Reducing non-communicable diseases among Palestinian populations in Gaza: A participatory comparative and cost-effectiveness modeling assessment.

We sought to assess the effectiveness and cost-effectiveness of potential new public health and healthcare NCD risk reduction efforts among Palestinians in Gaza. We created a microsimulation model using: (i) a cross-sectional household survey of NCD risk factors among 4,576 Palestinian adults aged ≥40 years old in Gaza; (ii) a modified Delphi process among local public health experts to identify potentially feasible new interventions; and (iii) reviews of intervention cost and effectiveness, modified to the Gazan and refugee contexts. The survey revealed 28.6% tobacco smoking, a 40.4% prevalence of hypertension diagnosis (with a 95.6% medication treatment rate), a 25.6% prevalence of diabetes diagnosis (with 95.3% on treatment), a 21.9% prevalence of dyslipidemia (with 79.6% on a statin), and a 9.8% prevalence of asthma or chronic obstructive pulmonary disease (without known treatment). A calibrated model estimated a loss of 9,516 DALYs per 10,000 population over the 10-year policy horizon. The interventions having an incremental cost-effectiveness ratio (ICER) less than three times the GDP per capita of Palestine per DALY averted (<$10,992 per DALY averted)(<$10,992 per DALY averted) included bans on tobacco smoking in indoor and public places [$34 per incremental DALY averted (95% CI: $17, $50)], treatment of asthma using low dose inhaled beclometasone and short-acting beta-agonists [$140 per DALY averted (95% CI: $77, $207)], treatment of breast cancer stages I and II [$730 per DALY averted (95% CI: $372, $1,100)], implementing a mass media campaign for healthier nutrition [$737 per DALY averted (95% CI: $403, $1,100)], treatment of colorectal cancer stages I and II [$7,657 per DALY averted (95% CI: $3,721, $11,639)], and (screening with mammography [$17,054 per DALY averted (95% CI: $8,693, $25,359)]). Despite high levels of NCD risk factors among Palestinians in Gaza, we estimated that several interventions would be expected to reduce the loss of DALYs within common cost-effectiveness thresholds.

Progress towards universal health coverage and inequalities in infant mortality: an analysis of 4·1 million births from 60 low-income and middle-income countries between 2000 and 2019.

BACKGROUND: Expanding universal health coverage (UHC) might not be inherently beneficial to poorer populations without the explicit targeting and prioritising of low-income populations. This study examines whether the expansion of UHC between 2000 and 2019 is associated with reduced socioeconomic inequalities in infant mortality in low-income and middle-income countries (LMICs). METHODS: We did a retrospective analysis of birth data compiled from Demographic and Health Surveys (DHSs). We analysed all births between 2000 and 2019 from all DHSs available for this period. The primary outcome was infant mortality, defined as death within 1 year of birth. Logistic regression models with country and year fixed effects assessed associations between country-level progress to UHC (using WHO's UHC service coverage index) and infant mortality (overall and by wealth quintile), adjusting for infant-level, mother-level, and country-level variables. FINDINGS: A total of 4 065 868 births to 1 833 011 mothers were analysed from 177 DHSs covering 60 LMICs between 2000 and 2019. A one unit increase in the UHC index was associated with a 1·2% reduction in the risk of infant death (AOR 0·988, 95% CI 0·981-0·995; absolute measure of association, 0·57 deaths per 1000 livebirths). An estimated 15·5 million infant deaths were averted between 2000 and 2019 because of increases in UHC. However, richer wealth quintiles had larger associated reductions in infant mortality from UHC (quintile 5 AOR 0·983, 95% CI 0·973-0·993) than poorer quintiles (quintile 1 0·991, 0·985-0·998). In the early stages of UHC, UHC expansion was generally beneficial to poorer populations (ie, larger reductions in infant mortality for poorer households [infant deaths per 1000 per one unit increase in UHC coverage: quintile 1 0·84 vs quintile 5 0·59]), but became less so as overall coverage increased (quintile 1 0·64 vs quintile 5 0·57). INTERPRETATION: Since UHC expansion in LMICs appears to become less beneficial to poorer populations as coverage increases, UHC policies should be explicitly designed to ensure lower income groups continue to benefit as coverage expands. FUNDING: UK National Institute for Health and Care Research.

