European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics.

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU's total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.

Trajectories of dietary patterns from pregnancy to 12 years post-pregnancy and associated maternal characteristics: evidence from the Avon Longitudinal Study of Parents and Children.

PURPOSE: Dietary patterns (DPs) during pregnancy have been well researched. However, little is known about maternal diet after pregnancy. The aim of the study was to explore maternal DPs longitudinally, examine trajectories over 12 years after pregnancy and identify associated factors. METHODS: Of 14,541 pregnant women enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC) complete dietary information was available for 5336 women. Principal components analysis (PCA) was used to derive DPs. DP scores at each time point were used to create DP trajectories using group-based trajectory modelling (GBTM). Multinomial logistic regression assessed the association with maternal factors. RESULTS: A total of six distinct DPs were identified over time with different numbers of DPs at each time point. The "healthy" and "processed" DPs persisted over the 12-year post-pregnancy. Three trajectories of "healthy" and "processed" DPs were identified from GBTM. Half the women were on the moderately healthy DP trajectory with 37% on the lower trajectory and 9% on the higher healthy DP trajectory. 59% of women were on the lower processed DP trajectory with 38% on the moderate trajectory and 3.3% on the higher processed DP trajectory. Low educational attainment, low social class and smoking in pregnancy were independently associated with being on a less favourable DP trajectory over the 12 years. CONCLUSION: Health professionals should provide support on smoking cessation along with healthy eating advice during ante-natal counselling. Continued support on eating healthily after pregnancy would be beneficial for mothers and families.

Life in lockdown: a qualitative study exploring the experience of living through the initial COVID-19 lockdown in the UK and its impact on diet, physical activity and mental health.

BACKGROUND: In response to the COVID-19 pandemic, the UK imposed a national lockdown prompting change to daily routines. Among behaviours impacted by the lockdown, diet and physical activity may be particularly important due to their association with mental health and physical health. The aim of this study was to explore people's experiences of how lockdown impacted their physical activity, dietary behaviours and mental health, with a view to informing public health promotion. METHODS: This phenomenological qualitative study used semi-structured telephone interviews. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted, guided by the Framework Approach. RESULTS: Forty participants (28 female) completed an interview (mean duration: 36 min) between May and July 2020. The overarching themes identified were (i) Disruption (loss of routines, social interaction and cues to physical activity) and (ii) Adaptation (structuring the day, accessing the outdoor environment, finding new ways for social support). The disruption to daily routines altered people's cues for physical activity and eating; some participants spoke of comfort eating and increased alcohol intake in the early days of lockdown, and how they consciously tried to change these when restrictions lasted longer than first anticipated. Others spoke of adapting to the restrictions using food preparation and meals to provide both routine and social time for families. Disruptions from the closure of workplaces resulted in flexible working times for some, allowing for physical activity to be built into the day. In later stages of restrictions, physical activity became an opportunity for social interaction and several participants reported intending to continue to replace sedentary means of socialising (e.g., meeting in cafes) with more active, outdoor activities (e.g., walking) once restrictions were lifted. Staying active and building activity into the day was seen as important to support physical and mental health during the challenging times of the pandemic. CONCLUSIONS: Whilst many participants found the UK lockdown challenging, adaptations to cope with the restrictions presented some positive changes related to physical activity and diet behaviours. Helping people sustain their new healthier activities since restrictions have lifted is a challenge but presents an opportunity for public health promotion.

'Making every contact count' with patients with musculoskeletal conditions: a qualitative exploration of acceptability to physiotherapists.

AIM: To qualitatively explore physiotherapists' experiences and acceptability of implementing 'Making Every Contact Count Healthy Conversation Skills' (MECC HCS) in routine practice with patients with musculoskeletal (MSK) conditions. METHODS: This article reports the second phase of a mixed method, sequential explanatory study. Physiotherapists trained in and delivering MECC HCS in their practice were invited to take part in semi-structured interviews. We hoped to develop a rich, in-depth understanding of their use and perceptions of the brief intervention and to contextualise findings from the first phase of the study. Qualitative data were analysed using Reflexive Thematic Analysis. RESULTS: Physiotherapists valued MECC HCS as being integral to their practice, promoting a person-centred approach to supporting behaviour change and enhancing self-management in patients with MSK conditions and pain. It was believed that this brief intervention could reduce workload pressure for physiotherapists and have significant wider benefits for health services. Time limitations associated with appointments did, however, pose as a challenge to MECC HCS delivery, and it was felt that more organisational-level support was needed to sustain it. CONCLUSIONS: These findings support our quantitative data, collected in the first phase of this study. MECC HCS is a highly acceptable brief intervention that can be delivered in physiotherapy care to support behaviour change in patients with MSK conditions. Future roll-out may be optimised within organisations by providing regular refresher training and adopting a MECC champion.

