Global sodium consumption and death from cardiovascular causes.

BACKGROUND: High sodium intake increases blood pressure, a risk factor for cardiovascular disease, but the effects of sodium intake on global cardiovascular mortality are uncertain. METHODS: We collected data from surveys on sodium intake as determined by urinary excretion and diet in persons from 66 countries (accounting for 74.1% of adults throughout the world), and we used these data to quantify the global consumption of sodium according to age, sex, and country. The effects of sodium on blood pressure, according to age, race, and the presence or absence of hypertension, were calculated from data in a new meta-analysis of 107 randomized interventions, and the effects of blood pressure on cardiovascular mortality, according to age, were calculated from a meta-analysis of cohorts. Cause-specific mortality was derived from the Global Burden of Disease Study 2010. Using comparative risk assessment, we estimated the cardiovascular effects of current sodium intake, as compared with a reference intake of 2.0 g of sodium per day, according to age, sex, and country. RESULTS: In 2010, the estimated mean level of global sodium consumption was 3.95 g per day, and regional mean levels ranged from 2.18 to 5.51 g per day. Globally, 1.65 million annual deaths from cardiovascular causes (95% uncertainty interval [confidence interval], 1.10 million to 2.22 million) were attributed to sodium intake above the reference level; 61.9% of these deaths occurred in men and 38.1% occurred in women. These deaths accounted for nearly 1 of every 10 deaths from cardiovascular causes (9.5%). Four of every 5 deaths (84.3%) occurred in low- and middle-income countries, and 2 of every 5 deaths (40.4%) were premature (before 70 years of age). The rate of death from cardiovascular causes associated with sodium intake above the reference level was highest in the country of Georgia and lowest in Kenya. CONCLUSIONS: In this modeling study, 1.65 million deaths from cardiovascular causes that occurred in 2010 were attributed to sodium consumption above a reference level of 2.0 g per day. (Funded by the Bill and Melinda Gates Foundation.).

Impact of Dietary and Metabolic Risk Factors on Cardiovascular and Diabetes Mortality in South Asia: Analysis From the 2010 Global Burden of Disease Study.

OBJECTIVES: To quantify cardiovascular disease and diabetes deaths attributable to dietary and metabolic risks by country, age, sex, and time in South Asian countries. METHODS: We used the 2010 Global Burden of Disease national surveys to characterize risk factor levels by age and sex. We derived etiological effects of risk factors-disease endpoints, by age, from meta-analyses. We defined optimal levels. We combined these inputs with cause-specific mortality rates to compute population-attributable fractions as a percentage of total cardiometabolic deaths. RESULTS: Suboptimal diet was the leading cause of cardiometabolic mortality in 4 of 5 countries, with population-attributable fractions from 40.7% (95% uncertainty interval = 37.4, 44.1) in Bangladesh to 56.9% (95% uncertainty interval = 52.4, 61.5) in Pakistan. High systolic blood pressure was the second leading cause, except in Bangladesh, where it superseded suboptimal diet. This was followed in all nations by high fasting plasma glucose, low fruit intake, and low whole grain intake. Other prominent burdens were more variable, such as low intake of vegetables, low omega-3 fats, and high sodium intake in India, Nepal, and Pakistan. CONCLUSIONS: Important similarities and differences are evident in cardiometabolic mortality burdens of modifiable dietary and metabolic risks across these countries, informing health policy and program priorities.

The science of epidemiology and the methods needed for public health assessments: a review of epidemiology textbooks.

OBJECTIVES: Epidemiology is often described as 'the science of public health'. Here we aim to assess the extent that epidemiological methods, as covered in contemporary standard textbooks, provide tools that can assess the relative magnitude of public health problems and can be used to help rank and assess public health priorities. STUDY DESIGN: Narrative literature review. METHODS: Thirty textbooks were grouped into three categories; pure, extended or applied epidemiology, were reviewed with attention to the ways the discipline is characterised and the nature of the analytical methods described. RESULTS: Pure texts tend to present a strict hierarchy of methods with those metrics deemed to best serve aetiological inquiry at the top. Extended and applied texts employ broader definitions of epidemiology but in most cases, the metrics described are also those used in aetiological inquiry and may not be optimal for capturing the consequences and social importance of injuries and disease onsets. CONCLUSIONS: The primary scientific purpose of epidemiology, even amongst 'applied' textbooks, is aetiological inquiry. Authors do not readily extend to methods suitable for assessing public health problems and priorities.

