Potential health gains and health losses in eleven EU countries attainable through feasible prevalences of the life-style related risk factors alcohol, BMI, and smoking: a quantitative health impact assessment.

BACKGROUND: Influencing the life-style risk-factors alcohol, body mass index (BMI), and smoking is an European Union (EU) wide objective of public health policy. The population-level health effects of these risk-factors depend on population specific characteristics and are difficult to quantify without dynamic population health models. METHODS: For eleven countries-approx. 80 % of the EU-27 population-we used evidence from the publicly available DYNAMO-HIA data-set. For each country the age- and sex-specific risk-factor prevalence and the incidence, prevalence, and excess mortality of nine chronic diseases are utilized; including the corresponding relative risks linking risk-factor exposure causally to disease incidence and all-cause mortality. Applying the DYNAMO-HIA tool, we dynamically project the country-wise potential health gains and losses using feasible, i.e. observed elsewhere, risk-factor prevalence rates as benchmarks. The effects of the "worst practice", "best practice", and the currently observed risk-factor prevalence on population health are quantified and expected changes in life expectancy, morbidity-free life years, disease cases, and cumulative mortality are reported. RESULTS: Applying the best practice smoking prevalence yields the largest gains in life expectancy with 0.4 years for males and 0.3 year for females (approx. 332,950 and 274,200 deaths postponed, respectively) while the worst practice smoking prevalence also leads to the largest losses with 0.7 years for males and 0.9 year for females (approx. 609,400 and 710,550 lives lost, respectively). Comparing morbidity-free life years, the best practice smoking prevalence shows the highest gains for males with 0.4 years (342,800 less disease cases), whereas for females the best practice BMI prevalence yields the largest gains with 0.7 years (1,075,200 less disease cases). CONCLUSION: Smoking is still the risk-factor with the largest potential health gains. BMI, however, has comparatively large effects on morbidity. Future research should aim to improve knowledge of how policies can influence and shape individual and aggregated life-style-related risk-factor behavior.

Health impacts of increasing alcohol prices in the European Union: a dynamic projection.

OBJECTIVE: Western Europe has high levels of alcohol consumption, with corresponding adverse health effects. Currently, a major revision of the EU excise tax regime is under discussion. We quantify the health impact of alcohol price increases across the EU. DATA AND METHOD: We use alcohol consumption data for 11 member states, covering 80% of the EU-27 population, and corresponding country-specific disease data (incidence, prevalence, and case-fatality rate of alcohol related diseases) taken from the 2010 published Dynamic Modelling for Health Impact Assessment (DYNAMO-HIA) database to dynamically project the changes in population health that might arise from changes in alcohol price. RESULTS: Increasing alcohol prices towards those of Finland (the highest in the EU) would postpone approximately 54,000 male and approximately 26,100 female deaths over 10 years. Moreover, the prevalence of a number of chronic diseases would be reduced: in men by approximately 97,800 individuals with diabetes, 65,800 with stroke and 62,200 with selected cancers, and in women by about 19,100, 23,500, and 27,100, respectively. CONCLUSION: Curbing excessive drinking throughout the EU completely would lead to substantial gains in population health. Harmonisiation of prices to the Finnish level would, for selected diseases, achieve more than 40% of those gains.

DYNAMO-HIA--a Dynamic Modeling tool for generic Health Impact Assessments.

