Arguments for the abolition of the defence of mental impairment.

This article summarises arguments for abolishing the mental impairment defence, using the example of the defence in Victoria, taking a historical and comparative approach. It considers the defence in practice, its origins and stagnation in medieval and Victorian England, a better approach based on modern developments in the UK and Europe, its resistance to meaningful reform, and its failure to achieve its laudable, humane and principled aim of sparing vulnerable people with severe mental health problems from punishment. We conclude that the only way to actually achieve this aim is to abolish the mental impairment defence and replace it with an approach that allows for flexible mental health disposals for mentally disordered offenders based on clinical needs and, where necessary, the need for containment, incorporated in and aligned with mental health legislation, regardless of culpability, and with modern systems and services that bring Victoria out of the nineteenth century.

Sentencing and mental disorder: the evolution of the Verdins Principles, strategic interdisciplinary advocacy and evidence-based reform.

In DPP v O'Neill, the Victorian Court of Appeal excluded personality disorders from the scope of the sentencing principles that apply to offenders with mental health problems around Australia (the 'Verdins principles'). This decision was based on a fundamental misunderstanding of the nature of personality disorders and had the potential to create serious injustice for many marginalised people. To redress this problem, the authors engaged in a unique process of strategic advocacy, which resulted in the Victorian Court of Appeal overturning O'Neill in the recent case of Brown v The Queen. This article examines the evolution of the Verdins principles, the problems that arose in O'Neill, the collaborative strategy used to address those problems and the successful outcome of that interdisciplinary strategy.

Personality disorders and forensic assessments: The benefits of ICD-11.

A recent landmark case in the Australian state of Victoria clarified the ways in which personality disorders may be taken into account when the courts are sentencing convicted offenders. The ruling especially emphasised: the need for evidence to be 'cogent'; the need to determine 'severity' of the personality disorder; the need to consider whether there is a 'connection to the offending'; the need for caution when diagnoses are based solely on behaviour; and the need to consider rehabilitative prospects and community protection. The ruling has significant implications for how forensic experts in all jurisdictions might most effectively assist the courts with the task of sentencing offenders with personality disorders. In this paper we argue that the approach to diagnosis taken in the newly published ICD-11 manual, that eschews 'categories' of personality disorder, in favour of a dimensional model supported by trait theory, is of much greater utility to forensic mental health experts striving to address these issues, compared to traditional 'categorical' approaches.

Strengthening of accountability systems to create healthy food environments and reduce global obesity.

To achieve WHO's target to halt the rise in obesity and diabetes, dramatic actions are needed to improve the healthiness of food environments. Substantial debate surrounds who is responsible for delivering effective actions and what, specifically, these actions should entail. Arguments are often reduced to a debate between individual and collective responsibilities, and between hard regulatory or fiscal interventions and soft voluntary, education-based approaches. Genuine progress lies beyond the impasse of these entrenched dichotomies. We argue for a strengthening of accountability systems across all actors to substantially improve performance on obesity reduction. In view of the industry opposition and government reluctance to regulate for healthier food environments, quasiregulatory approaches might achieve progress. A four step accountability framework (take the account, share the account, hold to account, and respond to the account) is proposed. The framework identifies multiple levers for change, including quasiregulatory and other approaches that involve government-specified and government-monitored progress of private sector performance, government procurement mechanisms, improved transparency, monitoring of actions, and management of conflicts of interest. Strengthened accountability systems would support government leadership and stewardship, constrain the influence of private sector actors with major conflicts of interest on public policy development, and reinforce the engagement of civil society in creating demand for healthy food environments and in monitoring progress towards obesity action objectives.

The future burden of obesity-related diseases in the 53 WHO European-Region countries and the impact of effective interventions: a modelling study.

