Objective Acute tonsillitis represents a significant proportion of admissions to ENT departments nationally. Given current hospital pressures, it is vital to look for safe alternatives to admission. This study explores the safe management of patients in an ambulatory medical unit, without the need for admission. Methods A retrospective review of 48 patients’ notes was carried out. Following the development and implementation of a guideline for acute tonsillitis, a prospective re-audit of 41 patients was carried out, measuring length of stay, overnight admissions and re-admissions. Results The rate of overnight admission following implementation of the guideline fell from 0.75 to 0.29, and average length of stay dropped from 19.2 to 9.5 hours. There were two re-admissions in each cycle of the audit, which represents a non-significant increase. Conclusion The tonsillitis guideline has significantly reduced admissions and length of stay. Re-admissions remain low, demonstrating that this is a safe and cost-effective intervention.

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.

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.

In every region of the world, poor diet is a leading cause of both malnutrition and chronic diseases including diabetes, cardiovascular diseases and specific cancers. (1-3) In 2013, 38.3 million deaths occurred due to chronic diseases globally (70% of all deaths), with most of these deaths occurring in developing countries. (4) Anecdotal evidence and more formal evaluations in a limited number of countries suggest that changes in traditional eating patterns and a growing reliance on new types of foods are major drivers of these transitions. However, data on global patterns of dietary habits, as well as differences by population characteristics are not well established. An empirical assessment of dietary intakes is needed for evidence-based policy-making to address global health challenges. In most nations worldwide, assessment of dietary habits has been limited by the absence of robust data on individual dietary intakes that can be used in comparative studies. Up to now, most global analyses have evaluated only single dietary factors or have used data on crude household expenditure or national food supply estimates that do not adequately capture individuals' actual consumption levels. (5,6) Moreover, types of foods consumed and diet-related diseases are often unevenly distributed within populations and it is therefore essential to collect data on specific demographic groups to understand the impact of diets on diseases. Furthermore, even when individual dietary intakes are available, these are rarely standardized or comparable across countries or time, due to differences in the data collection instruments and their intended use, in the design and administration of surveys, and in data processing and analysis. As part of our efforts for the 2010 Global Burden of Diseases study, we systematically identified the available data from national and subnational surveys of individual-based dietary intakes of key foods and nutrients worldwide, by age, sex, country and time (1980-2010). Our preliminary methods have been reported (7) and further details are available from the corresponding author on request. Briefly, we searched multiple electronic databases and used extensive personal communications with researchers and government authorities worldwide to identify and obtain nationally representative dietary intake surveys or, if these were unavailable, large subnational surveys. For countries without identified national or subnational individual-level dietary surveys, we searched for individual-level surveys from large cohort studies as well as other data sources on diet such as the World Health Organization (WHO) Global Infobase, the WHO STEPS database and household expenditure surveys. For trans-unsaturated fatty acids (trans-fats) and dietary sodium, we also searched for biomarker surveys measuring circulating or adipose trans-fat concentrations or 24-hour urinary sodium excretion. Finally, we used the comprehensive United Nations Food and Agricultural Organization (FAO) food balance sheets, (8) which provide country-level data on per capita food availability for major food groups in 187 countries and across the entire time period studied. For trans-fat, we also included industry estimates of nation-specific availability of partially hydrogenated oil, total oils/ fats and total packaged foods per capita from both retail and food-service establishments in 79 countries (Mark Stavro, Bunge LLC, personal communication, 23 May 2012). Due to the limited amount of relevant published data, most survey data were obtained by direct contacts with researchers and officials. By combining all these sources of information, including adjusted FAO data and industry estimates, our final estimates were derived from dietary information drawn from 187 countries. We included data from 325 dietary surveys and 145 urinary sample surveys. The total number of individuals sampled in each surveyed country ranged from several hundred to more than 10000. …

OBJECTIVESTo quantify cardiovascular disease and diabetes deaths attributable to dietary and metabolic risks by country, age, sex, and time in South Asian countries.METHODSWe 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.RESULTSSuboptimal 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.CONCLUSIONSImportant similarities and differences are evident in cardiometabolic mortality burdens of modifiable dietary and metabolic risks across these countries, informing health policy and program priorities.

