Etiologic effects and optimal intakes of foods and nutrients for risk of cardiovascular diseases and diabetes: Systematic reviews and meta-analyses from the Nutrition and Chronic Diseases Expert Group (NutriCoDE).

BACKGROUND: Dietary habits are major contributors to coronary heart disease, stroke, and diabetes. However, comprehensive evaluation of etiologic effects of dietary factors on cardiometabolic outcomes, their quantitative effects, and corresponding optimal intakes are not well-established. OBJECTIVE: To systematically review the evidence for effects of dietary factors on cardiometabolic diseases, including comprehensively assess evidence for causality; estimate magnitudes of etiologic effects; evaluate heterogeneity and potential for bias in these etiologic effects; and determine optimal population intake levels. METHODS: We utilized Bradford-Hill criteria to assess probable or convincing evidence for causal effects of multiple diet-cardiometabolic disease relationships. Etiologic effects were quantified from published or de novo meta-analyses of prospective studies or randomized clinical trials, incorporating standardized units, dose-response estimates, and heterogeneity by age and other characteristics. Potential for bias was assessed in validity analyses. Optimal intakes were determined by levels associated with lowest disease risk. RESULTS: We identified 10 foods and 7 nutrients with evidence for causal cardiometabolic effects, including protective effects of fruits, vegetables, beans/legumes, nuts/seeds, whole grains, fish, yogurt, fiber, seafood omega-3s, polyunsaturated fats, and potassium; and harms of unprocessed red meats, processed meats, sugar-sweetened beverages, glycemic load, trans-fats, and sodium. Proportional etiologic effects declined with age, but did not generally vary by sex. Established optimal population intakes were generally consistent with observed national intakes and major dietary guidelines. In validity analyses, the identified effects of individual dietary components were similar to quantified effects of dietary patterns on cardiovascular risk factors and hard endpoints. CONCLUSIONS: These novel findings provide a comprehensive summary of causal evidence, quantitative etiologic effects, heterogeneity, and optimal intakes of major dietary factors for cardiometabolic diseases, informing disease impact estimation and policy planning and priorities.

Cost effectiveness of a government supported policy strategy to decrease sodium intake: global analysis across 183 nations.

OBJECTIVE:  To quantify the cost effectiveness of a government policy combining targeted industry agreements and public education to reduce sodium intake in 183 countries worldwide. DESIGN:  Global modeling study. SETTING:  183 countries. POPULATION:  Full adult population in each country. INTERVENTION:  A "soft regulation" national policy that combines targeted industry agreements, government monitoring, and public education to reduce population sodium intake, modeled on the recent successful UK program. To account for heterogeneity in efficacy across countries, a range of scenarios were evaluated, including 10%, 30%, 0.5 g/day, and 1.5 g/day sodium reductions achieved over 10 years. We characterized global sodium intakes, blood pressure levels, effects of sodium on blood pressure and of blood pressure on cardiovascular disease, and cardiovascular disease rates in 2010, each by age and sex, in 183 countries. Country specific costs of a sodium reduction policy were estimated using the World Health Organization Noncommunicable Disease Costing Tool. Country specific impacts on mortality and disability adjusted life years (DALYs) were modeled using comparative risk assessment. We only evaluated program costs, without incorporating potential healthcare savings from prevented events, to provide conservative estimates of cost effectiveness MAIN OUTCOME MEASURE:  Cost effectiveness ratio, evaluated as purchasing power parity adjusted international dollars (equivalent to the country specific purchasing power of US$) per DALY saved over 10 years. RESULTS:  Worldwide, a 10% reduction in sodium consumption over 10 years within each country was projected to avert approximately 5.8 million DALYs/year related to cardiovascular diseases, at a population weighted mean cost of I$1.13 per capita over the 10 year intervention. The population weighted mean cost effectiveness ratio was approximately I$204/DALY. Across nine world regions, estimated cost effectiveness of sodium reduction was best in South Asia (I$116/DALY); across the world's 30 most populous countries, best in Uzbekistan (I$26.08/DALY) and Myanmar (I$33.30/DALY). Cost effectiveness was lowest in Australia/New Zealand (I$880/DALY, or 0.02×gross domestic product (GDP) per capita), although still substantially better than standard thresholds for cost effective (<3.0×GDP per capita) or highly cost effective (<1.0×GDP per capita) interventions. Most (96.0%) of the world's adult population lived in countries in which this intervention had a cost effectiveness ratio <0.1×GDP per capita, and 99.6% in countries with a cost effectiveness ratio <1.0×GDP per capita. CONCLUSION:  A government "soft regulation" strategy combining targeted industry agreements and public education to reduce dietary sodium is projected to be highly cost effective worldwide, even without accounting for potential healthcare savings.