OBJECTIVE: Non-communicable diseases (NCDs) are the biggest cause of death in Europe putting an unsustainable burden on already struggling health systems. Increases in obesity are a major cause of NCDs. This paper projects the future burden of coronary heart disease (CHD), stroke, type 2 diabetes and seven cancers by 2030 in 53 WHO European Region countries based on current and past body mass index (BMI) trends. It also tests the impact of obesity interventions on the future disease burden. SETTING AND PARTICIPANTS: Secondary data analysis of country-specific epidemiological data using a microsimulation modelling process. INTERVENTIONS: The effect of three hypothetical scenarios on the future burden of disease in 2030 was tested: baseline scenario, BMI trends go unchecked; intervention 1, population BMI decreases by 1%; intervention 2, BMI decreases by 5%. PRIMARY AND SECONDARY OUTCOME MEASURES: Quantifying the future burden of major NCDs and the impact of interventions on this future disease burden. RESULTS: By 2030 in the whole of the European region, the prevalence of diabetes, CHD and stroke and cancers was projected to reach an average of 3990, 4672 and 2046 cases/100 000, respectively. The highest prevalence of diabetes was predicted in Slovakia (10 870), CHD and stroke-in Greece (11 292) and cancers-in Finland (5615 cases/100 000). A 5% fall in population BMI was projected to significantly reduce cumulative incidence of diseases. The largest reduction in diabetes and CHD and stroke was observed in Slovakia (3054 and 3369 cases/100 000, respectively), and in cancers was predicted in Germany (331/100 000). CONCLUSIONS: Modelling future disease trends is a useful tool for policymakers so that they can allocate resources effectively and implement policies to prevent NCDs. Future research will allow real policy interventions to be tested; however, better surveillance data on NCDs and their risk factors are essential for research and policy.

Economics of chronic diseases protocol: cost-effectiveness modelling and the future burden of non-communicable disease in Europe.

BACKGROUND: The majority of chronic disease is caused by risk factors which are mostly preventable. Effective interventions to reduce these risks are known and proven to be applicable to a variety of settings. Chronic disease is generally developed long before the fatal outcome, meaning that a lot of people spend a number of years in poor health. Effective prevention measures can prolong lives of individuals and significantly improve their quality of life. However, the methods to measure cost-effectiveness are a subject to much debate. The Economics of Chronic Diseases project aims to establish the best possible methods of measuring cost-effectiveness as well as develop micro-simulation models apt at projecting future burden of chronic diseases, their costs and potential savings after implementation of cost-effective interventions. METHOD: This research project will involve eight European countries: Bulgaria, Finland, Greece, Lithuania, The Netherlands, Poland, Portugal and the United Kingdom (UK). A literature review will be conducted to identify scientific articles which critically review the methods of cost-effectiveness. Contact will be made health economists to inform and enrich this review. This evidence will be used as a springboard for discussion at a meeting with key European stakeholders and experts with the aim of reaching a consensus on recommendations for cost-effectiveness methodology. Epidemiological data for coronary heart disease, chronic kidney disease, type 2 diabetes and chronic obstructive pulmonary disease will be collected along with data on time trends in three major risk factors related to these diseases, specifically tobacco consumption, blood pressure and body mass index. Economic and epidemiological micro-simulation models will be developed to asses the future distributions of risks, disease outcomes, healthcare costs and the cost-effectiveness of interventions to reduce the burden of chronic diseases in Europe. DISCUSSION: This work will help to establish the best methods of measuring cost-effectiveness of health interventions as well as test a variety of scenarios to reduce the risk factors associated with selected chronic diseases. The modelling projections could be used to inform decisions and policies that will implement the best course of action to curb the rising incidence of chronic diseases.

Weight loss referrals for adults in primary care (WRAP): protocol for a multi-centre randomised controlled trial comparing the clinical and cost-effectiveness of primary care referral to a commercial weight loss provider for 12 weeks, referral for 52 weeks, and a brief self-help intervention [ISRCTN82857232].

