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Background Mortality rates due to coronary heart disease (CHD) have decreased in most countries, but increased in low and middle-income countries. Few studies have analyzed the trends of coronary heart disease mortality in Latin America, specifically the trends in young-adults and the effect of correcting these comparisons for nonspecific causes of death (garbage codes). The objective of this study was to describe and compare standardized, age-specific, and garbage-code corrected mortality trends for coronary heart disease from 1985 to 2015 in Argentina, Colombia, and Mexico. Methods Deaths from coronary heart disease were grouped by country, year of registration, sex, and 10-year age bands to calculate age-adjusted and age and sex-specific rates for adults aged ≥25. We corrected for garbage-codes using the methodology proposed by the Global Burden of Disease. Finally, we fitted Joinpoint regression models. Results In 1985, age-standardized mortality rates per 100,000 population were 136.6 in Argentina, 160.6 in Colombia, and 87.51 in Mexico; by 2015 rates decreased 51% in Argentina and 6.5% in Colombia, yet increased by 61% in Mexico, where an upward trend in mortality was observed in young adults. Garbage-code corrections produced increases in mortality rates, particularly in Argentina with approximately 80 additional deaths per 100,000, 14 in Colombia and 13 in Mexico. Conclusions Latin American countries are at different stages of the cardiovascular disease epidemic. Garbage code correction produce large changes in the mortality rates in Argentina, yet smaller in Mexico and Colombia, suggesting garbage code corrections may be needed for specific countries. While coronary heart disease (CHD) mortality is falling in Argentina, modest falls in Colombia and substantial increases in Mexico highlight the need for the region to propose and implement population-wide prevention policies.

ObjectiveTo analyse the falls in coronary heart disease (CHD) mortality in England between 2000 and 2007 and quantify the relative contributions from preventive medications and population-wide changes in blood pressure (BP) and cholesterol levels, particularly by exploring socioeconomic inequalities.DesignA modelling study.SettingSources of data included controlled trials and meta-analyses, national surveys and official statistics.ParticipantsEnglish population aged 25+ in 2000–2007.Main outcome measuresNumber of deaths prevented or postponed (DPPs) in 2007 by socioeconomic status. We used the IMPACTSEC model which applies the relative risk reduction quantified in previous randomised controlled trials and meta-analyses to partition the mortality reduction among specific treatments and risk factor changes.ResultsBetween 2000 and 2007, approximately 20 400 DPPs were attributable to reductions in BP and cholesterol in the English population. The substantial decline in BP was responsible for approximately 13 000 DPPs. Approximately 1800 DPPs came from medications and some 11 200 DPPs from population-wide changes. Reduction in population BP prevented almost twofold more deaths in the most deprived quintile compared with the most affluent. Reduction in cholesterol resulted in approximately 7400 DPPs; approximately 5300 DPPs were attributable to statin use and approximately 2100 DPPs to population-wide changes. Statins prevented almost 50% more deaths in the most affluent quintile compared with the most deprived. Conversely, population-wide changes in cholesterol prevented threefold more deaths in the most deprived quintile compared with the most affluent.ConclusionsPopulation-wide secular changes in systolic blood pressure (SBP) and cholesterol levels helped to substantially reduce CHD mortality and the associated socioeconomic disparities. Mortality reductions were, in absolute terms, greatest in the most deprived quintiles, mainly reflecting their bigger initial burden of disease. Statins for high-risk individuals also made an important contribution but maintained socioeconomic inequalities. Our results strengthen the case for greater emphasis on preventive approaches, particularly population-based policies to reduce SBP and cholesterol.

Nanocrystalline boehmite obtained by limited hydrolysis of aluminum tri-sec-butoxide or aluminum chloride was aged under different conditions before being calcined above the dehydroxylation temperature. When aging was carried out under hydrothermal conditions, the condensation of the structural units obeyed a first-order kinetic law with apparent activation energy of 12.2 kcal/mol. Under dehydroxylation conditions, the boehmite fragmentation is accounted for by a simple power law that links its volume to that of the resulting γ-alumina. The main variable is the volatile compounds content (water for instance) in the fresh sample. In terms of texture, a better organization of the initial nanoparticles in the boehmite means a lower surface area and larger pore diameter in the corresponding γ-alumina.