Impact of Dietary and Metabolic Risk Factors on Cardiovascular and Diabetes Mortality in South Asia: Analysis From the 2010 Global Burden of Disease Study.

OBJECTIVES: To quantify cardiovascular disease and diabetes deaths attributable to dietary and metabolic risks by country, age, sex, and time in South Asian countries. METHODS: We used the 2010 Global Burden of Disease national surveys to characterize risk factor levels by age and sex. We derived etiological effects of risk factors-disease endpoints, by age, from meta-analyses. We defined optimal levels. We combined these inputs with cause-specific mortality rates to compute population-attributable fractions as a percentage of total cardiometabolic deaths. RESULTS: Suboptimal diet was the leading cause of cardiometabolic mortality in 4 of 5 countries, with population-attributable fractions from 40.7% (95% uncertainty interval = 37.4, 44.1) in Bangladesh to 56.9% (95% uncertainty interval = 52.4, 61.5) in Pakistan. High systolic blood pressure was the second leading cause, except in Bangladesh, where it superseded suboptimal diet. This was followed in all nations by high fasting plasma glucose, low fruit intake, and low whole grain intake. Other prominent burdens were more variable, such as low intake of vegetables, low omega-3 fats, and high sodium intake in India, Nepal, and Pakistan. CONCLUSIONS: Important similarities and differences are evident in cardiometabolic mortality burdens of modifiable dietary and metabolic risks across these countries, informing health policy and program priorities.

The impact of dietary habits and metabolic risk factors on cardiovascular and diabetes mortality in countries of the Middle East and North Africa in 2010: a comparative risk assessment analysis.

OBJECTIVE/DESIGN: We conducted a comparative risk assessment analysis to estimate the cardiometabolic disease (CMD) mortality attributable to 11 dietary and 4 metabolic risk factors in 20 countries of the Middle East by age, sex and time. The national exposure distributions were obtained from a systematic search of multiple databases. Missing exposure data were estimated using a multilevel Bayesian hierarchical model. The aetiological effect of each risk factor on disease-specific mortality was obtained from clinical trials and observational studies. The number of disease-specific deaths was obtained from the 2010 Global Burden of Disease mortality database. Mortality due to each risk factor was determined using the population attributable fraction and total number of disease-specific deaths. SETTING/POPULATION: Adult population in the Middle East by age, sex, country and time. RESULTS: Suboptimal diet was the leading risk factor for CMD mortality in 11 countries accounting for 48% (in Morocco) to 72% (in the United Arab Emirates) of CMD deaths. Non-optimal systolic blood pressure was the leading risk factor for CMD deaths in eight countries causing 45% (in Bahrain) to 68% (in Libya) of CMD deaths. Non-optimal body mass index and fasting plasma glucose were the third and fourth leading risk factors for CMD mortality in most countries. Among individual dietary factors, low intake of fruits accounted for 8% (in Jordan) to 21% (in Palestine) of CMD deaths and low intake of whole grains was responsible for 7% (in Palestine) to 22% (in the United Arab Emirates) of CMD deaths. Between 1990 and 2010, the CMD mortality attributable to most risk factors had decreased except for body mass index and trans-fatty acids. CONCLUSIONS: Our findings highlight key similarities and differences in the impact of the dietary and metabolic risk factors on CMD mortality in the countries of the Middle East and inform priorities for policy measures to prevent CMD.

Dietary quality among men and women in 187 countries in 1990 and 2010: a systematic assessment.