'I can feel myself coming out of the rut': a brief intervention for supporting behaviour change is acceptable to patients with chronic musculoskeletal conditions.

AIM: To a) understand the perceptions and experiences of patients with musculoskeletal (MSK) conditions in relation to their physiotherapy care and their acceptability of 'Making Every Contact Count Healthy Conversation Skills' (MECC HCS) as a brief intervention within this care and, b) explore the mechanisms through which MECC HCS might facilitate behaviour change and enhance self-management in patients with MSK conditions. METHODS: This study adopted an exploratory qualitative design, in which individual, semi-structured interviews with participants were conducted. Eight participants were interviewed. Five had been engaging with physiotherapists trained in and delivering MECC HCS within their routine physiotherapy appointments and three had been engaging with physiotherapists who had not received this training and were instead delivering usual care. MECC HCS is a person-centred approach to behaviour change that aims to empower individuals to take control of their health behaviours by building self-efficacy. The MECC HCS training programme helps healthcare professionals to develop skills in i) using 'open discovery' questions to explore context and allow patients to identify barriers and generate solutions; ii) listening more than giving information/ making suggestions; iii) reflecting on practice and iv) supporting Specific, Measurable, Action-oriented, Realistic, Timed, Evaluated, Reviewed (SMARTER) goal setting. RESULTS: Those who had engaged with MECC HCS trained physiotherapists found their physiotherapy care highly acceptable and felt that their physiotherapist listened to them, tried to understand their context and world, and helped them plan for change. These individuals experienced increases in self-efficacy and motivation for self-managing their MSK conditions. A need for continued support following physiotherapy treatment was, however, emphasised for long-term self-management. CONCLUSIONS: MECC HCS is highly acceptable to patients with MSK conditions and pain and may successfully facilitate health-promoting behaviour change and enhance self-management. Providing opportunities to join support groups following physiotherapy treatment may promote long-term self-management and provide social and emotional benefits for individuals. The positive findings of this small qualitative study warrant further investigation on the differences in experiences and outcomes between patients engaging with MECC HCS physiotherapists and those receiving treatment as usual during routine physiotherapy care.

European Society of Cardiology: cardiovascular disease statistics 2021.

AIMS: This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries. METHODS AND RESULTS: Statistics pertaining to 2019, or the latest available year, are presented. Data sources include the World Health Organization, the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards World Health Organization (WHO) 2025 targets for non-communicable diseases. Salient observations in this report: (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high income (81.6 years) compared with middle-income (74.2 years) countries. (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese with similar prevalence in high and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five-member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures. CONCLUSION: Risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO NCD targets for 2025 are unlikely to be met across ESC member countries.

Life in lockdown: a longitudinal study investigating the impact of the UK COVID-19 lockdown measures on lifestyle behaviours and mental health.