In Sweden, previous favourable trends in blood cholesterol levels have recently levelled off or even increased in some age groups since 2003, potentially reflecting changing fashions and attitudes towards dietary saturated fatty acids (SFA). We aimed to examine the potential effect of different SFA intake on future coronary heart disease (CHD) mortality in 2025. We compared the effect on future CHD mortality of two different scenarios for fat intake a) daily SFA intake decreasing to 10 energy percent (E%), and b) daily SFA intake rising to 20 E%. We assumed that there would be moderate improvements in smoking (5%), salt intake (1g/day) and physical inactivity (5% decrease) to continue recent, positive trends. In the baseline scenario which assumed that recent mortality declines continue, approximately 5,975 CHD deaths might occur in year 2025. Anticipated improvements in smoking, dietary salt intake and physical activity, would result in some 380 (-6.4%) fewer deaths (235 in men and 145 in women). In combination with a mean SFA daily intake of 10 E%, a total of 810 (-14%) fewer deaths would occur in 2025 (535 in men and 275 in women). If the overall consumption of SFA rose to 20 E%, the expected mortality decline would be wiped out and approximately 20 (0.3%) additional deaths might occur. CHD mortality may increase as a result of unfavourable trends in diets rich in saturated fats resulting in increases in blood cholesterol levels. These could cancel out the favourable trends in salt intake, smoking and physical activity.

BackgroundPost-stroke cognitive impairment (PSCI) is a common consequence of stroke, leading to reduced quality of life and increased care needs. However, rehabilitation services for this condition in Ireland are very limited. The aim was to apply estimates of PSCI incidence to the Irish population and project the number with PSCI in the population in 2025.MethodsWe developed a deterministic Markov model to estimate future incidence of PSCI in the population aged 40–89 years living in Ireland up to 2025. Population data, estimates and projections to 2025 were obtained from the Irish Central Statistics Office. Data from the Irish Longitudinal Study on Ageing were used to estimate age and sex specific stroke prevalence in 2014. Age and sex specific stroke incidence was estimated using 2015 public hospital discharge data (n=6,155). Transition probabilities across six health states defined by cognitive impairment, physical disability, dementia and death were estimated using data from stroke survivors in the English Longitudinal Study on Ageing (n=490) (2002–2011). Published data from the South London Stroke Register were used to estimate annual stroke recurrence.ResultsThe Irish population aged 40–89 years in 2015–2025 (n=2.7m) is projected to have a cumulative incidence of stroke of approximately 2.3% by 2025 (n=63,100). Of these incident strokes, approximately 22.5% are estimated to have died due to stroke (n=14,200), and 23.8% to have died of another cause (n=15,000) by 2025. Of the survivors in 2025 (n=30600), approximately 50.9% are predicted to have cognitive impairment without dementia (n=15500), and 19.4% to have dementia (n=5900). The total number of stroke survivors is projected to increase from 26700 in 2015 to 41400 in 2025, equivalent to a 55% increase in numbers, and the number with post-stroke dementia is projected to more than double from 3900 in 2015 to 8700 in 2025.DiscussionIn 2025, over two thirds of Irish people who have survived a stroke in the preceding 10 years will have cognitive impairment. The number of people with post-stroke dementia is set to double between 2015 and 2025. The model is limited by its deterministic nature, and the assumption that age-specific disease incidence will remain stable. The model will be further developed to include a probabilistic sensitivity analysis, to model alternative scenarios for trends in disease incidence, and to extend the projections to 2035. The model will also be used in an economic evaluation of alternative strategies for stroke management, including cognitive rehabilitation.

