Inequalities in exposure to second-hand smoke among adolescent boys and girls in 122 countries: Evidence from the Global Youth Tobacco Survey.

BACKGROUND: Secondhand smoke exposure (SHS) is a major modifiable risk factor for morbidity and premature mortality. No study has assessed inequalities by sex in SHS exposure among adolescents globally. This study aims to explore the variations in SHS exposure among adolescents globally based on sex. METHODS: Most recent data from 122 countries and territories that conducted the Global Youth Tobacco Survey between 1 January 2013 and 31 December 2020, comprising 557,332 respondents aged 11-17 years, were used to assess the prevalence of SHS exposure at home, in other enclosed public places, and at school. Multivariable Poisson regression models were performed to investigate the association between sex and SHS exposure in each country. RESULTS: A total of 195,299 (35.0 %) adolescents reported exposure to SHS at home, 256,938 (46.1 %) in other enclosed public places, 258,528 (46.4 %) at school, and 399,644 (71.7 %) in any place. There were important inequalities in the prevalence of SHS exposure between countries. More girls than boys reported exposure to SHS at home in 54 countries (vs. one country with prevalence higher in boys than girls) and in other enclosed public places in 50 countries (vs. six countries). In contrast, the prevalence of SHS exposure at school was significantly higher in boys than girls in 25 countries while the opposite was observed in 14 countries. CONCLUSIONS: These findings emphasize the disparities in SHS exposure between adolescent boys and girls and, hence, highlight the urgent need to strengthen smoke-free policies and adopt targeted policies to address them.

Ultra-processed foods, adiposity and risk of head and neck cancer and oesophageal adenocarcinoma in the European Prospective Investigation into Cancer and Nutrition study: a mediation analysis.

PURPOSE: To investigate the role of adiposity in the associations between ultra-processed food (UPF) consumption and head and neck cancer (HNC) and oesophageal adenocarcinoma (OAC) in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. METHODS: Our study included 450,111 EPIC participants. We used Cox regressions to investigate the associations between the consumption of UPFs and HNC and OAC risk. A mediation analysis was performed to assess the role of body mass index (BMI) and waist-to-hip ratio (WHR) in these associations. In sensitivity analyses, we investigated accidental death as a negative control outcome. RESULTS: During a mean follow-up of 14.13 ± 3.98 years, 910 and 215 participants developed HNC and OAC, respectively. A 10% g/d higher consumption of UPFs was associated with an increased risk of HNC (hazard ratio [HR] = 1.23, 95% confidence interval [CI] 1.14-1.34) and OAC (HR = 1.24, 95% CI 1.05-1.47). WHR mediated 5% (95% CI 3-10%) of the association between the consumption of UPFs and HNC risk, while BMI and WHR, respectively, mediated 13% (95% CI 6-53%) and 15% (95% CI 8-72%) of the association between the consumption of UPFs and OAC risk. UPF consumption was positively associated with accidental death in the negative control analysis. CONCLUSIONS: We reaffirmed that higher UPF consumption is associated with greater risk of HNC and OAC in EPIC. The proportion mediated via adiposity was small. Further research is required to investigate other mechanisms that may be at play (if there is indeed any causal effect of UPF consumption on these cancers).

Changes in diet and physical activity following a community-wide pilot intervention to tackle childhood obesity in a deprived inner-London ward.

BACKGROUND: Local authorities in England have an important role in shaping healthy local environments contributing to childhood obesity. This study examined changes in diet and physical activity in primary school children following a three-year, complex, community-based intervention in Golborne ward, the second most deprived ward in London. METHODS: The Go-Golborne intervention aimed to shape the local environment across multiple settings with the engagement of a large number of local government and community stakeholders in a joint approach. Activities focused on six co-created themes to make changes to local environments and reduce sugary snacks and beverage consumption, increase fruit and vegetable intake, promote healthy snacks, increase active play and travel, and reduce screen time. We analysed changes in self-reported diet and physical activity, collected annually between 2016 and 2019, from 1,650 children aged 6-11 years through six local schools, who all received the intervention. We used multilevel, linear and logistic random-slope regression models adjusted for time on study, baseline age, gender, ethnicity, deprivation quintile, school, and baseline weight status. RESULTS: After three years of follow-up, there were reductions in sugar-sweetened beverage consumption (adjusted beta -0·43 occasions/day, 95% CI -0·55 to -0·32), fruit and vegetable consumption (adjusted beta -0.22 portions, 95% CI -0.44 to 0.001) and car travel to and from school (adjusted OR 0·19, 95% CI 0·06 to 0·66), while screen time increased (high versus moderate/low: OR 2·30, 95% CI 1·36 to 3·90). For other behavioural outcomes, there was no statistically significant evidence of changes. CONCLUSION: Local authorities have substantial powers to make positive changes to the obesogenic environment but programmes remain under-evaluated. Results from the ambitious Go-Golborne intervention demonstrated mixed results in health behaviours following programme implementation. These results underline the importance of a coordinated and comprehensive policy response to support changes in wider environmental and social conditions as well as appropriate and holistic evaluations of initiatives to inform local actions on obesogenic environments.