The effect of nutrition-specific and nutrition-sensitive interventions on the double burden of malnutrition in low-income and middle-income countries: a systematic review.

BACKGROUND: Low-income and middle-income countries (LMICs) experiencing nutrition transition face an increasing double burden of malnutrition (DBM). WHO has urged the identification of risks and opportunities in nutrition interventions to mitigate the DBM, but robust evidence is missing. This review summarises the effect of nutrition-specific and nutrition-sensitive interventions on undernutrition and overnutrition in LMICs. METHODS: We searched four major databases and grey literature for publications in English, French, Portuguese, and Spanish from Jan 1, 2000, to Aug 14, 2023. Eligible studies evaluated nutrition-specific or nutrition-sensitive interventions on both undernutrition and overnutrition, employing robust study designs (individually randomised, cluster randomised, and non-randomised trials; interrupted time series; controlled before-after; and prospective cohort studies). Studies were synthesised narratively, and classified as DBM-beneficial, potentially DBM-beneficial, DBM-neutral, potentially DBM-harmful, and DBM-harmful, using vote counting. This review is registered with PROSPERO (CRD42022320131). FINDINGS: We identified 26 studies evaluating 20 nutrition-specific (maternal and child health [MCH] and school-based programmes) and six nutrition-sensitive (conditional cash transfers and other social policies) interventions. Seven of eight MCH interventions providing food-based or nutritional supplements indicated possible DBM-harmful effects, associated with increased maternal or child overweight. Most school-based programmes and MCH interventions that target behavioural change were considered potentially DBM-beneficial. Two studies of conditional cash transfers suggested DBM-beneficial effects in children, whereas one indicated potentially harmful effects on maternal overweight. A study on a family planning service and one on an education reform revealed possible long-term harmful effects on obesity. INTERPRETATION: There is considerable scope to repurpose existing nutrition interventions to reduce the growing burden of the DBM in LMICs. In settings undergoing rapid nutrition transition, specific policy attention is required to ensure that food-based or supplement-based MCH programmes do not unintentionally increase maternal or child overweight. Consistent reporting of undernutrition and overnutrition outcomes in all nutrition interventions is essential to expand the evidence base to identify and promote interventions maximising benefits and minimising harms on the DBM. FUNDING: President's Scholarship (Imperial College London) and National Institute for Health and Care Research. TRANSLATIONS: For the Portuguese, Spanish and French translations of the abstract see Supplementary Materials section.

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).

Racial inequalities in mental healthcare use and mortality: a cross-sectional analysis of 1.2 million low-income individuals in Rio de Janeiro, Brazil 2010-2016.

INTRODUCTION: Mental health inequalities across racial and ethnic groups are large and unjust in many countries, yet these inequalities remain under-researched, particularly in low-income and middle-income countries such as Brazil. This study investigates racial and socioeconomic inequalities in primary healthcare usage, hospitalisation and mortality for mental health disorders in Rio de Janeiro, Brazil. METHODS: A cohort of 1.2 million low-income adults from Rio de Janeiro, Brazil with linked socioeconomic, demographic, healthcare use and mortality records was cross-sectionally analysed. Poisson regression models were used to investigate associations between self-defined race/colour and primary healthcare (PHC) usage, hospitalisation and mortality due to mental disorders, adjusting for socioeconomic factors. Interactions between race/colour and socioeconomic characteristics (sex, education level, income) explored if black and pardo (mixed race) individuals faced compounded risk of adverse mental health outcomes. RESULTS: There were 272 532 PHC consultations, 10 970 hospitalisations and 259 deaths due to mental disorders between 2010 and 2016. After adjusting for a wide range of socioeconomic factors, the lowest PHC usage rates were observed in black (adjusted rate ratio (ARR): 0.64; 95% CI 0.60 to 0.68; compared with white) and pardo individuals (ARR: 0.87; 95% CI 0.83 to 0.92). Black individuals were more likely to die from mental disorders (ARR: 1.68; 95% CI 1.19 to 2.37; compared with white), as were those with lower educational attainment and household income. In interaction models, being black or pardo conferred additional disadvantage across mental health outcomes. The highest educated black (ARR: 0.56; 95% CI 0.47 to 0.66) and pardo (ARR: 0.75; 95% CI 0.66 to 0.87) individuals had lower rates of PHC usage for mental disorders compared with the least educated white individuals. Black individuals were 3.7 times (ARR: 3.67; 95% CI 1.29 to 10.42) more likely to die from mental disorders compared with white individuals with the same education level. CONCLUSION: In low-income individuals in Rio de Janeiro, racial/colour inequalities in mental health outcomes were large and not fully explainable by socioeconomic status. Black and pardo Brazilians were consistently negatively affected, with lower PHC usage and worse mental health outcomes.