BACKGROUND: Currently, no standard tool is publicly available that allows researchers or policy-makers to quantify the impact of policies using epidemiological evidence within the causal framework of Health Impact Assessment (HIA). A standard tool should comply with three technical criteria (real-life population, dynamic projection, explicit risk-factor states) and three usability criteria (modest data requirements, rich model output, generally accessible) to be useful in the applied setting of HIA. With DYNAMO-HIA (Dynamic Modeling for Health Impact Assessment), we introduce such a generic software tool specifically designed to facilitate quantification in the assessment of the health impacts of policies. METHODS AND RESULTS: DYNAMO-HIA quantifies the impact of user-specified risk-factor changes on multiple diseases and in turn on overall population health, comparing one reference scenario with one or more intervention scenarios. The Markov-based modeling approach allows for explicit risk-factor states and simulation of a real-life population. A built-in parameter estimation module ensures that only standard population-level epidemiological evidence is required, i.e. data on incidence, prevalence, relative risks, and mortality. DYNAMO-HIA provides a rich output of summary measures--e.g. life expectancy and disease-free life expectancy--and detailed data--e.g. prevalences and mortality/survival rates--by age, sex, and risk-factor status over time. DYNAMO-HIA is controlled via a graphical user interface and is publicly available from the internet, ensuring general accessibility. We illustrate the use of DYNAMO-HIA with two example applications: a policy causing an overall increase in alcohol consumption and quantifying the disease-burden of smoking. CONCLUSION: By combining modest data needs with general accessibility and user friendliness within the causal framework of HIA, DYNAMO-HIA is a potential standard tool for health impact assessment based on epidemiologic evidence.

Mejorando la evidencia de intervenciones y programas efectivos diseñados para aumentar el consumo de frutas y verduras a nivel mundial

Este artículo de revisión sistemática de literatura, discute las implicancias de políticas futuras y de investigación científica sobre la efectividad de las intervenciones y programas promoviendo el consumo de frutas y verduras en ambos adultos y niños a lo largo del mundo, realizadas en 2004. Los resultados indican que pequeños aumentos en el consumo de frutas y verduras son posibles en subgrupos poblacionales y que estos cambios pueden ser alcanzados desde varios acercamientos (a niveles individual, poblacional y desarrollo de políticas macro e intervenciones ambientales) tanto en niños como en adultos. Mientras muchos programas de promoción de frutas y verduras han sido conducidos o iniciados en todas las regiones del mundo, nuestro artículo muestra que los diseños de estudio utilizados han sido frecuentemente sub-óptimos para evaluar efectividad, particularmente en países menos desarrollados. Aunque es necesario mayor esfuerzo para mejorar el diseño y la evaluación de dichas intervenciones a lo largo del mundo, estos resultados son estimulantes y sugieren que los gobiernos deben seguir desarrollando políticas para mejorar la nutrición que tengan un énfasis fuerte en el consumo de frutas y verduras.

The burden of cardiovascular disease and cancer attributable to low fruit and vegetable intake in the European Union: differences between old and new Member States.

OBJECTIVE: To estimate the burden of disease attributable to low fruit and vegetable intake in the 15 countries that were members of the European Union (EU) before May 2004 (EU-15) and the 10 countries that then joined it (EU-10). DESIGN: Data on fruit and vegetable intake, target levels of intake and estimates of relative risks, deaths and disability were combined to obtain the burden of ischaemic heart disease, ischaemic stroke and four types of cancer (lung/bronchus/trachea, stomach, oesophagus, and colon/rectum) attributable to low fruit and vegetable consumption. SETTING: EU-15 and EU-10 Member States. RESULTS: The number of lives potentially saved annually from the selected outcomes if fruit and vegetable intake increased to 600 g person(-1) day(-1) reached 892,000 and 423,000 in the EU-15 and EU-10, respectively; total disease burden could decrease by 1.9% and 3.6%, respectively. The burden of ischaemic heart disease and stroke could be reduced by up to 17% and 10%, respectively, in the EU-15 and by 24% and 15%, respectively, in the EU-10; potential reductions for the selected cancers varied from 1% to 12% in the EU-15 and from 2% to 17% in the EU-10. CONCLUSIONS: The potential health gain of increased fruit and vegetable intake is particularly large in the new Member States, and particularly high for cardiovascular diseases, a main cause of health divide in Europe. This stresses the need for better nutrition programmes and policies that take account of economic, social and cultural specificities.

The global burden of disease attributable to low consumption of fruit and vegetables: implications for the global strategy on diet.