Environmental impact of dietary patterns in 10 European countries; a cross-sectional analysis of nationally representative dietary surveys.

BACKGROUND: Changing dietary patterns is essential to reducing the substantial environment impact of agriculture and food production systems. We performed a cross-country comparison of dietary patterns and their associated environmental impact in Europe, including by sociodemographic factors. METHODS: We analyzed pooled cross-sectional dietary records collected during 2010-18 from 10 European countries using the European Food Safety Authority (EFSA) Comprehensive European Food Database (16 508 adults; aged 18-79 years). Each food consumed was mapped to the corresponding environmental impact data using the SHARP Indicators Database, which provides greenhouse gas emission (GHGE) and land use (LU) values of approximately 900 foods. Total diet-associated environmental impact was calculated for each person and averaged across multiple days. Multivariable linear regression models were used to compare diet-associated GHGE and LU between population subgroups (gender, age, education and diet type) with country-level fixed effects. RESULTS: The mean dietary GHGE and LU per capita ranged from 4.0 kgCO2/day and 5.0 m2*year/day in Spain to 6.5 kgCO2eq/day and 8.2 m2*year/day in France. Diet-related GHGE and LU (per kg/food) were lower among females (2.6 kgCO2eq/day, B = -0.08, P < 0.01; 3.2 m2*year/day, B = -0.11, P < 0.01), older population aged 66-79 (2.6 kgCO2eq/day, B = -0.03, P < 0.01; 3.4 m2*year/day, B = -0.4, P < 0.01), people following vegetarian diets (1.7 kgCO2eq/day, B = -0.07, P < 0.01; 2.0 m2*year/day, B = -0.07, P < 0.01), and higher among individuals with secondary education (2.7 kgCO2eq/day, B = 0.05, P < 0.01; 3.6 m2*year/day, B = -0.05, P < 0.01). CONCLUSIONS: Environmental footprints vary substantially across countries, dietary patterns and between different sociodemographic groups in Europe. These findings are crucial for the development of country-specific food policies aimed at promoting environmentally sustainable diets.

The ultra-processed food content of school meals and packed lunches in the UK, 2008-17: a pooled cross-sectional study.

BACKGROUND: British children have the highest ultra-processed food (UPF) intake in Europe, concerning as UPF is linked to adverse health outcomes. Schools are a potential setting for intervention, yet the rate of UPFs consumed at schools is currently unknown. This study aimed to describe the UPF content of school food in the UK and to explore differences in UPF content by meal type (school meals and packed lunches [food from home]) and children's household income. METHODS: We performed a pooled cross-sectional analysis of 1895 primary school children (aged 4-11 years) and 1408 secondary school children (aged 11-18 years) using data from the UK's National Diet and Nutrition Survey (from Feb, 2008, to June, 2017). Student's meal type was recorded using food diaries. UPF intake was defined using the NOVA food classification system. Income was measured through interview. We used quantile regression models to assess the association between meal type and lunchtime UPF intake (by both the percentage of calories and weight). We stratified models by school phase (primary or secondary) and interacted meal type with income. FINDINGS: The majority of schoolchildren's lunch was defined as UPFs, with secondary school children having higher median intakes of UPFs than primary school children (78% kcal [IQR 58-95] vs 73% kcal [55-86). School meals were associated with a lower median UPF intake than packed lunches for primary school children (61% kcal [IQR 44-75] vs 81% kcal [71-91]) and for secondary school children (70% kcal [IQR 48-89] vs 84% kcal [65-99]). Results were similar when UPFs were analysed as a percentage of the total weight of lunch. Overall, income was inversely associated with UPF lunch content. However, in primary school children, there was no significant association between percentage of UPF content of school meals by weight. INTERPRETATION: In the first nationally representative study, we showed that UK school children have a high intake of UPFs at lunch. UPF intake was increased in children who consumed packed lunches, secondary school children, and children of a lower income. School meal procurement policies must be re-evaluated to protect children from high UPF intake. FUNDING: This study was funded by the National Institute for Health Research School for Public Health Research.