Consumption of ultra-processed foods and risk of multimorbidity of cancer and cardiometabolic diseases: a multinational cohort study.

Background: It is currently unknown whether ultra-processed foods (UPFs) consumption is associated with a higher incidence of multimorbidity. We examined the relationship of total and subgroup consumption of UPFs with the risk of multimorbidity defined as the co-occurrence of at least two chronic diseases in an individual among first cancer at any site, cardiovascular disease, and type 2 diabetes. Methods: This was a prospective cohort study including 266,666 participants (60% women) free of cancer, cardiovascular disease, and type 2 diabetes at recruitment from seven European countries in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Foods and drinks consumed over the previous 12 months were assessed at baseline by food-frequency questionnaires and classified according to their degree of processing using Nova classification. We used multistate modelling based on Cox regression to estimate cause-specific hazard ratios (HR) and their 95% confidence intervals (CI) for associations of total and subgroups of UPFs with the risk of multimorbidity of cancer and cardiometabolic diseases. Findings: After a median of 11.2 years of follow-up, 4461 participants (39% women) developed multimorbidity of cancer and cardiometabolic diseases. Higher UPF consumption (per 1 standard deviation increment, ∼260 g/day without alcoholic drinks) was associated with an increased risk of multimorbidity of cancer and cardiometabolic diseases (HR: 1.09, 95% CI: 1.05, 1.12). Among UPF subgroups, associations were most notable for animal-based products (HR: 1.09, 95% CI: 1.05, 1.12), and artificially and sugar-sweetened beverages (HR: 1.09, 95% CI: 1.06, 1.12). Other subgroups such as ultra-processed breads and cereals (HR: 0.97, 95% CI: 0.94, 1.00) or plant-based alternatives (HR: 0.97, 95% CI: 0.91, 1.02) were not associated with risk. Interpretation: Our findings suggest that higher consumption of UPFs increases the risk of cancer and cardiometabolic multimorbidity. Funding: Austrian Academy of Sciences, Fondation de France, Cancer Research UK, World Cancer Research Fund International, and the Institut National du Cancer.

The heterogeneous effects of China's hierarchical medical system reforms on health service utilisation and health outcomes among elderly populations: a longitudinal quasi-experimental study.

