major contributors to trend changes can be obtained by studying trends in levels stratified by socioeconomic circumstances. Scotland and England offer particular opportunities for detailed studies of trends in CHD mortality using high quality data including socioeconomic status. The resulting picture is complex. The recent flattening in CHD mortality trends observed in young adults was confined to the most deprived groups in Scotland, but was more uniform in England. A marked deterioration of medical care is implausible, meaning that the most likely explanation for this recent flattening of CHD mortality must be adverse trends in major cardiovascular risk factors. The CHD mortality modelling in England produced intriguing results. As expected, socio-economic patterning of risk factor changes were observed. For example, decline in smoking levels contributed more to the observed decline amongst the more deprived groups. Social patterning was less clear among young adults in England. Moreover, the IMPACT SEC model analysis suggested that approximately half the CHD mortality fall was attributable to improved treatment uptake, with benefits occurring surprisingly equitably across all social groups. A similar analysis of the Scottish trends is therefore urgently needed to gain better insights on the drivers of the socioeconomic patterning underlying the observed trends. Conclusions The recent flattening in CHD mortality in young adults seen in many countries experiencing an overall decline in deaths strongly suggests that favourable trends can reverse. Furthermore, the rapid reversal observed in some age groups in the Netherlands and in the entire population in Poland suggests that recovery can occur very quickly. These rapid mortality changes have been observed in many countries and cannot easily be dismissed as artefact. There is a strong case to mainly attribute these trends to changes in cardiovascular risk factors, since marked deterioration of medical care in these affluent countries appears implausible. This interpretation is also consistent with evidence from the rapid risk reductions observed in randomised drug and diet trials. Furthermore, several populations experienced “natural experiments” when socio-economic events producing beneficial effects on cardiovascular risk factors were rapidly followed by dramatic changes in CHD mortality. These rapid mortality changes challenge some aspects of our current understanding of CHD causation. Specifically that the temporal relationship between changes in risk factors and changes in fatal outcomes are probably operating over much shorter timescales than previously assumed, within a few years rather than decades. The public health implications of these findings are thus clear: large changes in CHD burden can be achieved quickly, probably reflecting trends in dietary and other cardiovascular risk factors. Population level prevention interventions might therefore be both powerful and rapid

The ‘developmental gradient’ revisited: Australian children’s time with adult caregivers from infancy to middle childhood

Children’s time use patterns represent a potentially important mechanism for the transmission of disadvantage across generations. Recent US research indicates that more educated mothers tailor the content of time with children to favour activities that are particularly important at different developmental stages – a finding that has been termed the ‘developmental gradient’. Using time diary data for a sample of Australian children, this paper seeks to extend previous work in several ways. We first establish whether a ‘developmental gradient’ exists in Australian children’s time with mothers, comparable to the US evidence. We go further, however, by extending the analysis to consider time investments provided by fathers and other adult caregivers, and examining the importance of resources for explaining the patterns of time use. Consistent with theory, our results indicate that educational gaps in time spent ‘teaching’ are largest in the 4-5 age group, gaps in ‘play’ time with fathers are largest for toddlers (2-3), and gaps in ‘enrichment’ are largest for 6-7 and 8-9. Time with parents appears to be the primary driver of observed patterns of time spent ‘teaching’ and ‘playing’, while for ‘enrichment,’ differences are distributed across caregivers, but largest for non-parent caregivers. These results are not driven by differential access to resources. Our results suggest that the developmental gradient represents a plausible mechanism for the transmission of intergenerational disadvantage in Australia, and that policy responses focussed on better educating parents to understand the developmental needs of their children are likely to be an effective response

Enriching the rich? A review of extracurricular activities, socioeconomic status and adolescent achievement

This paper reviews the literature on adolescent extracurricular activity participation, socioeconomic status and academic and labour market outcomes. We consider socioeconomic gradients of extracurricular activity participation in Australia and internationally, and contributors to the patterns found. The literature on the effect of extracurricular activity participation on academic and labour market outcomes in adolescence and early adulthood is also examined. Extracurricular activity participation is more common among more advantaged youths, a finding which is mostly attributable to budgetary and other objective constraints but may also be influenced by non-material family resources and values. There is good evidence that extracurricular activity participation positively affects grades and college attendance in the United States. However, based on the current literature we cannot conclude that the positive associations between participation and standardised test scores, college graduation, and labour market outcomes are anything more than correlational. This absence of high quality studies permitting causal inference was identified as a significant gap in the literature

Continuing decrease in coronary heart disease mortality in Sweden

BACKGROUND: Deaths from coronary heart disease (CHD) have been decreasing in most Western countries over the last few decades. In contrast, a flattening of the decrease in mortality has been recently reported among younger age groups in some countries. We aimed to determine whether the decrease in CHD mortality is flattening among Swedish young adults. METHODS: We examined trends in CHD mortality in Sweden between 1987 and 2009 among persons aged 35 to 84 years using CHD mortality data from the Swedish National Register on Cause of Death. Annual percent changes in rates were examined using Joinpoint software. RESULTS: Overall, CHD mortality rates decreased by 67.4% in men and 65.1% in women. Among men aged 35–54 years, there was a modest early attenuation from a marked initial decrease. In the oldest women aged 75–84 years, an attenuation in the mortality decrease was observed from 1989 to 1992, followed by a decrease, as in all other age groups. CONCLUSIONS: In Sweden, coronary heart disease deaths are still falling. We were unable to confirm a flattening of the decline in young people. Death rates continue to decline in men and women across all age groups, albeit at a slower pace in younger men since 1991. Continued careful monitoring of CHD mortality trends in Sweden is required, particularly among young adults

Modelling the impact of specific food policy options on coronary heart disease and stroke deaths in Ireland

Objective: To estimate the potential reduction in cardiovascular (CVD) mortality possible by decreasing salt, trans fat and saturated fat consumption, and by increasing fruit and vegetable (F/V) consumption in Irish adults aged 25–84years for 2010. Design: Modelling study using the validated IMPACT Food Policy Model across two scenarios. Sensitivity analysis was undertaken. First, a conservative scenario: reductions in dietary salt by 1 g/day, trans fat by 0.5% of energy intake, saturated fat by 1% energy intake and increasing F/V intake by 1 portion/day. Second, a more substantial but politically feasible scenario: reductions in dietary salt by 3 g/day, trans fat by 1% of energy intake, saturated fat by 3% of energy intake and increasing F/V intake by 3 portions/day. Setting: Republic of Ireland. Outcomes: Coronary heart disease (CHD) and stroke deaths prevented. Results: The small, conservative changes in food policy could result in approximately 395 fewer cardiovascular deaths per year; approximately 190 (minimum 155, maximum 230) fewer CHD deaths in men, 50 (minimum 40, maximum 60) fewer CHD deaths in women, 95 (minimum 75, maximum 115) fewer stroke deaths in men, and 60 (minimum 45, maximum 70) fewer stroke deaths in women. Approximately 28%, 22%, 23% and 26% of the 395 fewer deaths could be attributable to decreased consumptions in trans fat, saturated fat, dietary salt and to increased F/V consumption, respectively. The 395 fewer deaths represent an overall 10% reduction in CVD mortality. Modelling the more substantial but feasible food policy options, we estimated that CVD mortality could be reduced by up to 1070 deaths/year, representing an overall 26% decline in CVD mortality. Conclusions: A considerable CVD burden is attributable to the excess consumption of saturated fat, trans fat, salt and insufficient fruit and vegetables. There are significant opportunities for Government and industry to reduce CVD mortality through effective, evidence-based food policies