Twenty-year trajectories of cardio-metabolic factors among people with type 2 diabetes by dementia status in England: a retrospective cohort study.

To assess 20-year retrospective trajectories of cardio-metabolic factors preceding dementia diagnosis among people with type 2 diabetes (T2D). We identified 227,145 people with T2D aged > 42 years between 1999 and 2018. Annual mean levels of eight routinely measured cardio-metabolic factors were extracted from the Clinical Practice Research Datalink. Multivariable multilevel piecewise and non-piecewise growth curve models assessed retrospective trajectories of cardio-metabolic factors by dementia status from up to 19 years preceding dementia diagnosis (dementia) or last contact with healthcare (no dementia). 23,546 patients developed dementia; mean (SD) follow-up was 10.0 (5.8) years. In the dementia group, mean systolic blood pressure increased 16-19 years before dementia diagnosis compared with patients without dementia, but declined more steeply from 16 years before diagnosis, while diastolic blood pressure generally declined at similar rates. Mean body mass index followed a steeper non-linear decline from 11 years before diagnosis in the dementia group. Mean blood lipid levels (total cholesterol, LDL, HDL) and glycaemic measures (fasting plasma glucose and HbA1c) were generally higher in the dementia group compared with those without dementia and followed similar patterns of change. However, absolute group differences were small. Differences in levels of cardio-metabolic factors were observed up to two decades prior to dementia diagnosis. Our findings suggest that a long follow-up is crucial to minimise reverse causation arising from changes in cardio-metabolic factors during preclinical dementia. Future investigations which address associations between cardiometabolic factors and dementia should account for potential non-linear relationships and consider the timeframe when measurements are taken.

Cigarette taxation and price differentials in 195 countries during 2014-2018.

INTRODUCTION: Raising tobacco prices via increased taxation may be undermined by tobacco industry tactics to keep budget cigarettes on the market. Price differentials between budget and premium cigarettes allow smokers to trade down in the face of average price rises thus attenuating health benefits. This study examines global trends of price differentials and associations with taxation. METHODS: Ecological analysis of country-level panel data of 195 countries' price differentials was performed and compared against total, specific excise, ad valorem and other taxation. Price differentials were expressed as the difference between budget cigarette and premium pack prices (as % of premium pack prices). Two-level linear regression models with repeated measurements (2014, 2016 and 2018) nested within each country assessed the association between country-level taxation structures and price differentials, adjusted for year, geographical region and income group. RESULTS: Worldwide, median price differential between budget and premium 20-cigarette packs was 49.4% (IQR 25.9%-70.0%) in 2014 and 44.4% (IQR 22.5%-69.4%) in 2018 with significant regional variation. The largest price differentials in 2018 were in Africa, with the lowest in Europe. Total taxation was negatively associated with price differentials (-1.5%, 95% CI -2.5% to -0.4% per +10% total taxation) as was specific excise taxation (-2.5%, 95% CI -3.7% to -1.2% per +10% specific excise tax). We found no statistically significant association between ad valorem taxation and price differentials. CONCLUSION: Total levels of taxation and specific excise taxes were associated with smaller price differentials. Implementing high specific excise taxes may reduce price differentials and improve health outcomes.

Dietary quality of school meals and packed lunches: a national study of primary and secondary schoolchildren in the UK.

