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Non-communicable disease (NCD) prevention strategies now prioritise four major risk factors: food, tobacco, alcohol and physical activity. Dietary salt intake remains much higher than recommended, increasing blood pressure, cardiovascular disease and stomach cancer. Substantial reductions in salt intake are therefore urgently needed. However, the debate continues about the most effective approaches. To inform future prevention programmes, we systematically reviewed the evidence on the effectiveness of possible salt reduction interventions. We further compared \"downstream, agentic\" approaches targeting individuals with \"upstream, structural\" policy-based population strategies. We searched six electronic databases (CDSR, CRD, MEDLINE, SCI, SCOPUS and the Campbell Library) using a pre-piloted search strategy focussing on the effectiveness of population interventions to reduce salt intake. Retrieved papers were independently screened, appraised and graded for quality by two researchers. To facilitate comparisons between the interventions, the extracted data were categorised using nine stages along the agentic/structural continuum, from \"downstream\": dietary counselling (for individuals, worksites or communities), through media campaigns, nutrition labelling, voluntary and mandatory reformulation, to the most \"upstream\" regulatory and fiscal interventions, and comprehensive strategies involving multiple components. After screening 2,526 candidate papers, 70 were included in this systematic review (49 empirical studies and 21 modelling studies). Some papers described several interventions. Quality was variable. Multi-component strategies involving both upstream and downstream interventions, generally achieved the biggest reductions in salt consumption across an entire population, most notably 4g/day in Finland and Japan, 3g/day in Turkey and 1.3g/day recently in the UK. Mandatory reformulation alone could achieve a reduction of approximately 1.45g/day (three separate studies), followed by voluntary reformulation (-0.8g/day), school interventions (-0.7g/day), short term dietary advice (-0.6g/day) and nutrition labelling (-0.4g/day), but each with a wide range. Tax and community based counselling could, each typically reduce salt intake by 0.3g/day, whilst even smaller population benefits were derived from health education media campaigns (-0.1g/day). Worksite interventions achieved an increase in intake (+0.5g/day), however, with a very wide range. Long term dietary advice could achieve a -2g/day reduction under optimal research trial conditions; however, smaller reductions might be anticipated in unselected individuals. Comprehensive strategies involving multiple components (reformulation, food labelling and media campaigns) and \"upstream\" population-wide policies such as mandatory reformulation generally appear to achieve larger reductions in population-wide salt consumption than \"downstream\", individually focussed interventions. This 'effectiveness hierarchy' might deserve greater emphasis in future NCD prevention strategies.

The Academy of Medical Sciences defines a chronic condition as \"a physical non-communicable disease of long duration, such as a cardiovascular disease or cancer; a mental health condition of long duration, such as a mood disorder or dementia; an infectious disease of long duration, such as HIV or hepatitis C.\"5 Some conditions, however, might meet the criterion but also present as an acute episode (eg, anxiety), or might not be chronic (eg, gastritis). Stigma and institutional discrimination are other possible contributors to biases in estimates—for example, the under-detection of mental health conditions in primary care datasets despite the known association between multiple conditions and prevalent and incident mental health conditions.7 8 As with the use of appropriate terms for multiple morbidity, listening to patients is important to understand their experiences and priorities.9 This paper highlights that definitions of multimorbidity should be multidimensional to reflect clinical complexity, timeframes, and disease pathways simultaneously. A key factor is to flexibly adapt definitions based on the intended use of the analysis and to understand the combined impact on crucial operational outcomes, such as economic impact, productivity, workforce, and resource planning, as well as long term and social care needs. Variation in the estimated prevalence of Multimorbidity: systematic review and meta-analysis of 193 International studies.