BACKGROUND: System-wide, comprehensive, primary health care (PHC)-oriented health reforms are infrequently introduced in low-income and middle-income countries and often poorly studied. China initiated a large-scale reform in 2015 that included multiple policies: partial gatekeeping, a family physician scheme, and increased system integration. These policies aimed to build a PHC-oriented health system and improve primary care utilisation. This study assessed the heterogeneous effects of the reforms on health service utilisation and health outcomes across regions and over time. METHODS: In this longitudinal quasi-experimental study, we used longitudinal data (2011-18) from a national survey on elderly populations and governmental yearbooks. This study exploits the staggered rollout of the reforms at the city level identified using web-scrapping. We employed an event study design to assess reform effects on (1) visits to PHC facilities, (2) admissions to hospital, (3) out-of-pocket expenditures (OOPEs), and (4) self-reported health. Models were adjusted for city and time fixed effects, along with demographic and socioeconomic characteristics at individual and provincial levels. Analysis was separated into rural and urban populations. FINDINGS: 18 988 Chinese individuals aged 45 and older (mean age 60·4 years [SD 10·3], 9990 [52·6%] women, 8998 [47·4%] men) were included in the analysis. The reform was associated with increasing odds of visiting PHC facilities among rural populations, which became stronger in the 2 years after the reform (adjusted odd ratio [aOR] 1·35, 95% CI 1·02-1·84, p=0·0374; absolute effect sizes [probability] 3%) before it faded. Meanwhile, urban populations were unaffected (from aOR 1·22, 0·82-1·81 to 0·89, 0·50-1·57). The reform did not have a significant effect on admission to hospital (rural: from 0·97, 0·72-1·31 to 1·47, 0·85-2·55; urban: from 1·00, 0·69-1·43 to 1·59, 0·76-3·30) or OOPEs (rural: from 260·32 Chinese Yuan, 95% CI -6·34 to 526·97, to 693·07 Chinese Yuan, -102·96 to 1489·09; urban: from 235·37 Chinese Yuan, -405·10 to 875·83, to 859·93 Chinese Yuan, -199·02 to 1918·88). Urban populations reported higher self-reported health after the reforms than the year before the reforms (1·50, 1·12-2·01, p=0·0002; 5%). INTERPRETATION: System-wide PHC-oriented reforms might contribute to short-term increases in primary care utilisation in elderly populations with implications for urban-rural inequalities. Effects on financial protection and health inequality were limited. Efforts in improving the accessibility and quality of primary care in deprived areas are indispensable to addressing the persistent inverse care law and to achieving Universal Health Coverage for all countries. FUNDING: None.

The contribution to policies of an exposome-based approach to childhood obesity.

Childhood obesity is an increasingly severe public health problem, with a prospective impact on health. We propose an exposome approach to identify actionable risk factors for this condition. Our assumption is that relationships between external exposures and outcomes such as rapid growth, overweight, or obesity in children can be better understood through a "meet-in-the-middle" model. This is based on a combination of external and internal exposome-based approaches, that is, the study of multiple exposures (in our case, dietary patterns) and molecular pathways (metabolomics and epigenetics). This may strengthen causal reasoning by identifying intermediate markers that are associated with both exposures and outcomes. Our biomarker-based studies in the STOP consortium suggest (in several ways, including mediation analysis) that branched-chain amino acids (BCAAs) could be mediators of the effect of dietary risk factors on childhood overweight/obesity. This is consistent with intervention and animal studies showing that higher intake of BCAAs has a positive impact on body composition, glycemia, and satiety. Concerning food, of particular concern is the trend of increasing intake of ultra-processed food (UPF), including among children. Several mechanisms have been proposed to explain the impact of UPF on obesity and overweight, including nutrient intake (particularly proteins), changes in appetite, or the role of additives. Research from the Avon Longitudinal Study of Parents and Children cohort has shown a relationship between UPF intake and trajectories in childhood adiposity, while UPF was related to lower blood levels of BCAAs. We suggest that an exposome-based approach can help strengthening causal reasoning and support policies. Intake of UPF in children should be restricted to prevent obesity.

Characterizing restrictions on commercial advertising and sponsorship of harmful commodities in local government policies: a nationwide study in England.

BACKGROUND: Commercial advertising and sponsorship drive the consumption of harmful commodities. Local authorities (LAs) have considerable powers to reduce such exposures. This study aimed to characterize local commercial policies across all English LAs. METHODS: We conducted a census of all English LAs (n = 333) to identify local commercial policies concerning advertising and sponsorship of tobacco, alcohol, less healthy foods and gambling, through online searches and Freedom of Information requests. We explored policy presence, commodity frequency and type, and associations with LA characteristics (region, urban/rural and deprivation). RESULTS: Only a third (106) of LAs in England had a relevant policy (32%). These included restrictions on tobacco (91%), gambling (79%), alcohol (74%) and/or less healthy foods (24%). Policy prevalence was lowest in the East of England (22%), North East (25%) and North West (27%), higher in urban areas (36%) than rural areas (28%) and lower in the least (27%) compared with the most (38%) deprived areas. Definitions in policies varied, particularly for alcohol and less healthy foods. CONCLUSIONS: English LAs currently underutilize their levers to reduce the negative impacts of harmful commodity industry marketing, particularly concerning less healthy foods. Standardized guidance, including clarity on definitions and application, could inform local policy development.