OBJECTIVE: School lunches represent a key opportunity to improve diets and health of schoolchildren. No recent nationally representative studies have examined the nutritional differences between school meals and packed lunches in the UK. This study aimed to characterise and compare the nutritional quality of school meals and packed lunches among primary and secondary school-age children. DESIGN: A pooled cross-sectional analysis of the UK's National Diet and Nutrition Survey (2008-2017). SETTING: United Kingdom. PARTICIPANTS: 3001 children (aged 4-16 years) who completed a 3/4-d food diary which recorded meal type (school meal/packed lunch). Multivariable logistic regression models assessed associations of meeting food and nutrient recommendations by meal type. Analyses were stratified by academic key stages (KS). RESULTS: KS-1 (4-7 years) and 2 (8-11 years) children consuming school meals were more likely to meet minimum recommendations for vegetables, protein-rich foods and fibre, and not exceed maximum recommendations for salt, savoury and sweet snacks compared with pupils consuming packed lunches. However, in KS-3 (12-14 years) and 4 (14-16 years), these effects were reduced. As children aged, the median weight of fruits, vegetables, protein-rich foods and dairy products consumed typically decreased for both school meals and packed lunches, and generally an increasing proportion of school meals contained sweet and savoury snacks. CONCLUSION: These findings suggest school meals are nutritionally superior to packed lunches but are not yet optimal. Quality declined at higher KS. Actions to improve lunches of primary and secondary schoolchildren across the UK are needed, with attention to KS-3 and 4 in secondary schools.

Ultra-processed food consumption and risk of obesity: a prospective cohort study of UK Biobank.

OBJECTIVE: The objective of this study was to examine the associations between ultra-processed food consumption and risk of obesity among UK adults. METHODS: Participants aged 40-69 years at recruitment in the UK Biobank (2006-2019) with dietary intakes collected using 24-h recall and repeated measures of adiposity--body mass index (BMI), waist circumference (WC) and percentage of body fat (% BF)--were included (N = 22,659; median follow-up: 5 years). Ultra-processed foods were identified using the NOVA classification and their consumption was expressed as a percentage of total energy intake. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HR) of several indicators of obesity according to ultra-processed food consumption. Models were adjusted for sociodemographic and lifestyle characteristics. RESULTS: 947 incident cases of overall obesity (BMI ≥ 30 kg/m2) and 1900 incident cases of abdominal obesity (men: WC ≥ 102 cm, women: WC ≥ 88 cm) were identified during follow-up. Participants in the highest quartile of ultra-processed food consumption had significantly higher risk of developing overall obesity (HR 1.79; 95% CI 1.06─3.03) and abdominal obesity (HR 1.30; 95% CI 1.14─1.48). They had higher risk of experiencing a ≥ 5% increase in BMI (HR 1.31; 95% CI 1.20─1.43), WC (HR 1.35; 95% CI 1.25─1.45) and %BF (HR 1.14; 95% CI 1.03─1.25), than those in the lowest quartile of consumption. CONCLUSIONS: Our findings provide evidence that higher consumption of ultra-processed food is strongly associated with a higher risk of multiple indicators of obesity in the UK adult population. Policy makers should consider actions that promote consumption of fresh or minimally processed foods and reduce consumption of ultra-processed foods.

Is the healthy start scheme associated with increased food expenditure in low-income families with young children in the United Kingdom?

BACKGROUND: Healthy Start is a food assistance programme in the United Kingdom (UK) which aims to provide a nutritional safety-net and enable low-income families on welfare benefits to access a healthier diet through the provision of food vouchers. Healthy Start was launched in 2006 but remains under-evaluated. This study aims to determine whether participation in the Healthy Start scheme is associated with differences in food expenditure in a nationally representative sample of households in the UK. METHODS: Cross-sectional analyses of the Living Costs and Food Survey dataset (2010-2017). All households with a child (0-3 years) or pregnant woman were included in the analysis (n = 4869). Multivariable quantile regression compared the expenditure and quantity of fruit and vegetables (FV), infant formula and total food purchases. Four exposure groups were defined based on eligibility, participation and income (Healthy Start Participating, Eligible Non-participating, Nearly Eligible low-income and Ineligible high-income households). RESULTS: Of 876 eligible households, 54% participated in Healthy Start. No statistically significant differences were found in FV or total food purchases between participating and eligible non-participating households, but infant formula purchases were lower in Healthy Start participating households. Ineligible higher-income households had higher purchases of FV. CONCLUSION: This study did not find evidence of an association between Healthy Start participation and FV expenditure. Moreover, inequalities in FV purchasing persist in the UK. Higher participation and increased voucher value may help to improve programme performance and counteract the harmful effects of poverty on diet.

Prices and Illicit Trade of Cigarettes in the European Union: A Cross-sectional Analysis.