Taxes on sugar-sweetened beverages (SSBs) have been implemented globally to reduce the burden of cardiometabolic diseases by disincentivizing consumption through increased prices (e.g., 1 peso/litre tax in Mexico) or incentivizing industry reformulation to reduce SSB sugar content (e.g., tiered structure of the United Kingdom [UK] Soft Drinks Industry Levy [SDIL]). In Germany, where no tax on SSBs is enacted, the health and economic impact of SSB taxation using the experience from internationally implemented tax designs has not been evaluated. The objective of this study was to estimate the health and economic impact of national SSBs taxation scenarios in Germany. In this modelling study, we evaluated a 20% ad valorem SSB tax with/without taxation of fruit juice (based on implemented SSB taxes and recommendations) and a tiered tax (based on the UK SDIL) in the German adult population aged 30 to 90 years from 2023 to 2043. We developed a microsimulation model (IMPACTNCD Germany) that captures the demographics, risk factor profile and epidemiology of type 2 diabetes, coronary heart disease (CHD) and stroke in the German population using the best available evidence and national data. For each scenario, we estimated changes in sugar consumption and associated weight change. Resulting cases of cardiometabolic disease prevented/postponed and related quality-adjusted life years (QALYs) and economic impacts from healthcare (medical costs) and societal (medical, patient time, and productivity costs) perspectives were estimated using national cost and health utility data. Additionally, we assessed structural uncertainty regarding direct, body mass index (BMI)-independent cardiometabolic effects of SSBs and cross-validated results with an independently developed cohort model (PRIMEtime). We found that SSB taxation could reduce sugar intake in the German adult population by 1 g/day (95%-uncertainty interval [0.05, 1.65]) for a 20% ad valorem tax on SSBs leading to reduced consumption through increased prices (pass-through of 82%) and 2.34 g/day (95%-UI [2.32, 2.36]) for a tiered tax on SSBs leading to 30% reduction in SSB sugar content via reformulation. Through reductions in obesity, type 2 diabetes, and cardiovascular disease (CVD), 106,000 (95%-UI [57,200, 153,200]) QALYs could be gained with a 20% ad valorem tax and 192,300 (95%-UI [130,100, 254,200]) QALYs with a tiered tax. Respectively, €9.6 billion (95%-UI [4.7, 15.3]) and €16.0 billion (95%-UI [8.1, 25.5]) costs could be saved from a societal perspective over 20 years. Impacts of the 20% ad valorem tax were larger when additionally taxing fruit juice (252,400 QALYs gained, 95%-UI [176,700, 325,800]; €11.8 billion costs saved, 95%-UI [€6.7, €17.9]), but impacts of all scenarios were reduced when excluding direct health effects of SSBs. Cross-validation with PRIMEtime showed similar results. Limitations include remaining uncertainties in the economic and epidemiological evidence and a lack of product-level data. In this study, we found that SSB taxation in Germany could help to reduce the national burden of noncommunicable diseases and save a substantial amount of societal costs. A tiered tax designed to incentivize reformulation of SSBs towards less sugar might have a larger population-level health and economic impact than an ad valorem tax that incentivizes consumer behaviour change only through increased prices.

BackgroundA large proportion of chronic conditions are undiagnosed, preventing early treatment, and leading to poorer outcomes. Understanding how levels of underdiagnosis vary between diseases and population groups over time is crucial for effectively allocating resources and targeting interventions to increase diagnosis rates.MethodsWe used two annual national surveys: the Health Survey for England (cross-sectional) and the UK Household Longitudinal Survey, to identify people with diabetes, hypertension and depression. Diagnosed cases were defined as a self-report of being told by a nurse or doctor as having a condition; undiagnosed cases were defined as those where screening tools used in the survey identified clinical signs of the condition but the individual did not self-report a diagnosis. We used logistic regression to estimate the proportion of people with these three conditions who are undiagnosed for 540 population segments defined by age group, sex, deprivation quintile and region between 2011 and 2019. These predicted probabilities were applied to population estimates using microsimulation to model the proportion undiagnosed for each disease in each Clinical Commissioning Group (local health planning areas) in England.ResultsThe proportion of people with diabetes and depression who were undiagnosed reduced between 2011 and 2019, with no change in the proportion of hypertensives undiagnosed. For hypertension, people in more deprived areas were less likely to be undiagnosed than those in less deprived areas. The opposite was true for depression. Younger men with hypertension or diabetes were less likely to be diagnosed than older men. Both those aged under 30 and those over 70 with depression were less likely to be diagnosed compared with those aged 30–70.ConclusionStrategies aiming to improve undiagnosed hypertension case finding need to understand the reasons for little progress over the past decade. For depression, strategies to increase early diagnosis should prioritise deprived areas. Case finding for all three diseases would benefit from targeting younger age groups.