OBJECTIVE: We estimated the global burden of disease attributable to low consumption of fruit and vegetables, an increasingly recognized risk factor for cardiovascular disease and cancer, and compared its impact with that of other major risk factors for disease. METHODS: The burden of disease attributable to suboptimal intake of fruit and vegetables was estimated using information on fruit and vegetable consumption in the population, and on its association with six health outcomes (ischaemic heart disease, stroke, stomach, oesophageal, colorectal and lung cancer). Data from both sources were stratified by sex, age and by 14 geographical regions. FINDINGS: The total worldwide mortality currently attributable to inadequate consumption of fruit and vegetables is estimated to be up to 2.635 million deaths per year. Increasing individual fruit and vegetable consumption to up to 600 g per day (the baseline of choice) could reduce the total worldwide burden of disease by 1.8%, and reduce the burden of ischaemic heart disease and ischaemic stroke by 31% and 19% respectively. For stomach, oesophageal, lung and colorectal cancer, the potential reductions were 19%, 20%, 12% and 2%, respectively. CONCLUSION: This study shows the potentially large impact that increasing fruit and vegetable intake could have in reducing many noncommunicable diseases. It highlights the need for much greater emphasis on dietary risk factors in public health policy in order to tackle the rise in noncommunicable diseases worldwide, and suggests that the proposed intersectoral WHO/FAO fruit and vegetable promotion initiative is a crucial component in any global diet strategy.

Prevalence of smoking in 8 countries of the former Soviet Union: results from the living conditions, lifestyles and health study.

OBJECTIVES: We sought to provide comparative data on smoking habits in countries of the former Soviet Union. METHODS: We conducted cross-sectional surveys in 8 former Soviet countries with representative national samples of the population 18 years or older. RESULTS: Smoking rates varied among men, from 43.3% to 65.3% among the countries examined. Results showed that smoking among women remains uncommon in Armenia, Georgia, Kyrgyzstan, and Moldova (rates of 2.4%-6.3%). In Belarus, Ukraine, Kazakhstan, and Russia, rates were higher (9.3%-15.5%). Men start smoking at significantly younger ages than women, smoke more cigarettes per day, and are more likely to be nicotine dependent. CONCLUSIONS: Smoking rates among men in these countries have been high for some time and remain among the highest in the world. Smoking rates among women have increased from previous years and appear to reflect transnational tobacco company activity.

Determinants of smoking in eight countries of the former Soviet Union: results from the living conditions, lifestyles and health study.

AIMS: To provide accurate and timely data on the determinants of smoking in countries of the former Soviet Union in order to facilitate the development of effective tobacco control policies in the region. Such data are urgently needed given the absence of accurate comparative data in the region and the recent changes experienced. DESIGN: Cross-sectional surveys using standardized methods and representative samples of the adult population in eight former Soviet Union countries conducted as part of the EU-Copernicus Project Living Conditions, Lifestyle, and Health study. SETTING: Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine. PARTICIPANTS: A total of 18 428 adults aged 18 plus; response rates 71-88%. MEASUREMENTS: The association of smoking with demographic and socio-economic factors was investigated using multiple logistic regression analyses, stratifying by gender. FINDINGS: Age was a strong determinant of smoking in both genders, with elderly individuals being less likely to smoke. Men who were more socially disadvantaged (less educated, poorer economic situation and/or less social support) were more likely to smoke. In women, living in larger urban areas was the strongest predictor of smoking. Divorced, separated or widowed women were also more likely to smoke than married women. Muslim respondents smoked less frequently compared with other respondents. CONCLUSIONS: Smoking is a major public health issue in the FSU particularly affecting socially vulnerable men and young women living in urbanized areas. These high-risk groups should be targeted in future smoking prevention and cessation strategies in the region.

Physical inactivity in a country in transition: a population-based survey in Tirana City, Albania.