BACKGROUND: The COVID-19 pandemic led to the UK government enforcing lockdown restrictions to control virus transmission. Such restrictions present opportunities and barriers for physical activity and healthy eating. Emerging research suggests that in the early stages of the pandemic, physical activity levels decreased, consumption of unhealthy foods increased, while levels of mental distress increased. Our aims were to understand patterns of diet, physical activity, and mental health during the first lockdown, how these had changed twelve-months later, and the factors associated with change. METHODS: An online survey was conducted with UK adults (N = 636; 78% female) during the first national lockdown (May-June 2020). The survey collected information on demographics, physical activity, diet, mental health, and how participants perceived lifestyle behaviours had changed from before the pandemic. Participants who provided contact details were invited to complete a twelve-month follow-up survey (May-June 2021), 160 adults completed the survey at both time-points. Descriptive statistics, T-tests and McNemar Chi Square statistics were used to assess patterns of diet, physical activity, and mental health at baseline and change in behaviours between baseline and follow-up. Linear regression models were conducted to explore prospective associations between demographic and psycho-social variables at baseline with change in healthy eating habit, anxiety, and wellbeing respectively. RESULTS: Between baseline and follow-up, healthy eating habit strength, and the importance of and confidence in eating healthily reduced. Self-rated health (positively) and confidence in eating healthily (negatively) were associated with change in healthy eating habit. There were no differences between baseline and follow-up for depression or physical activity. Mean anxiety score reduced, and wellbeing increased, from baseline to follow-up. Living with children aged 12-17 (compared to living alone) was associated with an increase in anxiety, while perceiving mental health to have worsened during the first lockdown (compared to staying the same) was associated with reduced anxiety and an increase in mental wellbeing. CONCLUSIONS: While healthy eating habits worsened in the 12 months since the onset of the pandemic, anxiety and mental wellbeing improved. However, anxiety may have increased for parents of secondary school aged children.

ß-blocker prescription is associated with lower cumulative risk of knee osteoarthritis and knee pain consultations in primary care: a propensity score-matched cohort study.

OBJECTIVES: To examine the association between ß-blocker prescription and first primary-care consultation for knee OA, hip OA, knee pain and hip pain. METHODS: Data source: Clinical Practice Research Datalink. Participants aged ≥40 years in receipt of new oral ß-blocker prescriptions were propensity score (PS) matched to an unexposed control. Cox proportional hazard ratios (HRs) and 95% CIs were calculated, and adjusted for non-osteoporotic fractures, number of primary-care consultations for knee or hip injury, and, the number of primary-care consultations, out-patient referrals and hospitalizations in the 12 months preceding cohort entry. Analysis was stratified according to ß-blocker class and for commonly prescribed drugs. P < 0.05 was considered statistically significant. RESULTS: A total of 111 718 ß-blocker-exposed participants were 1:1 PS matched to unexposed controls. ß-blocker prescription was associated with reduced cumulative risk of knee OA, knee pain, and hip pain consultations [with a HR (95% CI) of 0.90 (0.83, 0.98), 0.88 (0.83, 0.92) and 0.85 (0.79, 0.90), respectively]. Propranolol and atenolol were associated with a lower incidence of knee OA and knee pain consultations with a HR of between 0.78 and 0.91. ß-blockers were associated with reduced incidence of consultation for large-joint lower-limb OA/pain as a composite outcome, defined as the earliest of knee OA, knee pain, hip OA or a hip pain consultation [with a HR (95% CI) of 0.87 (0.84, 0.90)]. CONCLUSION: Commonly used ß-blockers have analgesic properties for musculoskeletal pain. Atenolol might be a therapeutic option for OA and cardiovascular co-morbidities in which ß-blockers are indicated, while propranolol may be suitable for people with co-morbid anxiety. A confirmatory randomized controlled trial is needed before clinical practice is changed.

European Society of Cardiology: Cardiovascular Disease Statistics 2019.

AIMS: The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets. METHODS AND RESULTS: In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5-23.1%] vs. 15.7% (IQR 14.5-21.1%)}, diabetes [7.7% (IQR 7.1-10.1%) vs. 5.6% (IQR 4.8-7.0%)], and among males smoking [43.8% (IQR 37.4-48.0%) vs. 26.0% (IQR 20.9-31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0-10.8) vs. 16.7% (IQR 13.9-19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655-8115)] compared with high-income [2235 (IQR 1896-3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures. CONCLUSION: A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest.

Trends in the prevalence of overweight among Bangladeshi children aged 24-59 months (2004-2014) by sex and socioeconomic status.