Natural experiments for the evaluation of place-based public health interventions: a methodology scoping review.

Introduction: Place-based public health evaluations are increasingly making use of natural experiments. This scoping review aimed to provide an overview of the design and use of natural experiment evaluations (NEEs), and an assessment of the plausibility of the as-if randomization assumption. Methods: A systematic search of three bibliographic databases (Pubmed, Web of Science and Ovid-Medline) was conducted in January 2020 to capture publications that reported a natural experiment of a place-based public health intervention or outcome. For each, study design elements were extracted. An additional evaluation of as-if randomization was conducted by 12 of this paper's authors who evaluated the same set of 20 randomly selected studies and assessed 'as-if ' randomization for each. Results: 366 NEE studies of place-based public health interventions were identified. The most commonly used NEE approach was a Difference-in-Differences study design (25%), followed by before-after studies (23%) and regression analysis studies. 42% of NEEs had likely or probable as-if randomization of exposure (the intervention), while for 25% this was implausible. An inter-rater agreement exercise indicated poor reliability of as-if randomization assignment. Only about half of NEEs reported some form of sensitivity or falsification analysis to support inferences. Conclusion: NEEs are conducted using many different designs and statistical methods and encompass various definitions of a natural experiment, while it is questionable whether all evaluations reported as natural experiments should be considered as such. The likelihood of as-if randomization should be specifically reported, and primary analyses should be supported by sensitivity analyses and/or falsification tests. Transparent reporting of NEE designs and evaluation methods will contribute to the optimum use of place-based NEEs.

Health and health system impacts of China's comprehensive primary healthcare reforms: a systematic review.

China's comprehensive primary healthcare (PHC) reforms since 2009 aimed to deliver accessible, efficient, equitable and high-quality healthcare services. However, knowledge on the system-wide effectiveness of these reforms is limited. This systematic review synthesizes evidence on the reforms' health and health system impacts. In 13 August 2022, international databases and three Chinese databases were searched for randomized controlled trials, quasi-experimental studies and controlled before-after studies. Included studies assessed large-scale PHC policies since 2009; had a temporal comparator and a control group and assessed impacts on expenditures, utilization, care quality and health outcomes. Study quality was assessed using Risk of Bias In Non-randomized Studies of Interventions, and results were synthesized narratively. From 49 174 identified records, 42 studies were included-all with quasi-experimental designs, except for one randomized control trial. Nine studies were assessed as at low risk of bias. Only five low- to moderate-quality studies assessed the comprehensive reforms as a whole and found associated increases in health service utilization, whilst the other 37 studies examined single-component policies. The National Essential Medicine Policy (N = 15) and financing reforms (N = 11) were the most studied policies, whilst policies on primary care provision (i.e. family physician policy and the National Essential Public Health Services) were poorly evaluated. The PHC reforms were associated with increased primary care utilization (N = 17) and improved health outcomes in people with non-communicable diseases (N = 8). Evidence on healthcare costs was unclear, and impacts on patients' financial burden and care quality were understudied. Some studies showed disadvantaged regions and groups that accrued greater benefits (N = 8). China's comprehensive PHC reforms have made some progress in achieving their policy objectives including increasing primary care utilization, improving some health outcomes and reducing health inequalities. However, China's health system remains largely hospital-centric and further PHC strengthening is needed to advance universal health coverage.

Corrigendum: Characterization of the degree of food processing in the European Prospective Investigation into Cancer and Nutrition: application of the Nova classification and validation using selected biomarkers of food processing.

[This corrects the article DOI: 10.3389/fnut.2022.1035580.].

Associations between primary healthcare and infant health outcomes: a cohort analysis of low-income mothers in Rio de Janeiro, Brazil.