BACKGROUND: Healthy dietary patterns are a global priority to reduce non-communicable diseases. Yet neither worldwide patterns of diets nor their trends with time are well established. We aimed to characterise global changes (or trends) in dietary patterns nationally and regionally and to assess heterogeneity by age, sex, national income, and type of dietary pattern. METHODS: In this systematic assessment, we evaluated global consumption of key dietary items (foods and nutrients) by region, nation, age, and sex in 1990 and 2010. Consumption data were evaluated from 325 surveys (71·7% nationally representative) covering 88·7% of the global adult population. Two types of dietary pattern were assessed: one reflecting greater consumption of ten healthy dietary items and the other based on lesser consumption of seven unhealthy dietary items. The mean intakes of each dietary factor were divided into quintiles, and each quintile was assigned an ordinal score, with higher scores being equivalent to healthier diets (range 0-100). The dietary patterns were assessed by hierarchical linear regression including country, age, sex, national income, and time as exploratory variables. FINDINGS: From 1990 to 2010, diets based on healthy items improved globally (by 2·2 points, 95% uncertainty interval (UI) 0·9 to 3·5), whereas diets based on unhealthy items worsened (-2·5, -3·3 to -1·7). In 2010, the global mean scores were 44·0 (SD 10·5) for the healthy pattern and 52·1 (18·6) for the unhealthy pattern, with weak intercorrelation (r=-0·08) between countries. On average, better diets were seen in older adults compared with younger adults, and in women compared with men (p<0·0001 each). Compared with low-income nations, high-income nations had better diets based on healthy items (+2·5 points, 95% UI 0·3 to 4·1), but substantially poorer diets based on unhealthy items (-33·0, -37·8 to -28·3). Diets and their trends were very heterogeneous across the world regions. For example, both types of dietary patterns improved in high-income countries, but worsened in some low-income countries in Africa and Asia. Middle-income countries showed the largest improvement in dietary patterns based on healthy items, but the largest deterioration in dietary patterns based on unhealthy items. INTERPRETATION: Consumption of healthy items improved, while consumption of unhealthy items worsened across the world, with heterogeneity across regions and countries. These global data provide the best estimates to date of nutrition transitions across the world and inform policies and priorities for reducing the health and economic burdens of poor diet quality. FUNDING: The Bill & Melinda Gates Foundation and Medical Research Council.

Global sodium consumption and death from cardiovascular causes.

BACKGROUND: High sodium intake increases blood pressure, a risk factor for cardiovascular disease, but the effects of sodium intake on global cardiovascular mortality are uncertain. METHODS: We collected data from surveys on sodium intake as determined by urinary excretion and diet in persons from 66 countries (accounting for 74.1% of adults throughout the world), and we used these data to quantify the global consumption of sodium according to age, sex, and country. The effects of sodium on blood pressure, according to age, race, and the presence or absence of hypertension, were calculated from data in a new meta-analysis of 107 randomized interventions, and the effects of blood pressure on cardiovascular mortality, according to age, were calculated from a meta-analysis of cohorts. Cause-specific mortality was derived from the Global Burden of Disease Study 2010. Using comparative risk assessment, we estimated the cardiovascular effects of current sodium intake, as compared with a reference intake of 2.0 g of sodium per day, according to age, sex, and country. RESULTS: In 2010, the estimated mean level of global sodium consumption was 3.95 g per day, and regional mean levels ranged from 2.18 to 5.51 g per day. Globally, 1.65 million annual deaths from cardiovascular causes (95% uncertainty interval [confidence interval], 1.10 million to 2.22 million) were attributed to sodium intake above the reference level; 61.9% of these deaths occurred in men and 38.1% occurred in women. These deaths accounted for nearly 1 of every 10 deaths from cardiovascular causes (9.5%). Four of every 5 deaths (84.3%) occurred in low- and middle-income countries, and 2 of every 5 deaths (40.4%) were premature (before 70 years of age). The rate of death from cardiovascular causes associated with sodium intake above the reference level was highest in the country of Georgia and lowest in Kenya. CONCLUSIONS: In this modeling study, 1.65 million deaths from cardiovascular causes that occurred in 2010 were attributed to sodium consumption above a reference level of 2.0 g per day. (Funded by the Bill and Melinda Gates Foundation.).

Global, regional, and national consumption levels of dietary fats and oils in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys.