INTRODUCTION: Within the context of the World Health Organization Framework Convention on Tobacco Control Protocol to Eliminate Illicit Trade in Tobacco Products and the impending revision of the European Union (EU) directive on tobacco excise rules we assessed whether cigarettes price is linked to being offered illicit cigarettes. METHODS: We combined data being offered illicit cigarettes from the 2015 Special Eurobarometer Survey on Illicit Tobacco (N = 27,672) with area-level data on Gross Domestic Product, unemployment, perceived corruption, and sharing a border with a non-European Economic Area (non-EEA) state. We used the 2015 Weighted Average Price of cigarettes (WAP), which reflects the average price of a cigarette pack in each Member State. We assessed associations between prices and illicit trade using three-level ordered regression models. RESULTS: About 19.6% of respondents reported ever being offered illicit cigarettes, 6.4% repeatedly. In fully adjusted models WAP was not associated with being more likely to have been offered illicit market cigarettes more often (adjusted odds ratio = 1.02, 95% confidence interval: 0.91; 1.15). Sharing a border with a non-EEA Member State was associated with increased likelihood of reporting being offered illicit cigarettes more often (1.73, 1.26; 2.39). CONCLUSION: This study found no significant association between cigarette prices and reporting being offered illicit cigarettes; sharing a border with a non-EEA Member State was linked to illicit trade. This study adds to evidence that increasing prices of cigarettes are not associated with illicit trade and that the focus should remain on securing supply chains, including through features such as independent traceability systems. IMPLICATIONS: After adjusting for individual and regional factors, we did not identify an association between prices of cigarettes and likelihood of reporting being offered illicit cigarettes in the EU. Sharing a border with a non-EEA state, however, was associated with increased likelihood of reporting being offered illicit cigarettes more often. This study adds to evidence that increasing taxes and prices of cigarettes are not a driver of illicit trade and that policies should maintain their focus on securing the supply chain.

Impact of India's National Tobacco Control Programme on bidi and cigarette consumption: a difference-in-differences analysis.

BACKGROUND: Despite the importance of decreasing tobacco use to achieve mortality reduction targets of the Sustainable Development Goals in low-income and middle-income countries (LMICs), evaluations of tobacco control programmes in these settings are scarce. We assessed the impacts of India's National Tobacco Control Programme (NTCP), as implemented in 42 districts during 2007-2009, on household-reported consumption of bidis and cigarettes. METHODS: Secondary analysis of cross-sectional data from nationally representative Household Consumer Expenditure Surveys (1999-2000; 2004-2005 and 2011-2012). Outcomes were: any bidi/cigarette consumption in the household and monthly consumption of bidi/cigarette sticks per person. A difference-in-differences two-part model was used to compare changes in bidi/cigarette consumption between NTCP intervention and control districts, adjusting for sociodemographic characteristics and time-based heterogeneity. FINDINGS: There was an overall decline in household-reported bidi and cigarette consumption between 1999-2000 and 2011-2012. However, compared with control districts, NTCP districts had no significantly different reductions in the proportions of households reporting bidi (adjusted OR (AOR): 1.03, 95% CI: 0.84 to 1.28) or cigarette (AOR: 1.01 to 95% CI: 0.82 to 1.26) consumption, or for the monthly per person consumption of bidi (adjusted coefficient: 0.07, 95% CI: -0.13 to 0.28) or cigarette (adjusted coefficient: -0.002, 95% CI: -0.26 to 0.26) sticks among bidi/cigarette consuming households. INTERPRETATION: Our findings indicate that early implementation of the NTCP may not have produced reductions in tobacco use reflecting generally poor performance against the Framework Convention for Tobacco Control objectives in India. This study highlights the importance of strengthening the implementation and enforcement of tobacco control policies in LMICs to achieve national and international child health and premature NCD mortality reduction targets.

Child awareness of and access to cigarettes: impacts of the point-of-sale display ban in England.