BACKGROUND: While recent evidence suggests that the overall prevalence of overweight in young children in Bangladesh is low, little is known about variation in trends by sex, socioeconomic status, urbanicity, and region. We investigated the trends in overweight among children aged 24-59 months by these factors, using nationally representative samples from Bangladesh Demographic and Health Surveys (BDHS) between 2004 and 2014. METHODS: Data from four BDHS surveys conducted between 2004 and 2014, with valid height and weight measurements of children, were included in this study (n = 15,648). BMI was calculated and the prevalence of overweight (including obesity) was reported using the International Obesity Taskforce (IOTF) classification system. To explore the association between socioeconomic status and childhood overweight, we used multivariable logistic regression. RESULTS: The overall prevalence of overweight among children aged 24-59 months increased from 1.60% (95% CI: 1.20-2.05%) in 2004 to 2.33% (95% CI: 1.82-2.76%) in 2014. Among girls, the overweight trend increased significantly (adjusted odds ratio (OR) comparing 2014 vs. 2004: 2.02 95% CI: 1.52-2.68), whereas among boys the trend remained steady. When compared with households with the poorest wealth index, households with richest wealth index had higher odds of childhood overweight among both boys (OR 2.39, 95% CI: 1.76-3.25) and girls (OR 1.86, 95% CI: 1.35-2.55). Higher household education level was also associated with childhood overweight. Subgroup analyses showed that relative inequalities by these factors increased between 2004 and 2014 when adjusted for potential confounders. CONCLUSIONS: There is a rising trend in overweight prevalence exclusively among girls aged 24-59 months in Bangladesh. Childhood overweight is associated with higher household education and wealth index, and the relative disparity by these factors appears to be increasing over time. These unmet inequalities should be considered while developing national public health programs and strategies.

Epidemiology report: trends in sex-specific cerebrovascular disease mortality in Europe based on WHO mortality data.

AIMS: There have been substantial declines in cerebrovascular disease mortality across much of Europe, mirroring trends in deaths from cardiovascular disease as a whole. No study has investigated trends in cerebrovascular disease, and its subtypes within all European countries. This study aimed to examine sex-specific trends in cerebrovascular disease, and three of its sub-types: ischaemic stroke, haemorrhagic stroke, and subarachnoid haemorrhage (SAH), in Europe between 1980 and 2016. METHODS AND RESULTS: Sex-specific mortality data for each country of the World Health Organization (WHO) Europe region were extracted from the WHO global mortality database and analysed using Joinpoint software to examine trends. The number and location of significant joinpoints for each country by sex and subtype was determined using a log-linear model. The annual percentage change within each segment was calculated along with the average annual percentage change over the duration of all available data. The last 35 years have seen large overall declines in cerebrovascular disease mortality rates in the majority of European countries. While these declines have continued steadily in more than half of countries, this analysis has revealed evidence of recent plateauing and even increases in stroke mortality in a number of countries, in both sexes, and in all four geographical sub-regions of Europe. Analysis by stroke sub-type revealed that recent plateauing was most common for haemorraghic stroke and increases were most common for ischaemic stroke. CONCLUSION: These findings highlight the need for continued research into the inequalities in both current stroke mortality outcomes and trends across Europe, as well as the causes behind any recent plateauing of total cerebrovascular disease or its subtypes.

Examining trends in cardiovascular disease mortality across Europe: how does the introduction of a new European Standard Population affect the description of the relative burden of cardiovascular disease?

BACKGROUND: Some mortality statistics are misleading when comparing between countries due to varying age distributions in their populations. In order to adjust for these differences, age-standardised mortality rates (ASMRs) are often produced. ASMRs allow for comparisons between countries as if both had the same standardised population. We examined whether the updating of the standard population for Europe affected the description of the relative burden between countries in cardiovascular disease (CVD) mortality across the continent. METHODS: Mortality and population data were obtained from the World Health Organization (WHO) mortality database. ASMRs were calculated using the direct method and two European Standard Populations (ESP): 1976 ESP and 2013 ESP. We investigated differences in ASMR76 (calculated using 1976 ESP) and ASMR13 (calculated using 2013 ESP), changes in rankings of countries between the two ASMRs and differences in trends in CVD mortality in each country for the two ASMRs. RESULTS: CVD rates calculated using the 1976 ESP were on average half the size of rates calculated using the 2013 ESP. Spearman's rank coefficient showed that the ranks of countries by ASMRs calculated using the two ESPs were different for both sexes. Joinpoint analyses showed no difference in the direction of trend between ASMR76 and ASMR13 although differences in the magnitude of the change were found in some countries. CONCLUSION: ASMRs are commonly used in studying the epidemiology of a disease. It is crucial that policy makers understand the effect of changes in standard populations on these rates. This includes how populations with different age distributions compare to each other. Similar effects may be seen in other diseases that are also more prevalent in older age groups, such as cancer and dementia.