OBJECTIVES: To quantify global consumption of key dietary fats and oils by country, age, and sex in 1990 and 2010. DESIGN: Data were identified, obtained, and assessed among adults in 16 age- and sex-specific groups from dietary surveys worldwide on saturated, omega 6, seafood omega 3, plant omega 3, and trans fats, and dietary cholesterol. We included 266 surveys in adults (83% nationally representative) comprising 1,630,069 unique individuals, representing 113 of 187 countries and 82% of the global population. A multilevel hierarchical Bayesian model accounted for differences in national and regional levels of missing data, measurement incomparability, study representativeness, and sampling and modelling uncertainty. SETTING AND POPULATION: Global adult population, by age, sex, country, and time. RESULTS: In 2010, global saturated fat consumption was 9.4%E (95%UI=9.2 to 9.5); country-specific intakes varied dramatically from 2.3 to 27.5%E; in 75 of 187 countries representing 61.8% of the world's adult population, the mean intake was <10%E. Country-specific omega 6 consumption ranged from 1.2 to 12.5%E (global mean=5.9%E); corresponding range was 0.2 to 6.5%E (1.4%E) for trans fat; 97 to 440 mg/day (228 mg/day) for dietary cholesterol; 5 to 3,886 mg/day (163 mg/day) for seafood omega 3; and <100 to 5,542 mg/day (1,371 mg/day) for plant omega 3. Countries representing 52.4% of the global population had national mean intakes for omega 6 fat ≥ 5%E; corresponding proportions meeting optimal intakes were 0.6% for trans fat (≤ 0.5%E); 87.6% for dietary cholesterol (<300 mg/day); 18.9% for seafood omega 3 fat (≥ 250 mg/day); and 43.9% for plant omega 3 fat (≥ 1,100 mg/day). Trans fat intakes were generally higher at younger ages; and dietary cholesterol and seafood omega 3 fats generally higher at older ages. Intakes were similar by sex. Between 1990 and 2010, global saturated fat, dietary cholesterol, and trans fat intakes remained stable, while omega 6, seafood omega 3, and plant omega 3 fat intakes each increased. CONCLUSIONS: These novel global data on dietary fats and oils identify dramatic diversity across nations and inform policies and priorities for improving global health.

The science of epidemiology and the methods needed for public health assessments: a review of epidemiology textbooks.

OBJECTIVES: Epidemiology is often described as 'the science of public health'. Here we aim to assess the extent that epidemiological methods, as covered in contemporary standard textbooks, provide tools that can assess the relative magnitude of public health problems and can be used to help rank and assess public health priorities. STUDY DESIGN: Narrative literature review. METHODS: Thirty textbooks were grouped into three categories; pure, extended or applied epidemiology, were reviewed with attention to the ways the discipline is characterised and the nature of the analytical methods described. RESULTS: Pure texts tend to present a strict hierarchy of methods with those metrics deemed to best serve aetiological inquiry at the top. Extended and applied texts employ broader definitions of epidemiology but in most cases, the metrics described are also those used in aetiological inquiry and may not be optimal for capturing the consequences and social importance of injuries and disease onsets. CONCLUSIONS: The primary scientific purpose of epidemiology, even amongst 'applied' textbooks, is aetiological inquiry. Authors do not readily extend to methods suitable for assessing public health problems and priorities.

Cardiovascular risk in a rural adult West African population: is resting heart rate also relevant?

INTRODUCTION: Elevated resting heart rate (RHR) is a neglected marker in cardiovascular risk factor studies of sub-Saharan African populations. This study aimed to determine the prevalence of elevated RHR and other risk factors for cardiovascular disease (CVD) and to investigate any associations between RHR and these risk factors in a rural population in Ghana. DESIGN: Cross-sectional analysis. METHODS: A total of 574 adults aged between 18-65 years were randomly sampled from a population register. Data collected included those on sociodemographic variables and anthropometric, blood pressure (BP), and RHR measurements. Within-person variability in RHR was calculated using data from repeat measurements taken 2 weeks apart. RESULTS: Of study participants, 36% were male. Prevalence of casual high BP was 19%. In the population, 10% were current cigarette smokers and habitual alcohol use was high at 56%. As measured by body mass index, 2% were obese and 14% had abdominal obesity. RHR was elevated (>90 bpm) in 19%. Overall, 79% of study participants were found to have at least one CVD risk factor. RHR was significantly associated with age, waist circumference, and BP. Individuals with an elevated RHR had a higher risk (OR 1.94, 95% CI 1.15-3.26%, p = 0.013) of casual high BP compared with participants with normal RHR independently of several established CVD risk factors. The regression dilution ratio of RHR was 0.75 (95% CI 0.62-0.89). CONCLUSIONS: Significant associations were observed between RHR and several established cardiovascular risk factors. Prospective studies are needed in sub-Saharan African populations to establish the potential value of RHR in cardiovascular risk assessment.

Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide.

OBJECTIVES: To estimate global, regional (21 regions) and national (187 countries) sodium intakes in adults in 1990 and 2010. DESIGN: Bayesian hierarchical modelling using all identifiable primary sources. DATA SOURCES AND ELIGIBILITY: We searched and obtained published and unpublished data from 142 surveys of 24 h urinary sodium and 103 of dietary sodium conducted between 1980 and 2010 across 66 countries. Dietary estimates were converted to urine equivalents based on 79 pairs of dual measurements. MODELLING METHODS: Bayesian hierarchical modelling used survey data and their characteristics to estimate mean sodium intake, by sex, 5 years age group and associated uncertainty for persons aged 20+ in 187 countries in 1990 and 2010. Country-level covariates were national income/person and composition of food supplies. MAIN OUTCOME MEASURES: Mean sodium intake (g/day) as estimable by 24 h urine collections, without adjustment for non-urinary losses. RESULTS: In 2010, global mean sodium intake was 3.95 g/day (95% uncertainty interval: 3.89 to 4.01). This was nearly twice the WHO recommended limit of 2 g/day and equivalent to 10.06 (9.88-10.21) g/day of salt. Intake in men was ∼10% higher than in women; differences by age were small. Intakes were highest in East Asia, Central Asia and Eastern Europe (mean >4.2 g/day) and in Central Europe and Middle East/North Africa (3.9-4.2 g/day). Regional mean intakes in North America, Western Europe and Australia/New Zealand ranged from 3.4 to 3.8 g/day. Intakes were lower (<3.3 g/day), but more uncertain, in sub-Saharan Africa and Latin America. Between 1990 and 2010, modest, but uncertain, increases in sodium intakes were identified. CONCLUSIONS: Sodium intakes exceed the recommended levels in almost all countries with small differences by age and sex. Virtually all populations would benefit from sodium reduction, supported by enhanced surveillance.

Impact of a reduced red and processed meat dietary pattern on disease risks and greenhouse gas emissions in the UK: a modelling study.

OBJECTIVES: Consumption of red and processed meat (RPM) is a leading contributor to greenhouse gas (GHG) emissions, and high intakes of these foods increase the risks of several leading chronic diseases. The aim of this study was to use newly derived estimates of habitual meat intakes in UK adults to assess potential co-benefits to health and the environment from reduced RPM consumption. DESIGN: Modelling study using dietary intake data from the National Diet and Nutrition Survey of British Adults. SETTING: British general population. METHODS: Respondents were divided into fifths by energy-adjusted RPM intakes, with vegetarians constituting a sixth stratum. GHG emitted in supplying the diets of each stratum was estimated using data from life-cycle analyses. A feasible counterfactual UK population was specified, in which the proportion of vegetarians measured in the survey population doubled, and the remainder adopted the dietary pattern of the lowest fifth of RPM consumers. OUTCOME MEASURES: Reductions in risks of coronary heart disease, diabetes and colorectal cancer, and GHG emissions, under the counterfactual. RESULTS: Habitual RPM intakes were 2.5 times higher in the top compared with the bottom fifth of consumers. Under the counterfactual, statistically significant reductions in population aggregate risks ranged from 3.2% (95% CI 1.9 to 4.7) for diabetes in women to 12.2% (6.4 to 18.0) for colorectal cancer in men, with those moving from the highest to lowest consumption levels gaining about twice these averages. The expected reduction in GHG emissions was 0.45 tonnes CO(2) equivalent/person/year, about 3% of the current total, giving a reduction across the UK population of 27.8 million tonnes/year. CONCLUSIONS: Reduced consumption of RPM would bring multiple benefits to health and environment.

