Cardiometabolic risk management: insights from a European Society of Cardiology Cardiovascular Round Table.

Metabolic comorbidities are common in patients with cardiorenal disease; they can cause atherosclerotic cardiovascular disease (ASCVD), speed progression, and adversely affect prognosis. Common comorbidities are Type 2 diabetes mellitus (T2DM), obesity/overweight, chronic kidney disease (CKD), and chronic liver disease. The cardiovascular system, kidneys, and liver are linked to many of the same risk factors (e.g. dyslipidaemia, hypertension, tobacco use, diabetes, and central/truncal obesity), and shared metabolic and functional abnormalities lead to damage throughout these organs via overlapping pathophysiological pathways. The COVID-19 pandemic has further complicated the management of cardiometabolic diseases. Obesity, T2DM, CKD, and liver disease are associated with increased risk of poor outcomes of COVID-19 infection, and conversely, COVID-19 can lead to worsening of pre-existing ASCVD. The high rates of these comorbidities highlight the need to improve recognition and treatment of ASCVD in patients with obesity, insulin resistance or T2DM, chronic liver diseases, and CKD and equally, to improve recognition and treatment of these diseases in patients with ASCVD. Strategies to prevent and manage cardiometabolic diseases include lifestyle modification, pharmacotherapy, and surgery. There is a need for more programmes at the societal level to encourage a healthy diet and physical activity. Many pharmacotherapies offer mechanism-based approaches that can target multiple pathophysiological pathways across diseases. These include sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, selective mineralocorticoid receptor antagonists, and combined glucose-dependent insulinotropic peptide/glucagon-like peptide-1 receptor agonist. Non-surgical and surgical weight loss strategies can improve cardiometabolic disorders in individuals living with obesity. New biomarkers under investigation may help in the early identification of individuals at risk and reveal new treatment targets.

Tackling the cancer burden: the economic impact of primary prevention policies.

Cancer is a noncommunicable disease (NCD) with increasing incidence and therefore constitutes a major public health issue. To reduce the health and economic burden of cancer, policy-makers across the world have implemented a range of preventative interventions targeting risk factors with a known link to the disease. In this article, we examine the impact of six primary prevention interventions - related to physical inactivity, unhealthy diet or harmful alcohol use - on cancer-related health outcomes and healthcare expenditure. Here, we used the OECD Strategic Public Health Planning for NCDs (SPHeP-NCDs) model to quantify outcomes and costs for each intervention for years 2020-2050 across 37 countries. Results from the model indicate that all interventions could lead to a reduction in the number of new cancer cases, in particular those targeting harmful alcohol consumption. Introducing an alcohol tax, for instance, is estimated to reduce related cancer cases by 5619 a year or 174 193 by 2050. A breakdown of results by type of cancer revealed interventions had the largest impact on colorectal cancer with, on average, 41 140 cases avoided per intervention by 2050. In proportional terms, interventions had the greatest impact on new oesophageal and liver cancers. Findings from this article are designed to assist decision-makers efficiently allocate limited resources to meet public health objectives.

How will the main risk factors contribute to the burden of non-communicable diseases under different scenarios by 2050? A modelling study.

BACKGROUND: The future burden of non-communicable diseases (NCDs) depends on numerous factors such as population ageing, evolution of societal trends, behavioural and physiological risk factors of individuals (e.g. smoking, alcohol use, obesity, physical inactivity, and hypertension). This study aims to assess the burden of NCDs in Europe by 2050 under alternative scenarios. METHODS: This study combines qualitative and quantitative forecasting techniques to examine how population health in Europe may evolve from 2015 to 2050, taking into account future societal trends. Four scenarios were developed (one business-as-usual scenario, two response scenarios and one pessimistic scenario) and assessed against 'best' and 'worst'-case scenarios. This study provides quantitative estimates of both diseases and mortality outcomes, using a microsimulation model incorporating international survey data. FINDINGS: Each scenario is associated with a different risk factor prevalence rate across Europe during the period 2015-2050. The prevalence and incidence of NCDs consistently increase during the analysed time period, mainly driven by population ageing. In more optimistic scenarios, diseases will appear in later ages, while in the pessimistic scenarios, NCDs will impair working-age people. Life expectancy is expected to grow in all scenarios, but with differences by up to 4 years across scenarios and population groups. Premature mortality from NCDs will be reduced in more optimistic scenarios but stagnate in the worst-case scenario. INTERPRETATION: Population ageing will have a greater impact on the spread of NCDs by 2050 compared to risk factors. Nevertheless, risk factors, which are influenced by living environments, are an important factor for determining future life expectancy in Europe.