INTRODUCTION: England introduced a tobacco display ban for shops with >280 m2 floor area ('partial ban') in 2012, then a total ban in 2015. This study assessed whether these were linked to child awareness of and access to cigarettes. METHODS: Data come from the Smoking, Drinking and Drug Use survey, an annual survey of children aged 11-15 years for 2010-2014 and 2016. Multivariate logistic regression models assessed changes in having seen cigarettes on display, usual sources and ease of access to cigarettes in shops RESULTS: During the partial display ban in 2012, 89.9% of children reported seeing cigarettes on display in the last year, which was reduced to 86.0% in 2016 after the total ban (adjusted OR 0.58, 95% CI 0.50 to 0.66). Reductions were similar in small shops (84.1% to 79.3%)%) and supermarkets (62.6% to 57.3%)%). Although the ban was associated with a reduction in the proportion of regular child smokers reporting that they bought cigarettes in shops (57.0% in 2010 to 39.8% in 2016), we did not find evidence of changes in perceived difficulty or being refused sale among those who still did. DISCUSSION: Tobacco point-of-sale display bans in England reduced the exposure of children to cigarettes in shops and coincided with a decrease in buying cigarettes in shops. However, children do not report increased difficulty in obtaining cigarettes from shops, highlighting the need for additional measures to tackle tobacco advertising, stronger enforcement of existing laws and measures such as licencing for tobacco retailers.

Evaluation of community provision of a preventive cardiovascular programme - the National Health Service Health Check in reaching the under-served groups by primary care in England: cross sectional observational study.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of premature mortality and a major contributor of health inequalities in England. Compared to more affluent and white counterparts, deprived people and ethnic minorities tend to die younger due to preventable CVD associated with lifestyle. In addition, deprived, ethnic minorities and younger people are less likely to be served by CVD prevention services. This study assessed the effectiveness of community-based outreach providers in delivering England's National Health Services (NHS) Health Check programme, a CVD preventive programme to under-served groups. METHODS: Between January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appointments. Community outreach providers operated on evenings and weekends as well as during regular business hours in venues accessible to the general public. After exclusion criteria, we analysed and compared socio-demographic data of 43,177 Health Check attendees with the general population across 38 local authorities (LAs). We assessed variation between local authorities in terms of age, sex, deprivation and ethnicity structures using two sample t-tests and within local authority variation in terms of ethnicity and deprivation using Chi squared tests and two sample t-tests respectively. RESULTS: Using Index of Multiple Deprivation, the mean deprivation score of the population reached by community outreach providers was 6.01 higher (p < 0.05) than the general population. Screened populations in 29 of 38 LAs were significantly more deprived (p < 0.05). No statistically significant difference among ethnic minority groups was observed between LAs. Nonetheless some LAs - namely Leicester, Thurrock, Sutton, South Tyneside, Portsmouth and Gateshead were very successful in recruiting ethnic minority groups. The mean proportion of men screened was 11.39% lower (p < 0.001) and mean proportion of 40-49 and 50-59 year olds was 9.98% and 3.58% higher (p < 0.0001 and p < 0.01 respectively) than the general population across 38 LAs. CONCLUSIONS: Community-based outreach providers effectively reach under-served groups by delivering preventive CVD services to younger, more deprived populations, and a representative proportion of ethnic minority groups. If the programme is successful in motivating the under-served groups to improve lifestyle, it may reduce health inequalities therein.

Cognitive impairment at diagnosis predicts 10-year multiple sclerosis progression.

BACKGROUND: Cognitive impairment occurs from the early phases of multiple sclerosis (MS), and more frequently affects secondary progressive (SP) subjects than relapsing-remitting (RR). OBJECTIVE: To investigate relationships between cognitive dysfunctions in newly diagnosed RRMS, and long-term MS-related outcomes. METHODS: The present 10-year retrospective longitudinal study included 155 RRMS subjects, tested with the Rao Brief Repeatable Battery at MS diagnosis. The reaching of Expanded Disability Status Scale (EDSS) 4.0, and the SP conversion were recorded. RESULTS: 67 subjects (43.2%) reached EDSS 4.0, and 34 subjects (21.9%) converted to SP during a follow-up period of 10.0±1.8 years. Subjects with cognitive impairment at diagnosis had a rate of reaching EDSS 4.0 more than three times greater (p<0.001; HR=3.183), and a rate of SP conversion more than two times greater, as compared to cognitively preserved subjects (p=0.008; HR=2.535). In particular, better scores in the Selective Reminding Test-Delayed Recall and in the Symbol Digit Modalities Test at baseline were associated with lower SP conversion rates during the follow-up period (p=0.018; HR=0.835; and p=0.001; HR=0.941, respectively). CONCLUSION: Cognitive impairment, with particular involvement of processing speed and memory, predicts disability progression and SP conversion in newly diagnosed RRMS, highlighting the importance of cognitive assessment from the beginning of MS.

Impact of the National Health Service Health Check on cardiovascular disease risk: a difference-in-differences matching analysis.