Perceived challenges to public health in Central and Eastern Europe: a qualitative analysis.

BACKGROUND: There is a major gradient in burden of disease between Central and Eastern Europe compared to Western Europe. Many of the underlying causes and risk factors are amenable to public health interventions. The purpose of the study was to explore perceptions of public health experts from Central and Eastern European countries on public health challenges in their countries. METHODS: We invited 179 public health experts from Central and Eastern European countries to a 2-day workshop in Berlin, Germany. A total of 25 public health experts from 14 countries participated in May 2008. The workshop was structured into 8 sessions of 1.5 hours each, with the topic areas covering coronary heart disease, stroke, prevention, obesity, alcohol, tobacco, tuberculosis, and HIV/AIDS. The workshop was recorded and the proceedings transcribed verbatim. The transcripts were entered into atlas.ti for content analysis and coded according to the session headings. After analysis of the content of each session discussion, a re-coding of the discussions took place based on the themes that emerged from the analysis. RESULTS: Themes discussed recurred across disease entities and sessions. Major themes were the relationship between clinical medicine and public health, the need for public health funding, and the problems of proving the effectiveness of disease prevention. Areas for action identified included the need to engage with the public, to create a better scientific basis for public health interventions, to identify "best practices" of disease prevention, and to implement registries/surveillance instruments. The need for improved data collection was seen throughout all areas discussed, as was the need to harmonize data across countries. CONCLUSIONS: To reduce the burden of disease across Europe, closer collaboration of countries across Europe seems important in order to learn from each other. A more credible scientific basis for effective public health interventions is urgently needed. The monitoring of health trends is crucial to evaluate the impact of public health programmes.

The burden of trachoma in South Sudan: assessing the health losses from a condition of graded severity.

INTRODUCTION: Trachoma is a disease that can lead to visual impairment and ultimately blindness. Previous estimates of health losses from trachoma using the Global Burden of Disease methodology have not, however, included the stage prior to visual impairment. We estimated the burden of all stages of trachoma in South Sudan and assessed the uncertainty associated with the severity and duration of stages of trachoma prior to full blindness. METHODS: The prevalence of trachoma with normal vision, low vision and blindness in the Republic of South Sudan has been estimated previously. These estimates were used to model the incidence and duration of the different stages employing DISMOD II. Different assumptions about disability weights and duration were used to estimate the Years Lived with Disability (YLD). RESULTS: We have estimated the total burden of trachoma in South Sudan to be between 136,562 and 163,695 YLD and trichiasis with normal vision contributes between 5% and 21% of the total depending on the disability weight applied. Women experience more of this burden than men. The sensitivity of the results to different assumptions about the disability weights is partly dependent upon the assumed duration of the different disease states. INTERPRETATION: A better understanding of the natural history of trachoma is critical for a more accurate burden estimate.

Why choice of metric matters in public health analyses: a case study of the attribution of credit for the decline in coronary heart disease mortality in the US and other populations.

BACKGROUND: Reasons for the widespread declines in coronary heart disease (CHD) mortality in high income countries are controversial. Here we explore how the type of metric chosen for the analyses of these declines affects the answer obtained. METHODS: The analyses we reviewed were performed using IMPACT, a large Excel based model of the determinants of temporal change in mortality from CHD. Assessments of the decline in CHD mortality in the USA between 1980 and 2000 served as the central case study. RESULTS: Analyses based in the metric of number of deaths prevented attributed about half the decline to treatments (including preventive medications) and half to favourable shifts in risk factors. However, when mortality change was expressed in the metric of life-years-gained, the share attributed to risk factor change rose to 65%. This happened because risk factor changes were modelled as slowing disease progression, such that the hypothetical deaths averted resulted in longer average remaining lifetimes gained than the deaths averted by better treatments. This result was robust to a range of plausible assumptions on the relative effect sizes of changes in treatments and risk factors. CONCLUSIONS: Time-based metrics (such as life years) are generally preferable because they direct attention to the changes in the natural history of disease that are produced by changes in key health determinants. The life-years attached to each death averted will also weight deaths in a way that better reflects social preferences.

Cervical cancer in Indigenous women: The case of Australia.