Multimorbidity is projected to continue increasing in England and many other countries. Here, we use a validated microsimulation model to quantify the potential impact of improving exposure levels of eight risk factors on the burden of major illness among adults aged 30+ in England between 2023-2043. We find that the biggest contributors to incident major illness are body mass index, smoking, systolic blood pressure, and physical inactivity. Theoretical minimum risk exposure levels of all risk factors could reduce 2043 major illness prevalence by 2 percentage points (95% uncertainty intervals: 1.3, 2.7) compared to the continuing trends (base-case) scenario; under a 10% improvement in all risk factors, we project a 0.3 percentage points (0.2, 0.4) reduction in major illness. The impact on health inequalities is mixed. Our findings show that large improvements in risk factors are unlikely to substantially reduce the major illness burden by 2043 due to population ageing. Burden of major disease is projected to increase in England and many other countries. Here the authors model the impact of reducing eight known risk factors for disease burden, such as BMI and smoking, between 2023-2043 in England and report that reductions in risk factors may not substantially reduce the major illness burden by 2043 due to population ageing.

Aiming to contribute to prevention of cardiovascular disease (CVD), the National Health Service (NHS) Health Check programme has been implemented across England since 2009. The programme involves cardiovascular risk stratification-at 5-year intervals-of all adults between the ages of 40 and 74 years, excluding any with preexisting vascular conditions (including CVD, diabetes mellitus, and hypertension, among others), and offers treatment to those at high risk. However, the cost-effectiveness and equity of population CVD screening is contested. This study aimed to determine whether the NHS Health Check programme is cost-effective and equitable in a city with high levels of deprivation and CVD. IMPACTNCD is a dynamic stochastic microsimulation policy model, calibrated to Liverpool demographics, risk factor exposure, and CVD epidemiology. Using local and national data, as well as drawing on health and social care disease costs and health-state utilities, we modelled 5 scenarios from 2017 to 2040: Scenario (A): continuing current implementation of NHS Health Check;Scenario (B): implementation 'targeted' toward areas in the most deprived quintile with increased coverage and uptake;Scenario (C): 'optimal' implementation assuming optimal coverage, uptake, treatment, and lifestyle change;Scenario (D): scenario A combined with structural population-wide interventions targeting unhealthy diet and smoking;Scenario (E): scenario B combined with the structural interventions as above. We compared all scenarios with a counterfactual of no-NHS Health Check. Compared with no-NHS Health Check, the model estimated cumulative incremental cost-effectiveness ratio (ICER) (discounted £/quality-adjusted life year [QALY]) to be 11,000 (95% uncertainty interval [UI] -270,000 to 320,000) for scenario A, 1,500 (-91,000 to 100,000) for scenario B, -2,400 (-6,500 to 5,700) for scenario C, -5,100 (-7,400 to -3,200) for scenario D, and -5,000 (-7,400 to -3,100) for scenario E. Overall, scenario A is unlikely to become cost-effective or equitable, and scenario B is likely to become cost-effective by 2040 and equitable by 2039. Scenario C is likely to become cost-effective by 2030 and cost-saving by 2040. Scenarios D and E are likely to be cost-saving by 2021 and 2023, respectively, and equitable by 2025. The main limitation of the analysis is that we explicitly modelled CVD and diabetes mellitus only. According to our analysis of the situation in Liverpool, current NHS Health Check implementation appears neither equitable nor cost-effective. Optimal implementation is likely to be cost-saving but not equitable, while targeted implementation is likely to be both. Adding structural policies targeting cardiovascular risk factors could substantially improve equity and generate cost savings.