Background: Expanding primary healthcare to urban poor populations is a priority in many low-and middle-income countries and is essential to achieve universal health coverage (UHC). Between 2008 and 2016 the city of Rio de Janeiro undertook an ambitious programme to rapidly expand primary care to low-income areas through the family health strategy (FHS). Infant health impacts of this roll out are unknown. This study examines associations between maternal FHS utilisation and birth outcomes, neonatal and infant mortality. Methods: A cohort of 75,339 live births (January 2009-December 2014) to low-income mothers in Rio de Janeiro was linked to primary care, birth, hospital and death records. The relationship between maternal FHS use and infant health outcomes was assessed through logistic regression with inverse probability treatment weighting and regression adjustment. Socioeconomic inequalities in the associations between FHS use and outcomes were explored through interactions. Primary outcomes were neonatal and infant death. Thirteen secondary outcomes were also examined to explore other important health outcomes and potential mechanisms. Results: A total of 9002 (12.0%) infants were born to mothers in the cohort who used FHS services either before pregnancy or in the first two trimesters. There was a total of 527 neonatal and 893 infant deaths. Maternal FHS usage during the first two trimesters was associated with substantial reductions in neonatal [adjusted odds ratio (aOR): 0.527, 95% confidence interval (95% CI): 0.345; 0.806] and infant mortality (aOR: 0.672, 95% CI: 0.48; 0.924). Infants born to lower-income mothers and those without formal employment had larger reductions in neonatal and infant mortality associated with FHS use. Maternal FHS in the first two trimesters use was also associated with more antenatal care consultations and a lower risk of low birth weight and preterm birth. Interpretation: Expanding primary care to low-income populations in Rio de Janeiro was associated with improved infant health and health equity benefits. Funding: DFID/MRC/Wellcome Trust/ESRC.

Subsidised housing and diabetes mortality: a retrospective cohort study of 10 million low-income adults in Brazil.

INTRODUCTION: Housing-related factors can be predictors of health, including of diabetes outcomes. We analysed the association between subsidised housing residency and diabetes mortality among a large cohort of low-income adults in Brazil. RESEARCH DESIGN AND METHODS: A cohort of 9 961 271 low-income adults, observed from January 2010 to December 2015, was created from Brazilian administrative records of social programmes and death certificates. We analysed the association between subsidised housing residency and time to diabetes mortality using a Cox model with inverse probability of treatment weighting and regression adjustment. We assessed inequalities in this association by groups of municipality Human Development Index. Diabetes mortality included diabetes both as the underlying or a contributory cause of death. RESULTS: At baseline, the mean age of the cohort was 40.3 years (SD 15.6 years), with a majority of women (58.4%). During 29 238 920 person-years of follow-up, there were 18 775 deaths with diabetes as the underlying or a contributory cause. 340 683 participants (3.4% of the cohort) received subsidised housing. Subsidised housing residents had a higher hazard of diabetes mortality compared with non-residents (HR 1.17; 95% CI 1.05 to 1.31). The magnitude of this association was more pronounced among participants living in municipalities with lower Human Development Index (HR 1.30; 95% CI 1.04 to 1.62). CONCLUSIONS: Subsidised housing residents had a greater risk of diabetes mortality, particularly those living in low socioeconomic status municipalities. This finding suggests the need to intensify diabetes prevention and control actions and prompt treatment of the diabetes complications among subsidised housing residents, particularly among those living in low socioeconomic status municipalities.

Gender differences in active travel in major cities across the world.

There is lack of literature on international comparison of gender differences in the use of active travel modes. We used population-representative travel surveys for 19 major cities across 13 countries and 6 continents, representing a mix of cites from low-and-middle income (n = 8) and high-income countries (n = 11). In all the cities, females are more likely than males to walk and, in most cities, more likely to use public transport. This relationship reverses in cycling, with females often less likely users than males. In high cycling cities, both genders are equally likely to cycle. Active travel to access public transport contributes 30-50% of total active travel time. The gender differences in active travel metrics are age dependent. Among children (< 16 years), these metrics are often equal for girls and boys, while gender disparity increases with age. On average, active travel enables one in every four people in the population to achieve at least 30 min of physical activity in a day, though there is large variation across the cities. In general, females are more likely to achieve this level than males. The results highlight the importance of a gendered approach towards active transport policies. Such an approach necessitates reducing road traffic danger and male violence, as well as overcoming social norms that restrict women from cycling.