Globally, health inequities between Indigenous and non-Indigenous populations exist. The disparity in health outcomes between Indigenous and non-Indigenous Australians is exemplified by cervical cancer. Current evidence suggests that Indigenous women have higher age standardised incidence and mortality than non-Indigenous women when adjusted for stage at diagnosis and co-morbidities; however, there is little information pertaining to national estimates of cervical cancer in Indigenous women. In this paper we review available evidence on the difference in occurrence and case fatality of cervical cancer among Indigenous and non-Indigenous Australian women. The Australian Bureau of Statistics, Australian Institute of Health and Welfare, and State- or Territory-based Cancer Registries were utilised to collect surveillance data. To corroborate existing data, further available journal literature was identified through Medline and Embase. All papers selected for review were cross-referenced to identify further relevant studies. The most recent national estimate of age-standardised cervical cancer incidence rate was 16.9 and 7.1 per 100,000 women-years in Indigenous and non-Indigenous women respectively (incidence ratio 2.4). The Indigenous age-standardised mortality rate was 9.9 per 100,000 women years (95% CI 7.1-13.3), over 5 times the non-Indigenous rate. Cervical cancer incidence, in both Indigenous and non-Indigenous women, has decreased since 1991. Despite the decline, age-standardised incidence among Indigenous women is still higher than non-Indigenous women. The pattern of cervical cancer incidence and survival corroborates the health inequities that exist in Australia. Indigenous women are more likely than non-Indigenous women to develop cervical cancer and are less likely to survive it. Similar patterns exist in Indigenous populations worldwide, such as New Zealander Maoris and Canadian Aboriginals, suggesting that high rates of cervical cancer incidence and mortality may be a symptom of social and economic inequity.

Why my disease is important: metrics of disease occurrence used in the introductory sections of papers in three leading general medical journals in 1993 and 2003.

BACKGROUND: We assessed the metrics used in claims about disease importance made in the introductory sections of scientific papers published in 1993 and 2003. We were interested in the choice of metric in circumstances where establishing the relative social importance of a disease was, presumptively, a primary objective. METHODS: This study consisted of a textual examination of the introductory statements from papers retrieved from MEDLINE. Papers were published in the New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association during the first halves of 1993 and 2003, and were selected on the basis of keywords found in a pilot study to be associated with claims about disease importance. RESULTS: We found 143 papers in 1993 and 264 papers in 2003 included claims about disease importance in their introductory sections, and characteristics of these claims were abstracted. Of the quotes identified in the papers and articles examined, most used counts, prevalence, or incidence measurements. Some also used risk estimates and economic quantities to convey the importance of the disease. There was no change in the types of metrics used between 1993 and 2003. Very few articles, even in 2003, used metrics that weighted disease onsets by the expected consequent loss of healthy time -- such as years of life lost, quality-adjusted life years, and/or disability-adjusted life years. CONCLUSIONS: Claims about the relative importance of diseases continued to be overwhelmingly expressed in terms of counts (of deaths and disease onsets) and comparisons of counts, rates, and risks. Where the aim is to convey the burden that a given disease imposes on a society, "event-based" metrics might be less fit for the purpose than "time-based" metrics. More attention is needed to how the choice of metric should relate to the purpose at hand.

Perceived barriers to the development of modern public health in Bulgaria: a qualitative study.

OBJECTIVES: This qualitative investigation documents Bulgarian perspectives on public health following its accession to the European Union (EU) and explores perceived obstacles to the modernization of public health sciences to more effectively address the country's high rates of premature avoidable mortality. METHODS: 28 semi-structured interviews were conducted throughout Bulgaria in April 2007 with Bulgarian academics, clinicians, policymakers and students in Sofia, Varna and Pleven. Full transcripts were subjected to formal thematic analysis. RESULTS: Respondents identified various barriers to the development and modernization to public health infrastructures in Bulgaria that were classified by four key interlinked themes: (1) institutional and political, (2) financial, (3) dearth of local epidemiological studies, and (4) insufficient public health capacity. CONCLUSIONS: This study is the first to explore specific perspectives and beliefs regarding barriers to the development, modernization, and utilization of public health sciences in Bulgaria. Although the reorientation and strengthening of public health institutions are unlikely to proceed without resistance, optimism for improvement in this field exists now that Bulgaria has joined the EU.