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.

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.

Perceived challenges to public health in Central and Eastern Europe: a qualitative analysis.

BACKGROUND: There is a major gradient in burden of disease between Central and Eastern Europe compared to Western Europe. Many of the underlying causes and risk factors are amenable to public health interventions. The purpose of the study was to explore perceptions of public health experts from Central and Eastern European countries on public health challenges in their countries. METHODS: We invited 179 public health experts from Central and Eastern European countries to a 2-day workshop in Berlin, Germany. A total of 25 public health experts from 14 countries participated in May 2008. The workshop was structured into 8 sessions of 1.5 hours each, with the topic areas covering coronary heart disease, stroke, prevention, obesity, alcohol, tobacco, tuberculosis, and HIV/AIDS. The workshop was recorded and the proceedings transcribed verbatim. The transcripts were entered into atlas.ti for content analysis and coded according to the session headings. After analysis of the content of each session discussion, a re-coding of the discussions took place based on the themes that emerged from the analysis. RESULTS: Themes discussed recurred across disease entities and sessions. Major themes were the relationship between clinical medicine and public health, the need for public health funding, and the problems of proving the effectiveness of disease prevention. Areas for action identified included the need to engage with the public, to create a better scientific basis for public health interventions, to identify "best practices" of disease prevention, and to implement registries/surveillance instruments. The need for improved data collection was seen throughout all areas discussed, as was the need to harmonize data across countries. CONCLUSIONS: To reduce the burden of disease across Europe, closer collaboration of countries across Europe seems important in order to learn from each other. A more credible scientific basis for effective public health interventions is urgently needed. The monitoring of health trends is crucial to evaluate the impact of public health programmes.

Why my disease is important: metrics of disease occurrence used in the introductory sections of papers in three leading general medical journals in 1993 and 2003.

BACKGROUND: We assessed the metrics used in claims about disease importance made in the introductory sections of scientific papers published in 1993 and 2003. We were interested in the choice of metric in circumstances where establishing the relative social importance of a disease was, presumptively, a primary objective. METHODS: This study consisted of a textual examination of the introductory statements from papers retrieved from MEDLINE. Papers were published in the New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association during the first halves of 1993 and 2003, and were selected on the basis of keywords found in a pilot study to be associated with claims about disease importance. RESULTS: We found 143 papers in 1993 and 264 papers in 2003 included claims about disease importance in their introductory sections, and characteristics of these claims were abstracted. Of the quotes identified in the papers and articles examined, most used counts, prevalence, or incidence measurements. Some also used risk estimates and economic quantities to convey the importance of the disease. There was no change in the types of metrics used between 1993 and 2003. Very few articles, even in 2003, used metrics that weighted disease onsets by the expected consequent loss of healthy time -- such as years of life lost, quality-adjusted life years, and/or disability-adjusted life years. CONCLUSIONS: Claims about the relative importance of diseases continued to be overwhelmingly expressed in terms of counts (of deaths and disease onsets) and comparisons of counts, rates, and risks. Where the aim is to convey the burden that a given disease imposes on a society, "event-based" metrics might be less fit for the purpose than "time-based" metrics. More attention is needed to how the choice of metric should relate to the purpose at hand.

National cardiovascular prevention should be based on absolute disease risks, not levels of risk factors.

