Health Impact and Cost-Effectiveness of Achieving the National Salt and Sugar Reduction Initiative Voluntary Sugar Reduction Targets in the United States: A Microsimulation Study.

BACKGROUND: High intake of added sugar is linked to weight gain and cardiometabolic risk. In 2018, the US National Salt and Sugar Reduction Initiative proposed government-supported voluntary national sugar reduction targets. This intervention's potential effects and cost-effectiveness are unclear. METHODS: A validated microsimulation model, CVD-PREDICT (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends), coded in C++, was used to estimate incremental changes in type 2 diabetes, cardiovascular disease (CVD), quality-adjusted life-years (QALYs), costs, and cost-effectiveness of the US National Salt and Sugar Reduction Initiative policy. The model was run at the individual level, incorporating the annual probability of each person's transition between health statuses on the basis of risk factors. The model incorporated national demographic and dietary data from the National Health and Nutrition Examination Survey across 3 cycles (2011 through 2016), added sugar-related diseases from meta-analyses, and policy costs and health-related costs from established sources. A simulated nationally representative US population was created and followed until age 100 years or death, with 2019 as the year of intervention start. Findings were evaluated over 10 years and a lifetime from health care and societal perspectives. Uncertainty was evaluated in a 1-way analysis by assuming 50% industry compliance and probabilistic sensitivity analyses through a second-order Monte Carlo approach. Model outputs included averted diabetes cases, CVD events and CVD deaths, QALYs gained, and formal health care cost savings, stratified by age, race, income, and education. RESULTS: Achieving the US National Salt and Sugar Reduction Initiative sugar reduction targets could prevent 2.48 million CVD events, 0.49 million CVD deaths, and 0.75 million diabetes cases; gain 6.67 million QALYs; and save $160.88 billion net costs from a societal perspective over a lifetime. The policy became cost-effective (<150 000/QALYs) at 6 years, highly cost-effective (<50 000/QALYs) at 7 years, and cost-saving at 9 years. Results were robust from a health care perspective, with lower (50%) industry compliance, and in probabilistic sensitivity analyses. The policy could also reduce disparities, with greatest estimated health gains per million adults among Black or Hispanic individuals, lower income, and less educated Americans. CONCLUSIONS: Implementing and achieving the US National Salt and Sugar Reduction Initiative sugar reformation targets could generate substantial health gains, equity gains, and cost savings.

Serum long-chain n-3 polyunsaturated fatty acids and aortic calcification in middle-aged men: The population-based cross-sectional ERA-JUMP study.

BACKGROUND AND AIM: Few studies have examined the association of long-chain n-3 polyunsaturated fatty acids (LCn-3PUFAs) with the measures of atherosclerosis in the general population. This study aimed to examine the relationship of total LCn-3PUFAs, eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) with aortic calcification. METHODS AND RESULTS: In a multiethnic population-based cross-sectional study of 998 asymptomatic men aged 40-49 years (300 US-White, 101 US-Black, 287 Japanese American, and 310 Japanese in Japan), we examined the relationship of serum LCn-3PUFAs to aortic calcification (measured by electron-beam computed tomography and quantified using the Agatston method) using Tobit regression and ordinal logistic regression after adjusting for potential confounders. Overall 56.5% participants had an aortic calcification score (AoCaS) > 0. The means (SD) of total LCn-3PUFAs, EPA, and DHA were 5.8% (3.3%), 1.4% (1.3%), and 3.7% (2.1%), respectively. In multivariable-adjusted Tobit regression, a 1-SD increase in total LCn-3PUFAs, EPA, and DHA was associated with 29% (95% CI = 0.51, 1.00), 9% (95% CI = 0.68, 1.23), and 35% (95% CI = 0.46, 0.91) lower AoCaS, respectively. Results were similar in ordinal logistic regression analysis. There was no significant interaction between race/ethnicity and total LCn-3PUFAs, EPA or DHA on aortic calcification. CONCLUSIONS: This study showed the significant inverse association of LCn-3PUFAs with aortic calcification independent of conventional cardiovascular risk factors among men in the general population. This association appeared to be driven by DHA but not EPA.

A Meta-Analysis of Food Labeling Effects on Consumer Diet Behaviors and Industry Practices.