BackgroundEnsuring academic research leads to research that is useful for end users is a key challenge in the health research arena. Stakeholder engagement is being increasingly recognised as an important way to achieving impact. The workHORSE project was designed to continuously engage with stakeholders, via four iterative workshops and an e-platform, to inform the development of an open source/open access modelling tool to enable commissioners to quantify the potential cost-effectiveness and equity of the NHS Health Check Programme. An objective of the project is to evaluate the involvement of stakeholders in the process of building the workHORSE computer modelling tool.MethodsThe design of the workshop programme was theory-based using the Cairney/Oliver key co-production principles. We identified stakeholders using our extensive networks and snowballing techniques. Iterative development of the decision support modelling tool was informed through engaging with stakeholders during three workshops (to date). We used detailed scripts facilitating open discussion and opportunities for stakeholders to provide additional feedback subsequently. At the end of each workshop, stakeholders completed stakeholder engagement questionnaires to explore their views and experiences throughout the process. The research team also completed questionnaires to explore their expectations prior to the workshops and their experiences thereafter.ResultsA total of 25 stakeholders have participated, of which 11 attended two or more workshops. They spanned all levels: local (NHS commissioners, GPs, local authorities and academics), third sector and national organisations (including Public Health England).Stakeholders experiences were positive overall. They felt valued and commended the involvement of practitioners. Major reasons for attending included being able to influence development and having insight and understanding of what the tool could include and how it would work in practice. They appreciated the iterative process involving a series of workshops which provided opportunities for them to learn about and reflect upon the model’s capacity, usage and usefulness. Researchers saw the process as an opportunity for developing a common language and trust in the end product and ensuring the support tool was transparent. The workshops have acted as a reality check ensuring model scenarios and outputs are relevant and fit for purpose.ConclusionComputational modellers rarely consult with end users when developing tools to inform decision-making. The added value of co-production (collaboration and iteration with stakeholders) potentially enables modellers to produce a ‘real-world’ operational tool. Likewise, stakeholders have increased confidence in the decision support tool’s development and applicability in practice.

BackgroundGrowing evidence suggests that sugar sweetened beverage (SSB) intake can increase long-term weight gain and hence worsen the ongoing obesity epidemic. A tax on SSBs might offer an effective population wide intervention to reduce the burden of obesity, cardiovascular diseases (CVD) and common cancers. We aimed to estimate the potential impact on obesity of a 10% and 20% tax on SSBs in Turkey.MethodsWe developed a Markov model for the Turkish population aged 35 years and older. The model follows a closed cohort from year 2011 to 2031. The cohort has the probability of transition to healthy, overweight or obese states or to die from CVD, cancer or other causes. Model inputs were population and death records from Turkish Statistical Institute, overweight and obesity prevalence from Turkish National Chronic Disease Survey, 2011, daily mean SSB intake from Turkish National Diet and Nutrition Survey. We used DISMOD II software to estimate the incidence of overweight and obesity. The effect of tax was calculated using price elasticities obtained from previous published studies. We compared three scenarios: The baseline scenario involved no change in consumption of SSBs. In two additional scenarios, we modelled the effect of a 10% and 20% tax on decreasing SSBs intake. We then modelled the effect of this SSB decrease on BMI and obesity prevalence on the Turkish population. We further calculated the population attributable risk fraction of obesity to estimate the CVD and cancer cases potentially preventable. We also conducted a probabilistic sensitivity analysis to estimate 95% uncertainty intervals (95% UI).ResultsWe forecast that in this closed cohort, by the year 2031, approximately 4,201,100 (4,130,000–4,270,000) men and 5,419,000 (5,305,000–5,537,000) women would be obese. However implementing a 10% SSB tax could result in approximately 21,900 (19,800–29,040) fewer obese men and 13,500 (12,900–15,400) fewer obese women. A 20% tax might result in 41,900 (40,100–48,100) fewer obese men and 24,800 (15,600–28,700) fewer obese women. Overall, a 20% tax could result in a 0.7% reduction in obesity prevalence in the whole cohort. This might result in approximately 29,700 fewer CVD cases and 13,400 fewer obesity related cancer cases by 2031.ConclusionA tax on Sugar Sweetened Beverages in the Turkish population could usefully reduce the prevalence of obesity, cardiovascular disease and common cancers. These findings reinforce the growing evidence of health benefits with SSB taxation policies in diverse countries.