Diet quality of adolescents in rural Sri Lanka based on the Diet Quality Index-International: findings from the 'Integrating Nutrition Promotion and Rural Development' project.

OBJECTIVE: The current paper describes methods of evaluating dietary habits of Sri Lankan adolescents based on the Diet Quality Index-International (DQI-I), which has been used in multiple international studies to describe dietary variety, moderation, adequacy and balance. The paper describes the method for calculating DQI-I scores and examines associations between DQI-I scores and dietary intake, and between DQI-I scores and sociodemographic factors. DESIGN: The study followed a three-stage cluster randomised sampling method. Dietary intake was collected using a validated FFQ. Estimated micronutrient intakes and number of servings consumed were described according to DQI-I quartiles. DQI-I scores were tabulated according to sociodemographic characteristics. Multilevel modelling was used to examine associations between sociodemographic characteristics and DQI-I scores. SETTING: Secondary schools in rural Sri Lanka.ParticipantsAdolescents (n 1300) aged 12-18 years attending secondary school in rural Sri Lanka. RESULTS: DQI-I scores increased with consumption of fat (% energy), cholesterol (mg/d), energy (kJ/d), protein (% energy), Na (mg), dietary fibre (g), Fe (mg) and Ca (mg), but decreased according to percentage of energy coming from carbohydrates. DQI-I scores were significantly lower among females and students with lower levels of maternal education. CONCLUSIONS: Policies are needed to increase the availability and affordability of nutrient-rich foods such as fruits, vegetables and high-protein foods, particularly to students from lower socio-economic backgrounds. Significant differences in diet quality according to sex, socio-economic status and district suggest there is potential for targeted interventions that aim to increase access to affordable, nutrient-rich foods among these groups.

European Society of Cardiology: Cardiovascular Disease Statistics 2017.

Aims: The European Society of Cardiology (ESC) Atlas has been compiled by the European Heart Agency to document cardiovascular disease (CVD) statistics of the 56 ESC member countries. A major aim of this 2017 data presentation has been to compare high-income and middle-income ESC member countries to identify inequalities in disease burden, outcomes, and service provision. Methods and results: The Atlas utilizes a variety of data sources, including the World Health Organization, the Institute for Health Metrics and Evaluation, and the World Bank to document risk factors, prevalence, and mortality of cardiovascular disease and national economic indicators. It also includes novel ESC-sponsored survey data of health infrastructure and cardiovascular service provision provided by the national societies of the ESC member countries. Data presentation is descriptive with no attempt to attach statistical significance to differences observed in stratified analyses. Important differences were identified between the high-income and middle-income member countries of the ESC with regard to CVD risk factors, disease incidence, and mortality. For both women and men, the age-standardized prevalence of hypertension was lower in high-income countries (18% and 27%) compared with middle-income countries (24% and 30%). Smoking prevalence in men (not women) was also lower (26% vs. 41%) and together these inequalities are likely to have contributed to the higher CVD mortality in middle-income countries. Declines in CVD mortality have seen cancer becoming a more common cause of death in a number of high-income member countries, but in middle-income countries declines in CVD mortality have been less consistent where CVD remains the leading cause of death. Inequalities in CVD mortality are emphasized by the smaller contribution they make to potential years of life lost in high-income countries compared with middle-income countries both for women (13% vs. 23%) and men (20% vs. 27%). The downward mortality trends for CVD may, however, be threatened by the emerging obesity epidemic that is seeing rates of diabetes increasing across all the ESC member countries. Survey data from the National Cardiac Societies showed that rates of cardiac catheterization and coronary artery bypass surgery, as well as the number of specialist centres required to deliver them, were greatest in the high-income member countries of the ESC. The Atlas confirmed that these ESC member countries, where the facilities for the contemporary treatment of coronary disease were best developed, were often those in which declines in coronary mortality have been most pronounced. Economic resources were not the only driver for delivery of equitable cardiovascular health care, as some middle-income ESC member countries reported rates for interventional procedures and device implantations that matched or exceeded the rates in wealthier member countries. Conclusion: In documenting national CVD statistics, the Atlas provides valuable insights into the inequalities in risk factors, health care delivery, and outcomes of CVD across the ESC member countries. The availability of these data will underpin the ESC's ambitious mission 'to reduce the burden of cardiovascular disease' not only in its member countries but also in nation states around the world.