CONTEXT: The influence of food and beverage labeling (food labeling) on consumer behaviors, industry responses, and health outcomes is not well established. EVIDENCE ACQUISITION: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Ten databases were searched in 2014 for studies published after 1990 evaluating food labeling and consumer purchases/orders, intakes, metabolic risk factors, and industry responses. Data extractions were performed independently and in duplicate. Studies were pooled using inverse-variance random effects meta-analysis. Heterogeneity was explored with I2, stratified analyses, and meta-regression; and publication bias was assessed with funnel plots, Begg's tests, and Egger's tests. Analyses were completed in 2017. EVIDENCE SYNTHESIS: From 6,232 articles, a total of 60 studies were identified, including 2 million observations across 111 intervention arms in 11 countries. Food labeling decreased consumer intakes of energy by 6.6% (95% CI= -8.8%, -4.4%, n=31), total fat by 10.6% (95% CI= -17.7%, -3.5%, n=13), and other unhealthy dietary options by 13.0% (95% CI= -25.7%, -0.2%, n=16), while increasing vegetable consumption by 13.5% (95% CI=2.4%, 24.6%, n=5). Evaluating industry responses, labeling decreased product contents of sodium by 8.9% (95% CI= -17.3%, -0.6%, n=4) and artificial trans fat by 64.3% (95% CI= -91.1%, -37.5%, n=3). No significant heterogeneity was identified by label placement or type, duration, labeled product, region, population, voluntary or legislative approaches, combined intervention components, study design, or quality. Evidence for publication bias was not identified. CONCLUSIONS: From reviewing 60 intervention studies, food labeling reduces consumer dietary intake of selected nutrients and influences industry practices to reduce product contents of sodium and artificial trans fat.

Data on alcohol consumption and coronary artery calcification among asymptomatic middle-aged men for the ERA-JUMP study.

Data presented in this article are supplementary data to our primary article 'Association of Alcohol Consumption and Aortic Calcification in Healthy Men Aged 40-49 Years for the ERA JUMP Study' [1]. In this article, we have presented supplementary tables showing the independent association of alcohol consumption with coronary artery calcification using Tobit conditional regression and ordinal logistic regression.

Association of alcohol consumption and aortic calcification in healthy men aged 40-49 years for the ERA JUMP Study.

BACKGROUND AND AIMS: Several studies have reported a significant inverse association of light to moderate alcohol consumption with coronary heart disease (CHD). However, studies assessing the relationship between alcohol consumption and atherosclerosis have reported inconsistent results. The current study was conducted to determine the relationship between alcohol consumption and aortic calcification. METHODS: We addressed the research question using data from the population-based ERA-JUMP Study, comprising of 1006 healthy men aged 40-49 years, without clinical cardiovascular diseases, from four race/ethnicities: 301 Whites, 103 African American, 292 Japanese American, and 310 Japanese in Japan. Aortic calcification was assessed by electron-beam computed tomography and quantified using the Agatston method. Alcohol consumption was categorized into four groups: 0 (non-drinkers), ≤1 (light drinkers), >1 to ≤3 (moderate drinkers) and >3 drinks per day (heavy drinkers) (1 drink = 12.5 g of ethanol). Tobit conditional regression and ordinal logistic regression were used to investigate the association of alcohol consumption with aortic calcification after adjusting for cardiovascular risk factors and potential confounders. RESULTS: The study participants consisted of 25.6% nondrinkers, 35.3% light drinkers, 23.5% moderate drinkers, and 15.6% heavy drinkers. Heavy drinkers [Tobit ratio (95% CI) = 2.34 (1.10, 4.97); odds ratio (95% CI) = 1.67 (1.11, 2.52)] had significantly higher expected aortic calcification score compared to nondrinkers, after adjusting for socio-demographic and confounding variables. There was no significant interaction between alcohol consumption and race/ethnicity on aortic calcification. CONCLUSIONS: Our findings suggest that heavy alcohol consumption may be an independent risk factor for atherosclerosis.

CVD Prevention Through Policy: a Review of Mass Media, Food/Menu Labeling, Taxation/Subsidies, Built Environment, School Procurement, Worksite Wellness, and Marketing Standards to Improve Diet.