Food processing and cancer risk in Europe: results from the prospective EPIC cohort study.

BACKGROUND: Food processing has been hypothesised to play a role in cancer development; however, data from large-scale epidemiological studies are scarce. This study investigated the association between dietary intake according to amount of food processing and risk of cancer at 25 anatomical sites using data from the European Prospective Investigation into Cancer and Nutrition (EPIC) study. METHODS: This study used data from the prospective EPIC cohort study, which recruited participants between March 18, 1991, and July 2, 2001, from 23 centres in ten European countries. Participant eligibility within each cohort was based on geographical or administrative boundaries. Participants were excluded if they had a cancer diagnosis before recruitment, had missing information for the NOVA food processing classification, or were within the top and bottom 1% for ratio of energy intake to energy requirement. Validated dietary questionnaires were used to obtain information on food and drink consumption. Participants with cancer were identified using cancer registries or during follow-up from a combination of sources, including cancer and pathology centres, health insurance records, and active follow-up of participants. We performed a substitution analysis to assess the effect of replacing 10% of processed foods and ultra-processed foods with 10% of minimally processed foods on cancer risk at 25 anatomical sites using Cox proportional hazard models. FINDINGS: 521 324 participants were recruited into EPIC, and 450 111 were included in this analysis (318 686 [70·8%] participants were female individuals and 131 425 [29·2%] were male individuals). In a multivariate model adjusted for sex, smoking, education, physical activity, height, and diabetes, a substitution of 10% of processed foods with an equal amount of minimally processed foods was associated with reduced risk of overall cancer (hazard ratio 0·96, 95% CI 0·95-0·97), head and neck cancers (0·80, 0·75-0·85), oesophageal squamous cell carcinoma (0·57, 0·51-0·64), colon cancer (0·88, 0·85-0·92), rectal cancer (0·90, 0·85-0·94), hepatocellular carcinoma (0·77, 0·68-0·87), and postmenopausal breast cancer (0·93, 0·90-0·97). The substitution of 10% of ultra-processed foods with 10% of minimally processed foods was associated with a reduced risk of head and neck cancers (0·80, 0·74-0·88), colon cancer (0·93, 0·89-0·97), and hepatocellular carcinoma (0·73, 0·62-0·86). Most of these associations remained significant when models were additionally adjusted for BMI, alcohol and dietary intake, and quality. INTERPRETATION: This study suggests that the replacement of processed and ultra-processed foods and drinks with an equal amount of minimally processed foods might reduce the risk of various cancer types. FUNDING: Cancer Research UK, l'Institut National du Cancer, and World Cancer Research Fund International.

Ultra-processed food consumption, cancer risk and cancer mortality: a large-scale prospective analysis within the UK Biobank.

Background: Global dietary patterns are increasingly dominated by relatively cheap, highly palatable, and ready-to-eat ultra-processed foods (UPFs). However, prospective evidence is limited on cancer development and mortality in relation to UPF consumption. This study examines associations between UPF consumption and risk of cancer and associated mortality for 34 site-specific cancers in a large cohort of British adults. Methods: This study included a prospective cohort of UK Biobank participants (aged 40-69 years) who completed 24-h dietary recalls between 2009 and 2012 (N = 197426, 54.6% women) and were followed up until Jan 31, 2021. Food items consumed were categorised according to their degree of food processing using the NOVA food classification system. Individuals' UPF consumption was expressed as a percentage of total food intake (g/day). Prospective associations were assessed using multivariable Cox proportional hazards models adjusted for baseline socio-demographic characteristics, smoking status, physical activity, body mass index, alcohol and total energy intake. Findings: The mean UPF consumption was 22.9% (SD 13.3%) in the total diet. During a median follow-up time of 9.8 years, 15,921 individuals developed cancer and 4009 cancer-related deaths occurred. Every 10 percentage points increment in UPF consumption was associated with an increased incidence of overall (hazard ratio, 1.02; 95% CI, 1.01-1.04) and specifically ovarian (1.19; 1.08-1.30) cancer. Furthermore, every 10 percentage points increment in UPF consumption was associated with an increased risk of overall (1.06; 1.03-1.09), ovarian (1.30; 1.13-1.50), and breast (1.16; 1.02-1.32) cancer-related mortality. Interpretation: Our UK-based cohort study suggests that higher UPF consumption may be linked to an increased burden and mortality for overall and certain site-specific cancers especially ovarian cancer in women. Funding: The Cancer Research UK and World Cancer Research Fund.