The short-term effect of BMI, alcohol use, and related chronic conditions on labour market outcomes: A time-lag panel analysis utilizing European SHARE dataset.

INTRODUCTION: Non-communicable diseases (NCDs) like cancer, cardiovascular disease, and diabetes have spread at a remarkable pace in European countries over the past decades. Overweight/obesity and alcohol use are two leading risk factors contributing to both economic and epidemiological burden associated with NCDs. In OECD countries, the impact of indirect costs of obesity varies between 0.20% and 1.21% of GDP. Indirect costs of alcohol use range from 0.19% (Portugal) to 1.6% (Estonia) of GDP. AIM: To assess the longitudinal impact of alcohol use and high body-mass index (BMI) on labour market outcomes in the European region by modeling the direct effect of high BMI and alcohol use, and the effect via associated diseases. METHODS: The impact of BMI, alcohol use, and associated diseases on employment likelihood, intent to retire early, days of absenteeism, and hours of work per week, were modelled via lagged Poisson and Zero-inflated Poisson regressions, adjusting for missingness via inverse probability weighting, as appropriate, using European SHARE data. RESULTS: Controlling for other chronic conditions, being overweight increases employment likelihood among men, but not among women. Obesity decreased female, but not male, employment chances. All chronic conditions linked with high BMI negatively affected employment likelihood, and increased the intention to retire early significantly. Alcohol use positively affects employment likelihood in women at all drinking levels relative to lifetime abstainers, but only in moderate (not heavy) male drinkers. There is super-additionality of impact of NCDs on absenteeism and hours worked, presenting a key economic argument to tackle NCD prevention and compression of morbidity. IMPLICATIONS: NCD prevention is not just important for employment and hours worked, but also for employee morale, especially given increasing retirement age in Europe and globally.

Use of healthcare services and expenditure in the US in 2025: The effect of obesity and morbid obesity.

OBJECTIVE: This paper explores the contribution of body-mass index (BMI) categories in shaping past trends of use of healthcare services and associated expenditure in the US and projects results to 2025. METHODS: The study uses Medical Expenditure Panel Survey (MEPS) data for 2000-2012, reweighted on National Health and Nutrition Survey (NHANES) data for 1972-2012 and US Census Bureau data, to carry out projections for up to 2025. A combination of logistic regressions and generalized linear models was used to model use and associated expenditure for the following healthcare services: inpatient care (with/without surgery), office-based care, outpatient-care, drug prescription and home health care. Quantile regressions were used to analyse and project BMI levels. RESULTS: 20.5 million individuals will be severely obese in 2025. Normal-weight and overweight individuals have stable trends in use for many healthcare services. Conversely, use of healthcare services in patients in class II and class III obesity will increase substantially. Total healthcare expenditure increases more quickly in the obese population than in normal-weight individuals. CONCLUSIONS: Class III obesity (BMI≥40 kg/m2) significantly affects demand and expenditure for all healthcare services. Careful healthcare service planning and implementing effective policy actions to counteract such trends is crucial to meet future demand.

Identifying patterns of unhealthy diet and physical activity in four countries of the Americas: a latent class analysis / Identificación de pautas poco saludables de alimentación y actividad física en cuatro países de la Región de las Américas: un análisis de clases latentes / Identificar padrões de alimentação pouco saudável e atividade física em quatro países das Américas: análise de classes latentes