Poor diet is the leading cause of cardiovascular disease in the USA and globally. Evidence-based policies are crucial to improve diet and population health. We reviewed the effectiveness for a range of policy levers to alter diet and diet-related risk factors. We identified evidence to support benefits of focused mass media campaigns (especially for fruits, vegetables, salt), food pricing strategies (both subsidies and taxation, with stronger effects at lower income levels), school procurement policies (for increasing healthful or reducing unhealthful choices), and worksite wellness programs (especially when comprehensive and multicomponent). Evidence was inconclusive for food and menu labeling (for consumer or industry behavior) and changes in local built environment (e.g., availability or accessibility of supermarkets, fast food outlets). We found little empiric evidence evaluating marketing restrictions, although broad principles and large resources spent on marketing suggest utility. Widespread implementation and evaluation of evidence-based policy strategies, with further research on other strategies with mixed/limited evidence, are essential "population medicine" to reduce health and economic burdens and inequities of diet-related illness worldwide.

Variability in freedom from loss of primary patency results in trials assessing stent implantation in the superficial femoral artery.

BACKGROUND: Primary patency (PP) in trials assessing superficial femoral artery (SFA) stenting is defined as a combination of vessel patency assessed by duplex ultrasound (DUS) at the 12-month follow-up exam and freedom from revascularization of the index vessel through 12 months of follow-up. Loss of PP is thus more likely to be identified during the mandated DUS assessment. Moreover, DUS is performed within a prespecified allowed window of time for the visit that exceeds 12 months (typically by 30 days). Therefore, the time frame for detecting patency with DUS exceeds the time frame in which revascularization is captured. Survival analyses are often applied to present estimates of freedom from loss of PP, but there are no clear guidelines as to the correct method for presenting these analyses in reports from clinical trials. We aimed to analyze the implications of applying different methods in assessing freedom from loss of PP in studies assessing stenting for diseased SFA. METHODS: Data were simulated based on existing available results from SFA bare-metal nitinol stent trials published between 2009 and 2013 and summarized in a previous analysis (STROLL, SUPERB, RESILIENT, DURABILITY I, DURABILTY II, COMPLETE SFA). Six different approaches to Kaplan Meier (KM) analyses were applied based on entry criteria into and time frame of the KM model. RESULTS: Six KM estimates of PP were generated for each of the 10,000 simulated datasets. The average exact PP rate was 70.6%, while the average estimated KM rates using the six different methods ranged between 68.0% and 81.9%. CONCLUSION: KM estimates of PP vary substantially according to the methods employed. These may lead to misrepresentation of results from clinical trials. The development of a unified approach is advocated.

[Relationship between exercise tolerance and early heart function impairment in patients with acute ST-elevation myocardial infarction and normal left ventricular ejection fraction].

OBJECTIVE: To explore the relationship between early heart function impairment and exercise tolerance in patients with acute ST-elevation myocardial infarction (STEMI) and normal left ventricular ejection fraction (LVEF). METHODS: A total of 229 patients with a LVEF of ≥ 50% were retrospectively reviewed. There were 199 males and 30 females with a mean age of 56.2 ± 11.1 years. They underwent cardiopulmonary exercise testing (CPET) early after STEMI in a single exercise laboratory. Demographic data, presence of concomitant diseases, characteristics of STEMI, echocardiography and CPET findings were evaluated. RESULTS: Their mean LVEF was 60.2% ± 6.9% and the values of Vo(2 peak) and Vo(2AT) were (21.8 ± 5.7) ml×kg(-1)×min(-1) and (19.4 ± 4.8) ml×kg(-1)×min(-1) respectively. Peak oxygen uptake (Vo(2 peak)) showed a positive correlation with LVEF (r = 0.17, P = 0.012), E/A (r = 0.15, P = 0.033) and peak myocardial systolic velocity (Sm) (r = 0.30, P < 0.001). On the contrary, it varied inversely with peak A wave velocity (A) (r = -0.20, P = 0.005), E/Em (r = -0.16, P = 0.022) and left atrial pressure (LAP) (r = -0.16, P = 0.021). And there was a similar correlation between oxygen uptake at anaerobic threshold (Vo(2AT)) and LAP (r = -0.17, P = 0.031). After adjustments of subject demographic features and cardiovascular risk factors, Vo(2 peak) was still associated with LVEF (ß = 0.149, s = 0.051, sß = 0.178, 95%CI 0.048 - 0.250, P = 0.004) and Sm (ß = 0.606, s = 0.167, sß = 0.245, 95%CI 0.277 - 0.936, P < 0.001). So did the relationship between Vo(2AT) and LAP (ß = -0.271, s = 0.117, sß = -0.172, 95%CI -0.501 - -0.040, P = 0.022). CONCLUSION: The exercise tolerance may be affected by early heart function impairment in STEMI patients. CPET is a sensitive detection tool of decreased heart function.