BACKGROUND: The National Health Service Health Check program in England is the largest cardiovascular risk assessment and management program in the world. We assessed the effect of this program on modelled risk of cardiovascular disease, individual risk factors for cardiovascular disease, prescribing of relevant medications and diagnosis of vascular disease. METHODS: We obtained retrospective electronic medical records for a randomly selected sample of 138 788 patients aged 40-74 years registered with 462 English general practices participating in the Clinical Practice Research Datalink between 2009 and 2013. We used a quasi-experimental design of difference-indifferences matching analysis to compare changes in outcomes between Health Check attendees and nonattendees, with a median follow-up time of 2 years. RESULTS: Overall, 21.4% of the eligible population attended a Health Check. After matching (n = 29 672 in each group), attendees had a significant absolute reduction in modelled risk for cardiovascular disease (-0.21%, 95% confidence interval [CI] -0.24% to -0.19%) and individual risk factors: systolic blood pressure (-2.51 mm Hg, 95% CI -2.77 to -2.25 mm Hg), diastolic blood pressure (-1.46 mm Hg, 95% CI -1.62 to -1.29 mm Hg), body mass index (-0.27, 95% CI -0.34 to -0.20) and total cholesterol (-0.15 mmol/L, 95% CI -0.18 to -0.13 mmol/L). Statins were prescribed for 39.9% of attendees who were at high risk for cardiovascular disease. The program resulted in significantly more diagnoses of selected vascular diseases among attendees, with the largest increases for hypertension (2.99%) and type 2 diabetes mellitus (1.31%). INTERPRETATION: The National Health Service Health Check program had statistically significant but clinically modest impacts on modelled risk for cardiovascular disease and individual risk factors, although diagnosis of vascular disease increased. Overall program performance was substantially below national and international targets, which highlights the need for careful planning, monitoring and evaluation of similar initiatives internationally.

Coverage of a national cardiovascular risk assessment and management programme (NHS Health Check): Retrospective database study.

OBJECTIVE: To determine coverage of NHS Health Check, a national cardiovascular risk assessment programme in England, in the first four years after implementation, and to examine prevalence of high cardiovascular disease (CVD) risk and uptake of statins in high risk patients. METHOD: Study sample was 95,571 patients in England aged 40-74years continuously registered with 509 practices in the Clinical Practice Research Datalink between April 2009 and March 2013. Multilevel logistic regression models were used to assess predictors of Health Check attendance; elevated CVD risk factors and statin prescribing among attendees. RESULTS: Programme coverage was 21.4% over four years, with large variations between practices (0%-72.7%) and regions (9.4%-30.7%). Coverage was higher in older patients (adjusted odds ratio 2.88, 95% confidence interval 2.49-3.31 for patients 70-74years) and in patients with a family history of premature coronary heart disease (2.37, 2.22-2.53), but lower in Black Africans (0.75, 0.61-0.92) and Chinese (0.68, 0.47-0.96) compared with White British. Coverage was similar in patients living in deprived and affluent areas. Prevalence of high CVD risk (QRISK2≥20%) among attendees was 4.6%. One third (33.6%) of attendees at high risk were prescribed a statin after Health Checks. CONCLUSIONS: Coverage of the programme and statin prescribing in high risk individuals was low. Coverage was similar in deprived and affluent groups but lower in some ethnic minority groups, possibly widening inequalities. These findings raise a question about whether recommendations by WHO to develop CVD risk assessment programmes internationally will deliver anticipated health benefits.

Implications of food ultra-processing on cardiovascular risk considering plant origin foods: an analysis of the UK Biobank cohort.