ABSTRACT Objectives To determine clusters of individuals who present similar health behaviors in terms of diet, physical activity, and sedentarism, in four countries of the Americas: Brazil (2013), Chile (2009), Mexico (2012), and the United States of America (2013). This makes it possible to determine which of these behaviors occur simultaneously, as well as the demographic and sociodemographic characteristics associated with each cluster. Methods The individual-level data analyzed were drawn from national health interviews and health examination surveys in Brazil, Chile, Mexico, and the United States, for different time periods. Using international physical activity guidelines and national dietary guidelines, the health behaviors of each individual were assessed. A latent class analysis was conducted to classify individuals into clusters based on these behaviors, and was followed by multinomial regressions to determine the characteristics of those in each class. Results Overall, most individuals belonged to the classes characterized by average or unhealthy diets but sufficient amounts of physical activity. However, large differences exist across countries and population groups. Men with higher socioeconomic characteristics were globally more likely to belong to the least healthy class in each country. Conclusions Findings from this analysis support the implementation of more refined policy actions to target specific unhealthy behaviors in different population groups, defined by gender, age group, socioeconomic status, and, to some extent, place of residence. The at-risk populations identified through this paper are those that should be targeted by upcoming interventions.

RESUMEN Objetivos Determinar conglomerados de personas que presentan comportamientos similares con respecto a la salud en materia de alimentación, actividad física y vida sedentaria en cuatro países de la Región de las Américas: Brasil (2013), Chile (2009), Estados Unidos de América (2013) y México (2012). Esto permite determinar cuáles de estos comportamientos se presentan simultáneamente, así como las características demográficas y sociodemográficas propias de cada conglomerado. Métodos Los datos a nivel individual que se analizaron se obtuvieron de entrevistas nacionales de salud y encuestas sobre exámenes de salud en Brasil, Chile, Estados Unidos y México para diferentes períodos. Se evaluaron los comportamientos de cada persona con respecto a la salud a partir de directrices de actividad física internacionales y directrices alimentarias nacionales. Se realizó un análisis de clases latentes para clasificar a los personas en conglomerados basados en dichos comportamientos, seguido de regresiones polinómicas para determinar las características de los integrantes de cada clase. Resultados En términos generales, la mayor parte de las personas pertenecían a las clases caracterizadas por una alimentación promedio o insalubre, pero con niveles suficientes de actividad física. Sin embargo, hay grandes diferencias entre los distintos países y grupos poblacionales. Los hombres con las características socioeconómicas más altas tenían más probabilidades en general de pertenecer a la clase menos saludable de cada país. Conclusiones Los resultados de este análisis apoyan la ejecución de acciones de políticas públicas más refinadas, dirigidas a determinados comportamientos nocivos en diferentes grupos poblacionales, definidos por género, grupo etario, nivel socioeconómico y, hasta cierto punto, lugar de residencia. Las próximas intervenciones deben dirigirse a los grupos poblacionales en riesgo establecidos en este artículo.

RESUMO Objetivos Determinar aglomerados de indivíduos com comportamentos de saúde semelhantes quanto à alimentação, atividade física e sedentarismo em quatro países das Américas: Brasil (2013), Chile (2009), México (2012) e Estados Unidos (2013) a fim de determinar os comportamentos que ocorrem simultaneamente e as características demográficas e sociodemográficas associadas a cada aglomerado. Métodos Os dados ao nível do indivíduo analisados no estudo foram obtidos em entrevistas de saúde nacionais e pesquisas de saúde realizadas no Brasil, Chile, México e Estados Unidos em diferentes períodos. Os comportamentos de saúde de cada indivíduo foram avaliados segundo as diretrizes internacionais de atividade física e as diretrizes nacionais de alimentação. Foi realizada uma análise de classes latentes para classificar os indivíduos em aglomerados de acordo com os comportamentos, seguida da análise por regressão polinômica para determinar as características destes comportamentos em cada classe. Resultados A maioria dos indivíduos pertencia a classes caracterizadas por alimentação média ou pouco saudável, porém com nível suficiente de atividade física. No entanto, existem grandes diferenças entre os países e os grupos populacionais. Verificou-se maior probabilidade de os indivíduos do sexo masculino de nível socioeconômico mais alto pertencerem à classe menos saudável em cada país. Conclusões Os achados desta análise apoiam a implementação de ações de política mais apuradas dirigidas a determinados comportamentos pouco saudáveis em diferentes grupos populacionais, definidos por gênero, faixa etária, condição socioeconômica e, em certa medida, local de residência. As populações em risco identificadas no estudo devem ser o principal alvo de intervenções imediatas.

European Code against Cancer 4th Edition: Alcohol drinking and cancer.