BACKGROUND: It has been shown that the prevention of multicausal diseases such as heart attack (at an individual level) should be guided by absolute risks rather than by the level of risk factors. Here, we show that an analogous argument should form the basis of population-level prevention. METHODS: Estimates of age- and sex-specific means and standard deviations for systolic blood pressures and blood cholesterol concentrations and for deaths assigned to all vascular causes in 2002 were obtained from the World Health Organization for 25 current member states of the European Union, for the ages 30-69 years. Predicted effects of 5 mmHg reductions in mean systolic blood pressures and 0.5 mmol l(-1) reductions in mean total blood cholesterol concentrations on deaths and years of life lost (YLL) per 100,000 person-years from vascular diseases were modelled using proportional risk coefficients from meta-analyses of cohort studies and randomized controlled trials. RESULTS: Potential absolute benefits were strongly positively associated with current levels of absolute mortality risk: in the case of systolic blood pressure, predicted vascular deaths averted in the highest risk populations (Romania, Bulgaria) were over five times higher than in the lowest risk populations (Spain, France). Potential benefits were only weakly related to existing levels of the risk factor of interest. CONCLUSIONS: High-risk populations should give the highest priority to achieving favourable shifts in all modifiable risk factors. Irrespective of the level of any particular risk factor, the rewards will be greatest in these populations.

Mortality attributable to excess adiposity in England and Wales in 2003 and 2015: explorations with a spreadsheet implementation of the Comparative Risk Assessment methodology.

BACKGROUND: Our aim was to estimate the burden of fatal disease attributable to excess adiposity in England and Wales in 2003 and 2015 and to explore the sensitivity of the estimates to the assumptions and methods used. METHODS: A spreadsheet implementation of the World Health Organization's (WHO) Comparative Risk Assessment (CRA) methodology for continuously distributed exposures was used. For our base case, adiposity-related risks were assumed to be minimal with a mean (SD) BMI of 21 (1) Kg m-2. All cause mortality risks for 2015 were taken from the Government Actuary and alternative compositions by cause derived. Disease-specific relative risks by BMI were taken from the CRA project and varied in sensitivity analyses. RESULTS: Under base case methods and assumptions for 2003, approximately 41,000 deaths and a loss of 1.05 years of life expectancy were attributed to excess adiposity. Seventy-seven percent of all diabetic deaths, 23% of all ischaemic heart disease deaths and 14% of all cerebrovascular disease deaths were attributed to excess adiposity. Predictions for 2015 were found to be more sensitive to assumptions about the future course of mortality risks for diabetes than to variation in the assumed trend in BMI. On less favourable assumptions the attributable loss of life expectancy in 2015 would rise modestly to 1.28 years. CONCLUSION: Excess adiposity appears to contribute materially but modestly to mortality risks in England and Wales and this contribution is likely to increase in the future. Uncertainty centres on future trends of associated diseases, especially diabetes. The robustness of these estimates is limited by the lack of control for correlated risks by stratification and by the empirical uncertainty surrounding the effects of prolonged excess adiposity beginning in adolescence.

Food, livestock production, energy, climate change, and health.

Food provides energy and nutrients, but its acquisition requires energy expenditure. In post-hunter-gatherer societies, extra-somatic energy has greatly expanded and intensified the catching, gathering, and production of food. Modern relations between energy, food, and health are very complex, raising serious, high-level policy challenges. Together with persistent widespread under-nutrition, over-nutrition (and sedentarism) is causing obesity and associated serious health consequences. Worldwide, agricultural activity, especially livestock production, accounts for about a fifth of total greenhouse-gas emissions, thus contributing to climate change and its adverse health consequences, including the threat to food yields in many regions. Particular policy attention should be paid to the health risks posed by the rapid worldwide growth in meat consumption, both by exacerbating climate change and by directly contributing to certain diseases. To prevent increased greenhouse-gas emissions from this production sector, both the average worldwide consumption level of animal products and the intensity of emissions from livestock production must be reduced. An international contraction and convergence strategy offers a feasible route to such a goal. The current global average meat consumption is 100 g per person per day, with about a ten-fold variation between high-consuming and low-consuming populations. 90 g per day is proposed as a working global target, shared more evenly, with not more than 50 g per day coming from red meat from ruminants (ie, cattle, sheep, goats, and other digastric grazers).

Dietary patterns and cardiovascular mortality in the Melbourne Collaborative Cohort Study.