BackgroundDiabetes is associated with an increased risk of dementia and disability. However, the implications of future trends in diabetes for the burden of these conditions are unclear. The aim of our study is to estimate the potential impact of trends in diabetes prevalence upon the future burden of dementia and disability in England & Wales by 2060.MethodsWe used a probabilistic multi-state, open-cohort, Markov model to integrate observed trends in Type 2 diabetes, cardiovascular disease and dementia to forecast the occurrence of disability and dementia to 2060. The model incorporated English Longitudinal Study of Ageing (ELSA) data, published effect estimates for state transition probabilities, trends in mortality and dementia incidence.The baseline scenario assumed that the recently observed trends in obesity would continue, resulting in a 26% increase in Type 2 diabetes cases by 2060. Against this baseline, we compared three other scenarios reflecting alternative projected trends in diabetes suggested by Public Health England models: increases of 7%, 20% and 49%. For each scenario, we then calculated the cumulative number of dementia and disability cases and number of life years lost or gained by 2060, in comparison to the baseline scenario.We used probabilistic sensitivity analysis to estimate 95% uncertainty intervals (UI).ResultsIf the relative prevalence of Type 2 diabetes increases 49% by 2060, we might expect approximately 106,000 (95%UI 97,500 to 112,800) cumulative additional cases of disability, some 86,000 (95%UI: 80,000 to 92,500) additional cases of dementia and approximately 2,570,000 (95%UI: 2,500,000 to 2,660,000) life years lost by 2060.If prevention policies succeed in slowing down the increase in Type 2 diabetes to 7% by 2060, we might expect approximately 94,000 (87,000 to 100,400) fewer new cases of disability, 77,000 (95%UI: 71,800 to 82,900) fewer cases of dementia and approximately 2,300,000 (95%UI: 2,220,000 to 2,370,000) life years gained by 2060. However, large benefits would only be seen after a substantial lag-time: only 4,700 (95%CI: 4,300 to 5,100) new cases of disability and 3,200 (95%CI: 2,900 to 3,500) new cases of dementia would be avoided by 2030.ConclusionSubstantial reductions in the future burden of dementia and disability appear eminently achievable if effective prevention policies succeed in halting the ongoing epidemic of obesity and associated Type 2 diabetes.However, these reductions might only become visible after a substantial lag-period.

BackgroundCardiovascular disease (CVD) contributes to dementia and disability risk. It also affects the cost of care. The English NHS long-term plan targets preventing 150,000 CVD events from 2019–2029. However, after decades of declines in CVD mortality in England, CVD mortality improvements have slowed since 2011, which may indicate a slowdown in incidence reduction from around 2006. Therefore, there is uncertainty about how CVD burden and associated health and social care costs might evolve in the next decade.MethodsSimulations for people aged 35–100 in England and Wales were carried out using the IMPACT Better Aging Model (BAM), an open-cohort, stochastic Markov model which synthesises observed trends in CVD incidence and mortality, dementia and disability in the English Longitudinal Study of Ageing (ELSA) and national ONS data. The synthesised trends were projected to 2029.We modelled undiscounted health and social care costs and quality adjusted life years (QALYs) for 2019–2029 under two scenarios:Basecase – age–specific CVD incidence continue to decline, following the long–term trends;Age–specific CVD incidence do not decline after 2006, following recent trends.Healthcare costs were based on hospital episode statistics (HES) data, matched to ELSA participants and calibrated to Office for Budget Responsibility healthcare cost estimates. Age-related social care costs were estimated using reported social care contact hours from ELSA combined with PSSRU unit costs. Utility weights for QALYs were from EQ-5D MEPS catalogue and Health Survey for England.ResultsIn the basecase scenario 1, median healthcare costs (2019 prices) are projected to increase by ∼12% between 2019–2029, from £93.0bn to £104.6bn per year. Social care costs are projected to increase by ∼27%, from £8.0bn to £10.2bn per year.In the CVD flat-lining scenario 2, median healthcare costs increased by ∼15% from £95.3bn in 2019 to £109.6bn in 2029, and social care costs increased by ∼30% from £8.2bn in 2019 to £10.7bn in 2029.When compared with scenario 2, the basecase scenario would generate ∼200,000 additional QALYs/year by 2029, which, valued at UK Treasury rate, would be worth some £12billion per year.ConclusionThis study projects future health and social care costs resulting from the recent slowdown in CVD incidence and mortality declines. We predict that social care costs will grow twice as fast as healthcare costs over the next decade, regardless of future improvements. Total funding policy therefore need to needs to be urgently addressed, which may prove politically challenging.