Alcohol consumption is the third leading risk factor for disease and mortality in Europe. As evaluated by the International Agency for Research on Cancer (IARC) Monographs, a causal relationship is established for consumption of alcoholic beverages and cancers of the oral cavity, pharynx, larynx, oesophagus, liver, colorectum and female breast, even at low and moderate alcohol intakes. The higher the amount of alcohol consumed, the higher the risk of developing cancer. In Europe, an estimated 10% (95% CI: 7%-13%) of all cancer cases in men and 3% (95% CI: 1%-5%) of all cancer cases in women are attributable to alcohol consumption. Several biological mechanisms explain the carcinogenicity of alcohol; among them, ethanol and its genotoxic metabolite, acetaldehyde, play a major role. Taking all this evidence into account, a recommendation of the 4th edition of European Code against Cancer is: "If you drink alcohol of any type, limit your intake. Not drinking alcohol is better for cancer prevention."

European Code against Cancer 4th Edition: Diet and cancer.

Lifestyle factors, including diet, have long been recognised as potentially important determinants of cancer risk. In addition to the significant role diet plays in affecting body fatness, a risk factor for several cancers, experimental studies have indicated that diet may influence the cancer process in several ways. Prospective studies have shown that dietary patterns characterised by higher intakes of fruits, vegetables, and whole-grain foods, and lower intakes of red and processed meats and salt, are related to reduced risks of death and cancer, and that a healthy diet can improve overall survival after diagnosis of breast and colorectal cancers. There is evidence that high intakes of fruit and vegetables may reduce the risk of cancers of the aerodigestive tract, and the evidence that dietary fibre protects against colorectal cancer is convincing. Red and processed meats increase the risk of colorectal cancer. Diets rich in high-calorie foods, such as fatty and sugary foods, may lead to increased calorie intake, thereby promoting obesity and leading to an increased risk of cancer. There is some evidence that sugary drinks are related to an increased risk of pancreatic cancer. Taking this evidence into account, the 4th edition of the European Code against Cancer recommends that people have a healthy diet to reduce their risk of cancer: they should eat plenty of whole grains, pulses, vegetables and fruits; limit high-calorie foods (foods high in sugar or fat); avoid sugary drinks and processed meat; and limit red meat and foods high in salt.

European Code against Cancer 4th Edition: Obesity, body fatness and cancer.

It is estimated that over half the population of the European Union (EU) is overweight or obese due to an imbalance between energy expenditure and energy intake; this is related to an obesogenic environment of sociocultural, economic and marketing challenges to the control of body weight. Excess body fat is associated with nine cancer sites - oesophagus, colorectum, gall bladder, pancreas, postmenopausal breast, endometrium, ovary, kidney and prostate (advanced) - and 4-38% of these cancers (depending on site and gender) can be attributed to overweight/obesity status. Metabolic alterations which accompany excess body weight are accompanied by increased levels of inflammation, insulin, oestrogens and other hormonal factors. There are some indications that intentional weight loss is associated with reduced cancer incidence (notably in postmenopausal breast and endometrial cancers). Excess body weight is also a risk factor for several other diseases, including diabetes and heart disease, and is related to higher risk of premature death. In reviewing the current evidence related to excess body fat and cancer, the European Code against Cancer Nutrition Working Group has developed the following recommendation: 'Take action to be a healthy body weight'.

European Code against Cancer 4th Edition: Physical activity and cancer.

Physical activity is a complex, multidimensional behavior, the precise measurement of which is challenging in free-living individuals. Nonetheless, representative survey data show that 35% of the European adult population is physically inactive. Inadequate levels of physical activity are disconcerting given substantial epidemiologic evidence showing that physical activity is associated with decreased risks of colon, endometrial, and breast cancers. For example, insufficient physical activity levels are thought to cause 9% of breast cancer cases and 10% of colon cancer cases in Europe. By comparison, the evidence for a beneficial effect of physical activity is less consistent for cancers of the lung, pancreas, ovary, prostate, kidney, and stomach. The biologic pathways underlying the association between physical activity and cancer risk are incompletely defined, but potential etiologic pathways include insulin resistance, growth factors, adipocytokines, steroid hormones, and immune function. In recent years, sedentary behavior has emerged as a potential independent determinant of cancer risk. In cancer survivors, physical activity has shown positive effects on body composition, physical fitness, quality of life, anxiety, and self-esteem. Physical activity may also carry benefits regarding cancer survival, but more evidence linking increased physical activity to prolonged cancer survival is needed. Future studies using new technologies - such as accelerometers and e-tools - will contribute to improved assessments of physical activity. Such advancements in physical activity measurement will help clarify the relationship between physical activity and cancer risk and survival. Taking the overall existing evidence into account, the fourth edition of the European Code against Cancer recommends that people be physically active in everyday life and limit the time spent sitting.