Prevalence and correlates of exposure to second hand smoke (SHS) among 14 to 15 year old schoolchildren in a medical officer of health area in Sri Lanka.

BACKGROUND: Despite reports that Southeast Asia has one of the highest prevalence for childhood exposure to second hand smoke (SHS), there are limited data on SHS exposure among schoolchildren in individual countries in the region, including Sri Lanka. This study aimed to determine the prevalence and correlates of SHS among schoolchildren in a Medical Officer of Health (MOH) region in the country. METHODS: We conducted a cross-sectional study, sampling from nice schools in one MOH region following a two-stage cluster sample design and probability proportionate to size sampling techniques. Data were obtained through a self-completed anonymous questionnaire on socio-demographic and health behaviour risk factors. We achieved an 89.5% response rate, corresponding to a total of 311 students in the final sample. RESULTS: The prevalence of exposure to SHS during the previous week was 17.6% at home and 25.7% in enclosed public places. There were no significant differences in exposure to SHS between sexes. Univariable analysis found that the presence of smokers at home and mother's unemployment status were significantly associated with a higher risk of exposure to SHS at home. These variables remained significant in multivariable analysis. Non-Sinhalese ethnicity and presence of smokers at home were significantly associated with exposure to SHS in public places, in both uni- and multivariable analysis. Unemployment status of mother was also found to be a significant determinant of exposure to SHS in public places in multivariable analysis. CONCLUSION: Despite numerous antismoking activities and strong antismoking legislation, the prevalence of SHS exposure among schoolchildren is higher in enclosed public places than homes. The implementation and enforcement of antismoking legislation is imperative to tackle this and should be supported by the provision of education for schoolchildren and their families on the health risks of SHS. The high-risk groups identified here could be prioritised for preventive programmes.

Challenges of research recruitment in a university setting in England.

The recruitment is an integral part of most research projects in medical sciences involving human participants. In health promotion research, there is increasing work on the impact of environments. Settings represent environments such as schools where social, physical and psychological development unfolds. In this study, we investigated weight gain in students within a university setting. Barriers to access and recruitment of university students within a specific setting, in the context of health research are discussed. An online survey on health behaviours of first year students across 101 universities in England was developed. Ethics committees of each institutions were contacted to obtain permission to recruit and access their students. Recruitment adverts were standardized and distributed within restrictions imposed by universities. Three time points and incentives were used. Several challenges in recruiting from a university setting were found. These included (i) ethics approval, (ii) recruitment approval, (iii) navigating restrictions on advertisement and (iv) logistics of varying university academic calendars. We also faced challenges of online surveys including low recruitment, retention and low eligibility of respondents. From the 101 universities, 28 allowed dissemination of adverts. We obtained 1026 responses at T1, 599 at T2 and 497 at T3. The complete-case sample represented 13% of those originally recruited at T1. Conducting research on students within the university setting is a time consuming and challenging task. To improve research-based health promotion, universities could work together to increase consistency as to their policies on student recruitment.

Comparing trends in mortality from cardiovascular disease and cancer in the United Kingdom, 1983-2013: joinpoint regression analysis.

BACKGROUND: We aimed to study the time trends underlying a change from cardiovascular disease (CVD) to cancer as the most common cause of age-standardized mortality in the UK between 1983 and 2013. METHODS: A retrospective trend analysis of the World Health Organization mortality database for mortality from all cancers, all CVDs, and their three most common types, by sex and age. Age-standardized mortality rates were adjusted to the 2013 European Standard Population and analyzed using joinpoint regression analysis for annual percent changes. RESULTS: The difference in mortality rate between total CVD and cancer narrowed over the study period as age-standardized mortality from CVD decreased more steeply than cancer in both sexes. We observed higher overall rates for both diseases in men compared to women, with high mortality rates from ischemic heart disease and lung cancer in men. Joinpoint regression analysis indicated that trends of decreasing rates of CVD have increased over time while decreasing trends in cancer mortality rates have slowed down since the 1990s. The lowest improvements in mortality rates were for cancer in those over 75 years of age and lung cancer in women. CONCLUSIONS: In 2011, the age-standardized mortality rate for cancer exceeded that of CVD in both sexes in the UK. These changing trends in mortality may support evidence for changes in policy and resource allocation in the UK.