Undiagnosed chronic disease has serious health consequences, and variation in rates of underdiagnosis between populations can contribute to health inequalities. We aimed to estimate the level of undiagnosed disease of 11 common conditions and its variation across sociodemographic characteristics and regions in England. We used linked primary care, hospital and mortality data on approximately 1.3 million patients registered at a GP practice for more than one year from 01/04/2008-31/03/2020 from Clinical Practice Research Datalink. We created a dynamic state model with six states based on the diagnosis and mortality of 11 conditions: coronary heart disease (CHD), stroke, hypertension, chronic obstructive pulmonary disease, type 2 diabetes, dementia, breast cancer, prostate cancer, lung cancer, colorectal cancer, and depression/anxiety. Undiagnosed disease was conceptualised as those who died with a condition but were not previously diagnosed. This was combined with observed data on the incidence of diagnosis, the case fatality rate in the diagnosed, and an assumption about how that rate varies with diagnosis to estimate the number of undiagnosed disease cases over the total number of disease cases (underdiagnosis) in each population group. We estimated underdiagnosis by year, sex, 10-year age group, relative deprivation, and administrative region. We then applied small-area estimation techniques to derive underdiagnosis estimates for health planning areas (CCGs). Levels of underdiagnosis varied between 16% for stroke and 69% for prostate cancer in 2018. For all diseases, the level of underdiagnosis declined over time. Underdiagnosis was not consistently concentrated in areas with high deprivation. For depression/anxiety and stroke, underdiagnosis was estimated to be higher in less deprived CCGs, whilst for CHD and T2DM, it was estimated to be higher in more deprived CCGs, with no apparent relationships for other conditions. We found no uniform spatial patterns of underdiagnosis across all diseases, and the relationship between age, deprivation and the probability of being undiagnosed varied greatly between diseases. Our findings suggest that underdiagnosis is not consistently concentrated in areas with high deprivation, nor is there a uniform spatial underdiagnosis pattern across diseases. This novel method for estimating the burden of underdiagnosis within England depends on the quality of routinely collected data, but it suggests that more research is needed to understand the key drivers of underdiagnosis.

BackgroundStatins are universally recommended for the primary prevention of cardiovascular diseases (CVD). However, studies suggest that statins also increase the incidence of type 2 diabetes mellitus (T2DM), which increases the risk of CVD in the long run. Empirical studies usually have short observation periods that may underestimate the consequences of living with diabetes. This modelling study aimed to quantify the 20-year impact of statins on CVD primary prevention adjusted for the T2DM harms.MethodsWe used the IMPACTNCD validated dynamic stochastic microsimulation to simulate four scenarios: 1) the base-case scenario with statin utilisation informed by the Health Survey for England; 2) in the cohort eligible for primary prevention of CVD in 2020, simulants without known T2DM aged 40–49 are prescribed Atorvastatin 20mg daily; 3) for the remaining two scenarios we changed the age to start statin at 50–59, and 60–69, respectively. The microsimulation was developed in R v4.0.4.High-quality meta-analyses of randomised controlled trials informed the effect of statins on CVD risk reduction and T2DM incidence. Informed by the same meta-analyses, we assumed a mean lag time of 4 years between the intervention and its effects. Based on evidence from Wales, we assumed that every year 2.5% discontinue statins. We additionally assumed a mean adherence of 82% based on evidence from Denmark.ResultsPreliminary results suggest that over 20 years and compared to the base-case, statins could prevent or postpone approximately 670 (95% Uncertainty Interval (UI): 160 to 1640) cases of CVD and cause approximately 330 (95% UI: 0 to 1100) new cases of T2DM in the 40–49 cohort. These estimates increased to approximately 3800 (95% UI: 2500 to 5500) CVD cases and 2300 (95% UI:300 to 4800) T2DM case incidents in the 50–59 cohort, and 6800 (95% UI: 3900 to 8900) CVD cases and 5130 (95% UI:1450 to 10400) T2DM case incidents in the 60–69 cohort. The probabilities of statins causing more harm than benefit using quality-adjusted life-years as a measure were 22%, 7%, and 13% for the 40–49, 50–59 and 60–69 cohorts, respectively. These probabilities were substantially larger between non-white (32%, 28%, and 44% respectively) reflecting a higher T2DM baseline risk among some ethnic groups.ConclusionThis modelling study provides evidence that the overall benefits from statins for primary CVD prevention outweigh the potential harms over 20 years. However, for non-white individuals, the balance may be unfavourable for specific cohorts, guaranteeing further investigation with empirical studies.