BACKGROUND: Recent trials demonstrate the acceptability and short term efficacy of primary care referral to a commercial weight loss provider for weight management. Commissioners now need information on the optimal duration of intervention and the longer term outcomes and cost effectiveness of such treatment to give best value for money. METHODS/DESIGN: This multicentre, randomised controlled trial with a parallel design will recruit 1200 overweight adults (BMI ≥28 kg/m2) through their primary care provider. They will be randomised in a 2:5:5 allocation to: Brief Intervention, Commercial Programme for 12 weeks, or Commercial Programme for 52 weeks. Participants will be followed up for two years, with assessments at 0, 3, 12 and 24 months. The sequential primary research questions are whether the CP interventions achieve significantly greater weight loss from baseline to 12 months than BI, and whether CP52 achieves significantly greater weight loss from baseline to 12 months than CP12. The primary outcomes will be an intention to treat analysis of between treatment differences in body weight at 12 months. Clinical effectiveness will be also be assessed by measures of weight, fat mass, and blood pressure at each time point and biochemical risk factors at 12 months. Self-report questionnaires will collect data on psychosocial factors associated with adherence, weight-loss and weight-loss maintenance. A within-trial and long-term cost-effectiveness analysis will be conducted from an NHS perspective. Qualitative methods will be used to examine the participant experience. DISCUSSION: The current trial compares the clinical and cost effectiveness of referral to a commercial provider with a brief intervention. This trial will specifically examine whether providing longer weight-loss treatment without altering content or intensity (12 months commercial referral vs. 12 weeks) leads to greater weight loss at one year and is sustained at 2 years. It will also evaluate the relative cost-effectiveness of the three interventions. This study has direct implications for primary care practice in the UK and will provide important information to inform the decisions of practitioners and commissioners about service provision. TRIAL REGISTRATION: Current Controlled Trials ISRCTN82857232. Date registered: 15/10/2012.

Obesity prevalence in Mexico: impact on health and economic burden.

OBJECTIVE: Along with other countries having high and low-to-middle income, Mexico has experienced a substantial change in obesity rates. This rapid growth in obesity prevalence has led to high rates of obesity-related diseases and associated health-care costs. DESIGN: Micro-simulation is used to project future BMI trends. Additionally thirteen BMI-related diseases and health-care costs are estimated. The results are simulated for three hypothetical scenarios: no BMI reduction and BMI reductions of 1 % and 5 % across the population. SETTING: Mexican Health and Nutrition Surveys 1999 and 2000, and Mexican National Health and Nutrition Survey 2006. SUBJECTS: Mexican adults. RESULTS: In 2010, 32 % of men and 26 % of women were normal weight. By 2050, the proportion of normal weight will decrease to 12 % and 9 % for males and females respectively, and more people will be obese than overweight. It is projected that by 2050 there will be 12 million cumulative incidence cases of diabetes and 8 million cumulative incidence cases of heart disease alone. For the thirteen diseases considered, costs of $US 806 million are estimated for 2010, projected to increase to $US 1·2 billion and $US 1·7 billion in 2030 and 2050 respectively. A 1 % reduction in BMI prevalence could save $US 43 million in health-care costs in 2030 and $US 85 million in 2050. CONCLUSIONS: Obesity rates are leading to a large health and economic burden. The projected numbers are high and Mexico should implement strong action to tackle obesity. Results presented here will be very helpful in planning and implementing policy interventions.

Alarming predictions for obesity and non-communicable diseases in the Middle East.