BACKGROUND: Despite increased cardiovascular disease risk factors, migrants to Australia from Mediterranean countries have lower mortality than do native-born Australians. Dietary patterns may contribute to this. OBJECTIVE: The objective was to investigate the relation between dietary patterns and mortality from cardiovascular (CVD) and ischemic heart disease (IHD) in an ethnically diverse population. DESIGN: This was a prospective cohort study (mean follow-up: 10.4 y) of 40 653 volunteers (23 980 women) aged 40-69 y in the Melbourne Collaborative Cohort Study (1990-1994); 24% of the subjects were Mediterranean born. RESULTS: Four dietary factors were identified from a food-frequency questionnaire with the use of principal components analysis. They explained 69% of intake variance and reflected frequent intakes of Mediterranean foods, vegetables, meat, and fresh fruit. The Mediterranean factor was inversely associated with CVD and IHD mortality in models adjusting for diabetes, waist-to-hip ratio, body mass index, and hypertension. For IHD, the hazard ratio (HR) for the highest compared with the lowest quartile of consumption was 0.59 (95% CI: 0.39, 0.89; P for trend = 0.03). Associations persisted in analyses excluding people with prior CVD (HR: 0.51; 95% CI: 0.30, 0.88; P for trend = 0.03). Vegetable and fresh fruit factors were inversely associated with CVD mortality but only among those without prior CVD. HRs (highest compared with lowest quartile) were 0.66 (95% CI: 0.48, 0.92; P for trend = 0.02) for vegetables and 0.69 (95% CI: 0.52, 0.93; P for trend = 0.04) for fresh fruit. The meat factor was not associated with CVD or IHD mortality. CONCLUSION: Our findings suggest that frequent consumption of traditional Mediterranean foods is associated with reduced cardiovascular mortality after controlling for important risk factors and country of birth.

Alcohol accounts for a high proportion of premature mortality in central and eastern Europe.

BACKGROUND: There is a west-east mortality gradient in Europe, more pronounced in men. The objective of this article was to quantify the contribution of alcohol use to the gap in premature adult mortality between three old (France, Sweden and United Kingdom) and four new (Czech Republic, Hungary, Lithuania and Poland) European Union (EU) member states for the year 2002. Russia was added as an external comparator. METHODS: Exposure data were taken from surveys and per capita consumption records from the World Health Organization (WHO) Global Alcohol Database. Mortality data were taken from the WHO databank. The risk relationships were taken from published meta-analyses and from the WHO Comparative Risk Assessment project. Alcohol exposure and relative risk information was combined to derive alcohol-attributable fractions for relevant causes of premature mortality. RESULTS: Alcohol consumption was responsible for 14.6% of all premature adult mortality in the eight countries, 17.3% in men and 8.0% in women. This proportion was clearly higher in the new EU member states and Russia compared with the comparison countries from the old EU. For men, Russia with 29.0 alcohol-attributable premature deaths per 10,000 population had a more than 10-fold higher rate compared with Sweden (2.7 deaths/10,000). For women, the ratio between Hungary (5.0 alcohol-attributable deaths/10,000) and Russia (4.7 deaths/10,000) compared with Sweden (0.5 deaths/10,000) was almost as high, but the rates were much lower. The Czech Republic and Poland showed proportionally less alcohol-attributable premature mortality than the other new EU member states or Russia for both genders, which, however, was still higher than in any of the old EU member states. CONCLUSIONS: Alcohol is a strong contributor to the health gap between western and central and eastern Europe, with both average volume of consumption and patterns of drinking contributing to burden of disease and injury. Alcohol also contributes substantially to male-female differences in mortality and life expectancy. However, there are feasible and cost-effective measures to reduce alcohol-related burden that should be implemented in central and eastern Europe.

Alcohol consumption and cardiovascular mortality accounting for possible misclassification of intake: 11-year follow-up of the Melbourne Collaborative Cohort Study.