Quantifying the global distribution of premature mortality from non-communicable diseases.

Background: Non-communicable diseases (NCDs) have slowly risen to the top of the global health agenda and the reduction of premature NCD mortality was recently enshrined in Target 3.4 of the UN Sustainable Development Goals. The unequal global distribution of NCDs is inadequately captured by the most commonly cited statistics. Methods: We analyzed 'WHO Global Health Estimates' mortality data to calculate the relative burden of NCDs for each World Bank income group, including the 'risk of premature NCD death' based on methods in the WHO Global Status Report. We included all deaths from cardiovascular disease, all cancers, respiratory diseases and diabetes in people aged 30-69 years. Results: Developing countries experience 82% of absolute global premature NCD mortality, but they also contain 82% of the world's population. Examining relative risk shows that individuals in developing countries face a 1.5 times higher risk of premature NCD death than people living in high-income countries. Premature NCD death rates are highest in lower middle-income countries. Conclusions: Although numbers of deaths are useful to describe the absolute burden of NCD mortality by country type, the inequitable distribution of premature NCD mortality for individuals is more appropriately conveyed with relative risk.

Barriers to healthy dietary choice amongst students in Sri Lanka as perceived by school principals and staff.

Summary: Sri Lanka has experienced a massive demographic, environmental, economic and social transition in recent decades. Over this period of time the country has undergone rapid urbanization leading to accompanying shifts in lifestyle and it suffers a double burden of under- and over-nutrition. Current programmes in the country focus on improving the dietary behaviour of secondary school students. The purpose of this study was to investigate principal's perceptions on barriers to healthy dietary choice among pupils within a socio-ecological framework. Focus groups (n = 11) were carried out with school principals and staff (n = 55) in two rural districts of Sri Lanka. Principals identified a number of barriers to healthy dietary choice by students, which could be found at a number of levels of influence of a socio-ecological framework: (i) structural level barriers included educational and agricultural policies, (ii) living and working level barriers included employment opportunities and local food production, (iii) social and community level barriers included traditions and social/cultural beliefs and (iv) individual level barriers included knowledge and preference. Findings from this study suggest that the barriers to healthy dietary choice amongst secondary school students in Sri Lanka occur at many levels supporting the use of multifactorial programmes to promote healthy eating. Only from understanding these barriers and finding ways to counter them can we hope to reduce the double burden of under- and over-nutrition the country is currently suffering.

Knowledge, attitudes and perception on dietary salt reduction of two communities in Grahamstown, South Africa.

INTRODUCTION: Dietary salt reduction has been identified as a cost effective way of addressing the global burden of non-communicable diseases (NCDs), particularly cardiovascular diseases. The World Health Organization has recommended three main strategies for achieving population-wide salt reduction in all member states: food reformulation, policies and consumer awareness campaigns. In 2013, the South African Ministry of Health announced the mandatory salt reduction legislation for the food manufacturing sector. These were set to come into effect on 30 June 2016. This decision was influenced by the need to reduce the incidence of NCDs and the fact that processed food is the source of 54% of the salt consumed in the South African diet. However, with discretionary salt also being a significant contributor, there is need for consumer awareness campaigns. The aim of this study was to assess the knowledge, attitudes and practices of guardians and cooks at two non-governmental organisations based in Grahamstown, South Africa, towards dietary salt reduction. METHOD: Data was collected through observation and explorative, voice-recorded semi-structured interviews and transcribed data was analysed using NVivo®. RESULTS: At both centres, salt shakers were not placed on the tables during mealtimes. Only 14% the participants perceived their personal salt intake to be a little. No participants were aware of the recommended daily salt intake limit or the relationship between salt and sodium. Only five out of the 19 participants had previously received information on dietary salt reduction from sources such as healthcare professionals and the media. CONCLUSION: The results from the first phase of this study highlighted gaps in the participants' knowledge, attitudes and practices towards dietary salt reduction. The aim of the second phase of the research is to design and implement a context specific and culturally appropriate educational intervention on dietary salt reduction.