OBJECTIVE: The present study aimed to model obesity trends and future obesity-related disease for nine countries in the Middle East; in addition, to explore how hypothetical reductions in population obesity levels could ameliorate anticipated disease burdens. DESIGN: A regression analysis of cross-sectional data v. BMI showed age- and sex-specific BMI trends, which fed into a micro simulation with a million Monte Carlo trials for each country. We also examined two alternative scenarios where population BMI was reduced by 1 % and 5 %. SETTING: Statistical modelling of obesity trends was carried out in nine Middle East countries (Bahrain, Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Saudi Arabia and Turkey). SUBJECTS: BMI data along with disease incidence, mortality and survival data from national and sub-national data sets were used for the modelling process. RESULTS: High rates of overweight and obesity increased in both men and women in most countries. The burden of incident type 2 diabetes, CHD and stroke would be moderated with even small reductions in obesity levels. CONCLUSIONS: Obesity is a growing problem in the Middle East which requires government action on the primary prevention of obesity. The present results are important for policy makers to know the effectiveness of obesity interventions on future disease burden.

Application of the UK foresight obesity model in Ireland: the health and economic consequences of projected obesity trends in Ireland.

BACKGROUND: Given the scale of the current obesity epidemic and associated health consequences there has been increasing concern about the economic burden placed on society in terms of direct healthcare costs and indirect societal costs. In the Republic of Ireland these costs were estimated at €1.13 billion for 2009. The total direct healthcare costs for six major obesity related conditions (coronary heart disease & stroke, cancer, hypertension, type 2 diabetes and knee osteoarthritis) in the same year were estimated at €2.55 billion. The aim of this research is to project disease burden and direct healthcare costs for these conditions in Ireland to 2030 using the established model developed by the Health Forum (UK) for the Foresight: Tackling Obesities project. METHODOLOGY: Routine data sources were used to derive incidence, prevalence, mortality and survival for six conditions as inputs for the model. The model utilises a two stage modelling process to predict future BMI rates, disease prevalence and costs. Stage 1 employs a non-linear multivariate regression model to project BMI trends; stage 2 employs a microsimulation approach to produce longitudinal projections and test the impact of interventions upon future incidence of obesity-related disease. RESULTS: Overweight and obesity are projected to reach levels of 89% and 85% in males and females respectively by 2030. This will result in an increase in the obesity related prevalence of CHD & stroke by 97%, cancers by 61% and type 2 diabetes by 21%. The direct healthcare costs associated with these increases will amount to €5.4 billion by 2030. A 5% reduction in population BMI levels by 2030 is projected to result in €495 million less being spent in obesity-related direct healthcare costs over twenty years. DISCUSSION: These findings have significant implications for policy, highlighting the need for effective strategies to prevent this avoidable health and economic burden.

Evolutionary and differential psychology: conceptual conflicts and the path to integration.

Evolutionary psychology has seen the majority of its success exploring adaptive features of the mind believed to be ubiquitous across our species. This has given rise to the belief that the adaptationist approach has little to offer the field of differential psychology, which concerns itself exclusively with the ways in which individuals systematically differ. By framing the historical origins of both disciplines, and exploring the means through which they each address the unique challenges of psychological description and explanation, the present article identifies the conceptual and theoretical problems that have kept differential psychology isolated not only from evolutionary psychology, but from explanatory approaches in general. Paying special attention to these conceptual problems, the authors review how these difficulties are being overcome by contemporary evolutionary research, and offer instructive suggestions concerning how differential researchers (and others) can best build upon these innovations.

Health and economic burden of obesity in Brazil.