AIMS: To investigate the relationship between usual daily alcohol intake, beverage type and drinking frequency on cardiovascular (CVD) and coronary heart disease (CHD) mortality, accounting for systematic misclassification of intake. DESIGN: Prospective cohort study with mean follow-up of 11.4 years. Setting The Melbourne Collaborative Cohort Study, Australia. PARTICIPANTS: A total of 38 200 volunteers (23 044 women) aged 40-69 years at baseline (1990-1994). MEASUREMENTS: Self-reported alcohol intake using beverage-specific quantity-frequency questions (usual intake) and drinking diary for previous week. FINDINGS: Compared with life-time abstention, usual daily alcohol intake was associated with lower CVD and CHD mortality risk for women but not men. For women, the hazard ratio [HR (95% CI)] for CVD for those drinking > 20 g/day alcohol was 0.43 (0.19-0.95; P trend = 0.18), and for CHD, 0.19 (0.05-0.82; P trend = 0.24). Male former drinkers had over twice the mortality risk for CVD [HR = 2.58 (1.51-4.41)] and CHD [HR = 2.91 (1.59-5.33)]. Wine was the only beverage associated inversely with mortality for women. Compared with drinkers who consumed no alcohol in the week before baseline, drinking frequency was associated inversely with CVD and CHD mortality risk for men but not women. HR for men drinking 6-7 days/week was 0.49 (0.29-0.81; P trend = 0.02) for CVD, and 0.49 (0.26-0.92: P trend = 0.23) for CHD. CONCLUSIONS: Usual daily alcohol intake was associated with reduced CVD and CHD mortality for women but not men. This benefit appeared to be mainly from wine, although comparison of beverages was not possible. Drinking frequency was associated inversely with CVD and CHD death for men but not women.

Potential generation of geographical inequities by the introduction of primary percutaneous coronary intervention for the management of ST segment elevation myocardial infarction.

BACKGROUND: Primary Percutaneous Coronary Intervention (PCI) is more efficacious than thrombolysis in the management of acute myocardial infarction, but, because of the requirement for prompt treatment, there are practical challenges in developing such services. We examined the proportion of patients with ST segment Elevation Myocardial Infarction (STEMI) who could receive timely treatment from a primary Percutaneous Coronary Intervention (PCI) service assuming different geographical locations of potential treatment centres in three English counties. METHODS AND RESULTS: Information on the residential location of patients with new STEMI hospitalisations recorded in Hospital Episodes Statistics was analysed and the proportion of episodes of STEMI within 60' and 45' travel time isochrones from potential primary PCI centres in three English counties was calculated. There were on average 1,815 new STEMI hospitalisations per year occurring in the studied population. Introduction of a primary PCI service in one, two or three potential treatment centres would have covered respectively 28%, 73% and 90% of such episodes within 60 minutes travel time, and 17%, 51% and 69% within 45 minutes travel time. CONCLUSION: In the study context, a primary PCI service in an existing tertiary centre would only cover a minority of STEMI events and would generate geographical inequities. A two-centre model would improve coverage and equity considerably, but may be associated with practical, clinical quality and financial challenges.

Informal knowledge transfer in the period before formal health education programmes: case studies of mass media coverage of HIV and SIDS in England and Wales.

BACKGROUND: How advances in knowledge lead via behaviour change to better health is not well understood. Here we report two case studies: a rapid reduction in HIV transmission in homosexual men and a decline in Sudden Infant Death Syndrome (SIDS) that took place in the period before the relevant national education programmes commenced, respectively, in 1986 and 1991. The role of newspapers in transferring knowledge relevant to reducing the risk of AIDS and SIDS is assessed. METHODS: HIV Searches were made of The Times (1981-1985), Gay News (1981-1984) and, for the key period of April to June 1983, of eight newspapers with the highest readership. Information on transmission route and educational messages were abstracted and analysed. SIDS Searches were made of The Times and the Guardian (1985-1991), The Sun (selected periods only, 1988-1991) and selected nursing journals published in England and Wales. Information on sleeping position and educational messages were abstracted and analysed. RESULTS: HIV Forty-five out of 50 articles identified in newspapers described homosexuals as an at risk group. Sexual transmission of AIDS was, however, covered poorly, with only 7 (14%) articles referring explicitly to sexual transmission. Only seven articles (14%) associated risk with promiscuity. None of the articles were specific about changes in behaviour that could be expected to reduce risk. Gay periodicals did not include specific advice on reducing the number of partners until early 1984. SIDS Out of 165 relevant articles in The Times and 84 in the Guardian, 7 were published before 1991 and associated risk with sleeping position. The reviewed nursing journals reflected a pervasive sense of uncertainty about the link between SIDS and sleeping position. CONCLUSION: Presumptively receptive audiences responded rapidly to new knowledge on how changes in personal behaviour might reduce risk, even though the 'signals' were not strong and were transmitted, at least partly, through informal and 'horizontal' channels. Advances in knowledge with the potential to prevent disease by behaviour change may thus yield substantial health benefits even without the mediation of formal education campaigns ('interventions'). Formal campaigns, when they came, did make important additional contributions, especially in the case of SIDS.