European Code against Cancer 4th Edition: Alcohol drinking and cancer.

Alcohol consumption is the third leading risk factor for disease and mortality in Europe. The International Agency for Research on Cancer (IARC) Monographs provide strengthened evidence that the consumption of alcoholic beverages is causally associated with cancers of the oral cavity, pharynx, larynx, oesophagus, liver, colorectum and female breast, even for low and moderate alcohol intakes. The risk of cancer increases in a dose-dependent manner, and the higher the amount of alcohol consumed, the higher the risk of developing cancer. Several biological mechanisms explain the carcinogenicity of alcohol; among them, ethanol and its genotoxic metabolite acetaldehyde play a major role. Taking all this evidence into account, a recommendation of the 4th edition of the European Code against Cancer (ECAC) is: "If you drink alcohol of any type, limit your intake. Not drinking alcohol is better for cancer prevention."

European Code against Cancer 4th Edition: Breastfeeding and cancer.

Breast cancer is the most frequent cancer in women, and incidence rates have been rising in European Union (EU) countries over recent decades due in part to a sharp decline in breastfeeding practices. Evidence for a protective association between breastfeeding and the risk of breast cancer at all ages is convincing, and modest protective relationships between breastfeeding and the risk of endometrial and ovarian cancers have been suggested. The reduction in breast cancer risk is estimated at 2% for an increase of 5 months of lifetime breastfeeding. The longer women breastfeed, the more they are protected against breast cancer. In addition, breastfeeding is associated with several health benefits for both the mother and the breastfed child. Taking all this evidence into account, the 4th edition of the European Code against Cancer recommends: "Breastfeeding reduces the mother's cancer risk. If you can, breastfeed your baby".

Tackling obesity requires efficient government policies.

Changes in food supply and eating habits, combined with a dramatic fall in physical activity, have made obesity a global epidemic. Across OECD countries, one in two adults is currently overweight and one in six is obese. Children have not been spared, with up to one in three currently overweight. Obese people are more likely to develop diseases such as diabetes, cardiovascular disease, and cancer, and have a shorter life expectancy than people of normal weight. A prevention strategy combining health promotion campaigns, government regulation, counseling of individuals at risk in primary care, and paying special attention to the most vulnerable, would enhance population health at an affordable cost, with likely beneficial effects on health inequalities. Failure to implement such a strategy would impose heavy burdens on future generations. The new IJHPR paper by Ginsberg and Rosenberg illustrates how particular countries can assess alternative strategies for tackling obesity in a rigorous fashion.This is a commentary on http://www.ijhpr.org/content/1/1/17/

Priority actions for the non-communicable disease crisis.

The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US$9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.

Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness.

The obesity epidemic is spreading to low-income and middle-income countries as a result of new dietary habits and sedentary ways of life, fuelling chronic diseases and premature mortality. In this report we present an assessment of public health strategies designed to tackle behavioural risk factors for chronic diseases that are closely linked with obesity, including aspects of diet and physical inactivity, in Brazil, China, India, Mexico, Russia, and South Africa. England was included for comparative purposes. Several population-based prevention policies can be expected to generate substantial health gains while entirely or largely paying for themselves through future reductions of health-care expenditures. These strategies include health information and communication strategies that improve population awareness about the benefits of healthy eating and physical activity; fiscal measures that increase the price of unhealthy food content or reduce the cost of healthy foods rich in fibre; and regulatory measures that improve nutritional information or restrict the marketing of unhealthy foods to children. A package of measures for the prevention of chronic diseases would deliver substantial health gains, with a very favourable cost-effectiveness profile.