Sodium consumption is a modifiable risk factor for higher blood pressure (BP) and cardiovascular disease (CVD). The US Food and Drug Administration (FDA) has proposed voluntary sodium reduction goals targeting processed and commercially prepared foods. We aimed to quantify the potential health and economic impact of this policy. We used a microsimulation approach of a close-to-reality synthetic population (US IMPACT Food Policy Model) to estimate CVD deaths and cases prevented or postponed, quality-adjusted life years (QALYs), and cost-effectiveness from 2017 to 2036 of 3 scenarios: (1) optimal, 100% compliance with 10-year reformulation targets; (2) modest, 50% compliance with 10-year reformulation targets; and (3) pessimistic, 100% compliance with 2-year reformulation targets, but with no further progress. We used the National Health and Nutrition Examination Survey and high-quality meta-analyses to inform model inputs. Costs included government costs to administer and monitor the policy, industry reformulation costs, and CVD-related healthcare, productivity, and informal care costs. Between 2017 and 2036, the optimal reformulation scenario achieving the FDA sodium reduction targets could prevent approximately 450,000 CVD cases (95% uncertainty interval: 240,000 to 740,000), gain approximately 2.1 million discounted QALYs (1.7 million to 2.4 million), and produce discounted cost savings (health savings minus policy costs) of approximately $41 billion ($14 billion to $81 billion). In the modest and pessimistic scenarios, health gains would be 1.1 million and 0.7 million QALYS, with savings of $19 billion and $12 billion, respectively. All the scenarios were estimated with more than 80% probability to be cost-effective (incremental cost/QALY < $100,000) by 2021 and to become cost-saving by 2031. Limitations include evaluating only diseases mediated through BP, while decreasing sodium consumption could have beneficial effects upon other health burdens such as gastric cancer. Further, the effect estimates in the model are based on interventional and prospective observational studies. They are therefore subject to biases and confounding that may have influenced also our model estimates. Implementing and achieving the FDA sodium reformulation targets could generate substantial health gains and net cost savings.

More than 90% of Rwandans rely on polluting solid fuels to meet their cooking needs. The negative impacts on health, climate, and the environment have led the Rwandan government to set a target of halving that number to 42% by 2024. A National Master Plan to promote scale up of liquefied petroleum gas (LPG) has been developed to define (i) the necessary market conditions, (ii) public and private sector interventions, and (iii) the expected societal impacts. Findings are reported from modelling scenarios of scaling LPG use towards the 2024 policy target and the 2030 target for “universal access to clean modern energy” (SDG7). Household LPG use is projected to increase from 5.6% in 2020 to 13.2% by 2024 and 38.5% by 2030. This level of adoption could result in a reduction of 7656 premature deaths and 403,664 disability-adjusted-life-years (DALYs), as well as 243 million trees saved. Reductions in carbon dioxide and black carbon emissions equivalents (CO2e and BCe, respectively) are estimated to reach 25.6 million MT and 14.9 MT, respectively, by 2030. While aggressive policy intervention is required, the health, environmental, and developmental benefits are clear. Implementation of the Rwanda National LPG Master Plan will provide a model for other sub-Saharan African countries to address the priorities for cessation of reliance on solid fuels as an energy source.