Cost effectiveness of a government supported policy strategy to decrease sodium intake: global analysis across 183 nations.

OBJECTIVE:  To quantify the cost effectiveness of a government policy combining targeted industry agreements and public education to reduce sodium intake in 183 countries worldwide. DESIGN:  Global modeling study. SETTING:  183 countries. POPULATION:  Full adult population in each country. INTERVENTION:  A "soft regulation" national policy that combines targeted industry agreements, government monitoring, and public education to reduce population sodium intake, modeled on the recent successful UK program. To account for heterogeneity in efficacy across countries, a range of scenarios were evaluated, including 10%, 30%, 0.5 g/day, and 1.5 g/day sodium reductions achieved over 10 years. We characterized global sodium intakes, blood pressure levels, effects of sodium on blood pressure and of blood pressure on cardiovascular disease, and cardiovascular disease rates in 2010, each by age and sex, in 183 countries. Country specific costs of a sodium reduction policy were estimated using the World Health Organization Noncommunicable Disease Costing Tool. Country specific impacts on mortality and disability adjusted life years (DALYs) were modeled using comparative risk assessment. We only evaluated program costs, without incorporating potential healthcare savings from prevented events, to provide conservative estimates of cost effectiveness MAIN OUTCOME MEASURE:  Cost effectiveness ratio, evaluated as purchasing power parity adjusted international dollars (equivalent to the country specific purchasing power of US$) per DALY saved over 10 years. RESULTS:  Worldwide, a 10% reduction in sodium consumption over 10 years within each country was projected to avert approximately 5.8 million DALYs/year related to cardiovascular diseases, at a population weighted mean cost of I$1.13 per capita over the 10 year intervention. The population weighted mean cost effectiveness ratio was approximately I$204/DALY. Across nine world regions, estimated cost effectiveness of sodium reduction was best in South Asia (I$116/DALY); across the world's 30 most populous countries, best in Uzbekistan (I$26.08/DALY) and Myanmar (I$33.30/DALY). Cost effectiveness was lowest in Australia/New Zealand (I$880/DALY, or 0.02×gross domestic product (GDP) per capita), although still substantially better than standard thresholds for cost effective (<3.0×GDP per capita) or highly cost effective (<1.0×GDP per capita) interventions. Most (96.0%) of the world's adult population lived in countries in which this intervention had a cost effectiveness ratio <0.1×GDP per capita, and 99.6% in countries with a cost effectiveness ratio <1.0×GDP per capita. CONCLUSION:  A government "soft regulation" strategy combining targeted industry agreements and public education to reduce dietary sodium is projected to be highly cost effective worldwide, even without accounting for potential healthcare savings.

Etiologic effects and optimal intakes of foods and nutrients for risk of cardiovascular diseases and diabetes: Systematic reviews and meta-analyses from the Nutrition and Chronic Diseases Expert Group (NutriCoDE).