INTRODUCTION: Higher and lower-middle income countries are increasingly affected by obesity. Obesity-related diseases are placing a substantial health and economic burden on Brazil. Our aim is to measure the future consequences of these trends on the associated disease burden and health care costs. METHOD: A previously developed micro-simulation model is used to project the extent of obesity, obesity-related diseases and associated healthcare costs to 2050. In total, thirteen diseases were considered: coronary heart disease, stroke, hypertension, diabetes, osteoarthritis, and eight cancers. We simulated three hypothetical intervention scenarios: no intervention, 1% and 5% reduction in body mass index (BMI). RESULTS: In 2010, nearly 57% of the Brazilian male population was overweight or obese (BMI ≥25 kg/m(2)), but the model projects rates as high as 95% by 2050. A slightly less pessimistic picture is predicted for females, increasing from 43% in 2010 to 52% in 2050. Coronary heart disease, stroke, hypertension, cancers, osteoarthritis and diabetes prevalence cases are projected to at least double by 2050, reaching nearly 34,000 cases of hypertension by 2050 (per 100,000). 1% and 5% reduction in mean BMI will save over 800 prevalence cases and nearly 3,000 cases of hypertension by 2050 respectively (per 100,000). The health care costs will double from 2010 ($5.8 billion) in 2050 alone ($10.1 billion). Over 40 years costs will reach $330 billion. However, with effective interventions the costs can be reduced to $302 billion by 1% and to $273 billion by 5% reduction in mean BMI across the population. CONCLUSION: Obesity rates are rapidly increasing creating a high burden of disease and associated costs. However, an effective intervention to decrease obesity by just 1% will substantially reduce obesity burden and will have a significant effect on health care expenditure.

High rates of obesity and non-communicable diseases predicted across Latin America.

Non-communicable diseases (NCDs) such as cardiovascular disease and stroke are a major public health concern across Latin America. A key modifiable risk factor for NCDs is overweight and obesity highlighting the need for policy to reduce prevalence rates and ameliorate rising levels of NCDs. A cross-sectional regression analysis was used to project BMI and related disease trends to 2050. We tested the extent to which interventions that decrease body mass index (BMI) have an effect upon the number of incidence cases avoided for each disease. Without intervention obesity trends will continue to rise across much of Latin America. Effective interventions are necessary if rates of obesity and related diseases are to be reduced.

Health and economic burden of the projected obesity trends in the USA and the UK.

Rising prevalence of obesity is a worldwide health concern because excess weight gain within populations forecasts an increased burden from several diseases, most notably cardiovascular diseases, diabetes, and cancers. In this report, we used a simulation model to project the probable health and economic consequences in the next two decades from a continued rise in obesity in two ageing populations--the USA and the UK. These trends project 65 million more obese adults in the USA and 11 million more obese adults in the UK by 2030, consequently accruing an additional 6-8·5 million cases of diabetes, 5·7-7·3 million cases of heart disease and stroke, 492,000-669,000 additional cases of cancer, and 26-55 million quality-adjusted life years forgone for USA and UK combined. The combined medical costs associated with treatment of these preventable diseases are estimated to increase by $48-66 billion/year in the USA and by £1·9-2 billion/year in the UK by 2030. Hence, effective policies to promote healthier weight also have economic benefits.

Changing the future of obesity: science, policy, and action.

The global obesity epidemic has been escalating for four decades, yet sustained prevention efforts have barely begun. An emerging science that uses quantitative models has provided key insights into the dynamics of this epidemic, and enabled researchers to combine evidence and to calculate the effect of behaviours, interventions, and policies at several levels--from individual to population. Forecasts suggest that high rates of obesity will affect future population health and economics. Energy gap models have quantified the association of changes in energy intake and expenditure with weight change, and have documented the effect of higher intake on obesity prevalence. Empirical evidence that shows interventions are effective is limited but expanding. We identify several cost-effective policies that governments should prioritise for implementation. Systems science provides a framework for organising the complexity of forces driving the obesity epidemic and has important implications for policy makers. Many parties (such as governments, international organisations, the private sector, and civil society) need to contribute complementary actions in a coordinated approach. Priority actions include policies to improve the food and built environments, cross-cutting actions (such as leadership, healthy public policies, and monitoring), and much greater funding for prevention programmes. Increased investment in population obesity monitoring would improve the accuracy of forecasts and evaluations. The integration of actions within existing systems into both health and non-health sectors (trade, agriculture, transport, urban planning, and development) can greatly increase the influence and sustainability of policies. We call for a sustained worldwide effort to monitor, prevent, and control obesity.