Background: Comprehensive research evidence is lacking on the role of ultra-processed foods (UPF) in the relationship between the consumption of plant-sourced foods and their impact on cardiovascular disease (CVD) outcomes. This study aims to assess CVD risk associated with the dietary contribution of food groups that consider both plant or animal origin and food processing categories, within a large cohort of British adults. Methods: Data from the UK Biobank participants (40-69 y) who completed at least two 24-h dietary recalls between 2009 and 2012 (n = 126,842; median follow-up: 9 y), with subsequent data linkage to hospital and mortality records, were used. Food groups were classified as either plant-sourced or non-plant/animal-sourced foods. These groups were further divided into non-UPF and UPF, and expressed as a percentage of total energy intake. Findings: Every 10 percentage points increase in plant-sourced non-UPF consumption was associated with a 7% lower risk of CVD (95% CI 0.91-0.95) and a 13% lower risk of CVD mortality (0.80-0.94). Conversely, plant-sourced UPF consumption was associated with a 5% increased risk (1.03-1.07) and a 12% higher mortality (1.05-1.20). The contribution of all UPF was linked to higher CVD risk and mortality, and no evidence for an association between contribution of all plant-sourced foods and CVD incidence and mortality was observed. Interpretation: The dietary contribution of plant-sourced non-UPF inversely linked to CVD risk, while plant-sourced UPF contribution showed a positive association. Recognizing the role of food processing is crucial for favourable CVD outcomes, even in plant-sourced diets. Funding: World Cancer Research Fund.

Degree of food processing and breast cancer risk: a prospective study in 9 European countries.

Recent epidemiological studies have suggested a positive association between ultra-processed food consumption and breast cancer risk, although some studies also reported no association. Furthermore, the evidence regarding the associations between intake of food with lower degrees of processing and breast cancer risk is limited. Thus, we investigated the associations between dietary intake by degree of food processing and breast cancer risk, overall and by breast cancer subtypes in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Dietary intake of EPIC participants was assessed via questionnaires at baseline. More than 11,000 food ingredients were classified into four groups of food processing levels using the NOVA classification system: unprocessed/minimally processed (NOVA 1), culinary ingredients (NOVA 2), processed (NOVA 3) and ultra-processed (NOVA 4). Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of breast cancer per standard deviation increase in daily consumption (grams) of foods from each NOVA group. The current analysis included 14,933 breast cancer cases, diagnosed among the 318,686 EPIC female participants, (median follow-up of 14.9 years). No associations were found between breast cancer risk and the level of dietary intake from NOVA 1 [HR per 1 SD=0.99 (95% CI 0.97 - 1.01)], NOVA 2 [HR per 1 SD =1.01 (95% CI 0.98 - 1.03)] and NOVA 4 [HR per 1 SD =1.01 (95% CI 0.99 - 1.03)] foods. However, a positive association was found between NOVA 3 and breast cancer risk [HR per 1 SD =1.05 (95% CI 1.03 - 1.07)] which became non-significant after adjustment for alcohol intake [HR per 1 SD =1.01 (95% CI 0.98 - 1.05)] or when beer and wine were excluded from this group [HR per 1 SD =0.99 (95% CI 0.97 - 1.01)]. The associations did not differ by breast cancer subtype, menopausal status or body mass index. Findings from this large-scale prospective study suggest that the positive association between processed food intake and breast cancer risk was likely driven by alcoholic beverage consumption. Supplementary Information: The online version contains supplementary material available at 10.1186/s43014-024-00264-2.

Price differences between capsule, menthol non-capsule and unflavoured cigarettes in 65 countries in 2018.

The global consumption of flavoured cigarettes, particularly capsule and menthol non-capsule cigarettes, has been rising rapidly. Their attractiveness has been fuelled by perceptions of improved palatability, along with industry marketing tactics such as lower price points in some regions. This study aimed to compare prices of unflavoured, capsule, and menthol non-capsule cigarettes across 65 countries by analysing 2018 cigarette price data from Euromonitor Passport. Median prices of capsule and menthol non-capsule cigarettes were each compared to unflavoured cigarettes at the country-level. Countries were included in the analysis if they contained price data for capsule or menthol non-capsule and unflavoured cigarettes (n = 65). The median price of capsule cigarettes was the same as unflavoured cigarettes in 12 out of 50 countries and not statistically different in another 31 countries (p > 0.05). Capsule cigarettes were more expensive than unflavoured cigarettes in five countries and cheaper in two (p < 0.05). The median price of menthol non-capsule cigarettes was the same as unflavoured cigarettes in 6 out of 51 countries and not statistically different in another 39 countries (p > 0.05). Menthol non-capsule cigarettes were more expensive than unflavoured cigarettes in five countries and cheaper in one country (p < 0.05). There was no pattern found in the pricing of capsule or menthol non-capsule cigarettes, suggesting variability in the tobacco industry's pricing strategies across countries. Tailoring tobacco control policies to match national market conditions, particularly in countries with significant market shares of capsule and menthol non-capsule cigarettes could help address the public health threat posed by the tobacco epidemic.