BACKGROUND: Dietary habits are major contributors to coronary heart disease, stroke, and diabetes. However, comprehensive evaluation of etiologic effects of dietary factors on cardiometabolic outcomes, their quantitative effects, and corresponding optimal intakes are not well-established. OBJECTIVE: To systematically review the evidence for effects of dietary factors on cardiometabolic diseases, including comprehensively assess evidence for causality; estimate magnitudes of etiologic effects; evaluate heterogeneity and potential for bias in these etiologic effects; and determine optimal population intake levels. METHODS: We utilized Bradford-Hill criteria to assess probable or convincing evidence for causal effects of multiple diet-cardiometabolic disease relationships. Etiologic effects were quantified from published or de novo meta-analyses of prospective studies or randomized clinical trials, incorporating standardized units, dose-response estimates, and heterogeneity by age and other characteristics. Potential for bias was assessed in validity analyses. Optimal intakes were determined by levels associated with lowest disease risk. RESULTS: We identified 10 foods and 7 nutrients with evidence for causal cardiometabolic effects, including protective effects of fruits, vegetables, beans/legumes, nuts/seeds, whole grains, fish, yogurt, fiber, seafood omega-3s, polyunsaturated fats, and potassium; and harms of unprocessed red meats, processed meats, sugar-sweetened beverages, glycemic load, trans-fats, and sodium. Proportional etiologic effects declined with age, but did not generally vary by sex. Established optimal population intakes were generally consistent with observed national intakes and major dietary guidelines. In validity analyses, the identified effects of individual dietary components were similar to quantified effects of dietary patterns on cardiovascular risk factors and hard endpoints. CONCLUSIONS: These novel findings provide a comprehensive summary of causal evidence, quantitative etiologic effects, heterogeneity, and optimal intakes of major dietary factors for cardiometabolic diseases, informing disease impact estimation and policy planning and priorities.

The contribution of smoking to socioeconomic differentials in mortality: results from the Melbourne Collaborative Cohort Study, Australia.

OBJECTIVE: To assess the contribution of smoking to the inverse association of mortality with years of formal education in men in Australia. DESIGN: Data were obtained from a prospective cohort study that included 17 049 men in Melbourne recruited from 1990 to 1994, most of whom were aged between 40 and 69 years at baseline. The outcome measured was all-cause mortality. The contribution of smoking to socioeconomic status differentials was estimated by including smoking as a variable in a Cox's proportional hazards model that also included education and other potential confounding variables. RESULTS: In men, the association between education and mortality was attenuated after adjustment for smoking, and the aetiological fraction for low levels of education was reduced from 16.5% to 10.6%. CONCLUSIONS: In men, smoking contributes substantially to socioeconomic differentials in mortality. Effective policies and interventions that target smoking among socially disadvantaged groups may substantially reduce socioeconomic differentials in health.

The contribution of leading diseases and risk factors to excess losses of healthy life in Eastern Europe: burden of disease study.

BACKGROUND: The East/West gradient in health across Europe has been described often, but not using metrics as comprehensive and comparable as those of the Global Burden of Disease 2000 and Comparative Risk Assessment studies. METHODS: Comparisons are made across 3 epidemiological subregions of the WHO region for Europe--A (very low child and adult mortality), B (low child and low adult mortality) and C (low child and high adult mortality)--with populations in 2000 of 412, 218 and 243 millions respectively, and using the following measures: 1. Probabilities of death by sex and causal group across 7 age intervals; 2. Loss of healthy life (DALYs) to diseases and injuries per thousand population; 3. Loss of healthy life (DALYs) attributable to selected risk factors across 3 age ranges. RESULTS: Absolute differences in mortality are most marked in males and in younger adults, and for deaths from vascular diseases and from injuries. Dominant contributions to east-west differences come from the nutritional/physiological group of risk factors (blood pressure, cholesterol concentration, body mass index, low fruit and vegetable consumption and inactivity) contributing to vascular disease and from the legal drugs--tobacco and alcohol. CONCLUSION: The main requirements for reducing excess health losses in the east of Europe are: 1) favorable shifts in all amenable vascular risk factors (irrespective of their current levels) by population-wide and personal measures; 2) intensified tobacco control; 3) reduced alcohol consumption and injury control strategies (for example, for road traffic injuries). Cost effective strategies are broadly known but local institutional support for them needs strengthening.