AIMS: This paper describes the work and leisure-time physical activity levels of adults living in Tirana City (Albania). METHODS: A cross-sectional survey was undertaken in Tirana City in mid-2001. It included 1120 adults aged 25 years and over (response rate=72.7%). RESULTS: Overall, 19.3% of male and 28.4% of female respondents reported a low level of physical activity at work. During leisure time, 49.5% of men and 57.6% of women (age-standardized prevalence [adjusted to the adult population of Tirana]: 43.4% and 51.9% for men and women respectively) said that they participated in only sedentary activities such as reading and watching television. The gender difference in the likelihood of low physical activity at work and during leisure time was significant even after adjusting for age (age adjusted odds ratios (OR)=1.86 99% confidence interval (CI) 1.12; 3.09 and OR=1.60 99% CI 1.17; 2.22 respectively). The likelihood of leisure-time sedentarity increased with age in both genders but it did not vary significantly with education level or income. Being sedentary during leisure time was also not significantly associated with other unhealthy lifestyle behaviours, including smoking, consumption of vegetables less than six days per week, and daily alcohol intake. CONCLUSIONS: In a country such as Albania that has undergone a rapid transition from a largely unmechanized society, characterized inevitably by high levels of exercise, the generalized high prevalence of low physical activity level during leisure time gives cause for concern regarding future health trends.

The burden of disease attributable to nutrition in Europe.

OBJECTIVE: This review examines the extent to which differences in nutrition could explain the diversity of health in Europe and how dietary patterns might contribute to the overall burden of disease in the region. SETTING: Europe. DESIGN: Between-country variations and time trends in dietary and health patterns in Europe are described, taking into account recent evidence on east-west mortality differentials. Existing information on the contribution of dietary factors to the overall burden of disease in Europe and to the burden of cardiovascular diseases and cancer is then reviewed, including a discussion of the methodological challenges that face those seeking to quantify this burden accurately. RESULTS: While evidence from ecological data have long suggested that variations in health patterns in Europe may be at least partly attributed to differences in dietary intake, recent research into the major risks to disease, disability and death is confirming the importance of poor nutrition to major health problems and overall disease burden in Europe. Findings from the Global Burden of Disease 2000 study suggest that 4.4% of the overall burden of disease in the region could be attributed to low fruit and vegetable intake, and 7.8% to overweight and obesity. CONCLUSIONS: The burden of disease attributed to poor nutrition in Europe appears to be substantial and probably underestimated. However, better quantification of the contribution of nutrition to the region's burden of disease awaits further research to assess the dietary intake of Europeans and to explore the relationship between nutritional factors and health outcomes in diverse parts of Europe.

Body weight patterns in a country in transition: a population-based survey in Tirana City, Albania.

OBJECTIVE: This paper reports the distribution and determinants of body mass index (BMI) and obesity in Tirana City (Albania). DESIGN: Cross-sectional survey conducted in mid-2001. SETTING: Tirana City. SUBJECTS: One thousand one hundred and twenty adults aged 25 years and over (response rate 72.7%), selected using multi-stage cluster sampling. RESULTS: Over three-quarters of male and female respondents had an excess body weight. The overall population prevalence of obesity in Tirana was estimated to be 22.0% in men and 30.9% in women. Obesity affected both genders (age-standardised prevalence in males 22.0%, females 30.9%; age-adjusted odds ratio (OR) 1.89; 99% confidence interval (CI) 1.33-2.67) and all age groups, but most particularly middle-aged women. The age-standardised overall prevalence of central obesity was 21.6% in men and 29.4% in women (age-adjusted OR 1.58; 99% CI 1.11-2.25), increasing with age (P<0.01). In women, the likelihood of being obese was inversely related to educational achievement (trend P=0.001) and alcohol consumption (trend P=0.009). Income, smoking and leisure-time physical activity were not associated with obesity. CONCLUSIONS: Excess weight and obesity are major public health problems in the adult population of Tirana, but most particularly in middle-aged women. The high obesity prevalence observed along with the recent decrease in physical activity, dietary changes and increase in smoking prevalence make it probable that there will be substantial increases in many non-communicable diseases in Albania in the coming decades. Health promotion strategies are needed that prevent excess weight gain in the Albanian population.