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.

Association of the retail food environment, BMI, dietary patterns, and socioeconomic position in urban areas of Mexico.

The retail food environment is a key modifiable driver of food choice and the risk of non-communicable diseases (NCDs). This study aimed to assess the relationship between the density of food retailers, body mass index (BMI), dietary patterns, and socioeconomic position in Mexico. Cross-sectional dietary data, BMI and socioeconomic characteristics of adult participants came from the nationally representative 2012 National Health and Nutrition Survey in Mexico. Geographical and food outlet data were obtained from official statistics. Densities of food outlets per census tract area (CTA) were calculated. Dietary patterns were determined using exploratory factor analysis and principal component analysis. The association of food environment variables, socioeconomic position, BMI, and dietary patterns was assessed using two-level multilevel linear regression models. Three dietary patterns were identified-the healthy, the unhealthy and the carbohydrates-and-drinks dietary pattern. Lower availability of fruit and vegetable stores was associated with an unhealthier dietary pattern whilst a higher restaurant density was associated with a carbohydrates-and-drinks pattern. A graded and inverse association was observed for fruit and vegetable store density and socioeconomic position (SEP)-lower-income populations had a reduced availability of fruit and vegetable stores, compared with higher-income populations. A higher density of convenience stores was associated with a higher BMI when adjusting for unhealthy dietary patterns. Upper-income households were more likely to consume healthy dietary patterns and middle-upper-income households were less likely to consume unhealthy dietary patterns when exposed to high densities of fruit and vegetable stores. When exposed to a high concentration of convenience stores, lower and upper-lower-income households were more likely to consume unhealthy dietary patterns. Food environment and sociodemographic conditions within neighbourhoods may affect dietary behaviours. Food environment interventions and policies which improve access to healthy foods and restrict access to unhealthy foods may facilitate healthier diets and contribute to the prevention of NCDs.

Typology of how 'harmful commodity industries' interact with local governments in England: a critical interpretive synthesis.

INTRODUCTION: Industries that produce and market potentially harmful commodities or services (eg, tobacco, alcohol, gambling, less healthy foods and beverages) are a major influence on the drivers of behavioural risk factors for non-communicable diseases. The nature and impact of interactions between public bodies and 'harmful commodity industries' (HCIs) has been widely recognised and discussed at national and international levels, but to date little is known about such interactions at local or regional government levels. This study aimed to identify and characterise actual and potential interactions and proposes a typology of interactions between HCIs and English local authorities (LAs). METHODS: Five electronic databases covering international literature (PubMed, EBSCO, OVID, Scopus and Web of Science) were searched up to June 2021. We also performed online searches for publicly available, web-based grey literature and documented examples of interactions in an English LA context. We conducted a critical interpretive synthesis of the published and grey literature to integrate and conceptualise the data in the context of English LAs. RESULTS: We included 47 published papers to provide the frame for the typology, which was refined and contextualised for English LAs through the available grey literature. Three categories were developed, describing the medium through which interactions occur: (1) direct involvement with LAs, (2) involvement through intermediaries and (3) involvement through the local knowledge space. Within these, we grouped interactions into 10 themes defining their nature and identified illustrative examples. CONCLUSION: Our typology identifies complex inter-relationships and characterises interactions between HCIs and LAs, with illustrative examples from English LAs. Drawn from well-established theories and frameworks in combination with contextual information on English LAs, this typology explores the LA perspective and could help local decision-makers to maximise population health while minimising negative impacts of HCIs. PROSPERO REGISTRATION NUMBER: CRD42021257311.