Public health policies might thus be thought of as the policies that guide these ‘organized efforts’ to protect and improve health. The scope of such policies depends a good deal, however, on what is considered to be entailed by ‘organized efforts’. and on how centrally ‘organized efforts’ are understood to be related to efforts that are more decentralized, more informal, less organized, perhaps even ‘spontaneous’. The relative importance and legitimacy of centralized versus decentralized uses of knowledge in protecting and enhancing health is a common underlying theme in discussion of public health policy. This chapter discusses public health policy, and differences in outcomes, across different developed countries.

BackgroundHealthy 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.MethodsIn 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.FindingsFrom 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.InterpretationConsumption 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.FundingThe Bill & Melinda Gates Foundation and Medical Research Council.

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.

BACKGROUND:The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. METHODS:Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. FINDINGS:All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. INTERPRETATION:Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. FUNDING:Bill & Melinda Gates Foundation.

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BACKGROUND: High intake of sodium is a major preventable risk factor for CVD mortality in Iran. While effective population strategies to reduce sodium intake have been identified, the cost-effectiveness of these strategies in Iran is not established. Objective: To evaluate the cost-effectiveness of a national sodium reduction program in Iran consisting of a voluntary agreement with industry to reduce the sodium content in processed foods and a mass media campaign to encourage consumers to make low-sodium choices. METHODS: We developed a Monte Carlo microsimulation model and simulated CVD events for a sequence of individuals by randomly drawing characteristics of each person (age, sex, CVD risk factors) from their corresponding population distributions and tracking the person individually one after the other from entry into the model until death. The study population included Iranian adults (>25 y) free of CVD and diabetes. Data on population distributions of the CVD risk factors, by age and sex, were obta...

Background: Excess sodium intake is a major risk factor for CVD globally. Yet, the cost-effectiveness of policy interventions to reduce sodium consumption in every country has not been quantified. Methods: We characterized global sodium intakes, blood pressure (BP) levels, effects of sodium on BP, and CVD rates, each by age and sex in 187 countries based on the 2010 Global Burden of Diseases study. Nation-specific costs of a policy that combined education with targeted industry agreements to reduce sodium were estimated using the WHO NCD Costing Tool. Nation-specific impacts on mortality and disability-adjusted life years (DALYs) were modeled using comparative risk assessment, based on various scenarios including 10%, 30%, 1 g/d, and 3 g/d achieved sodium reductions over 10 yrs. Cost-effectiveness (CE) was evaluated as PPP-adjusted international $ per DALY saved over 10 yrs. Results: Worldwide, a 10% sodium reduction within each country was projected to avert an average of 5,655,000 CVD-related DALYs/year, at an average cost of 1.11 international dollars per capita over the 10 yr intervention. The average CE ratio was I$207/DALY. Across 21 world regions, sodium reduction would be most CE in South Asia and East/Southeast Asia (each I$120/DALY); across 187 countries, the most CE were Moldova (I$9.89/DALY), Azerbaijan (I$12.82/DALY), and Uzbekistan (I$12.85/DALY). The least CE region was Australia/New Zealand (I$922/DALY), although this CE was still substantially below the usual threshold to define an intervention as CE (3.0 GDP per capita). 99% of the world's population live in countries in which the intervention had a CE ratio < 1.0 GDP per capita, and 95% in countries with a CE ratio < 0.1 GDP per capita - far below standard acceptable CE ratios of 3.0 GDP per capita. Conclusions: National education and industry-agreement strategies to reduce dietary sodium would have substantial impacts on CVD and be extremely cost-effective in nearly every country worldwide. CE of 10% reduction intervention: GDP/capita per DALY

Background: Suboptimal diet has become the leading cause of death and disability globally and in the US. Yet, the specific contributions of different dietary factors to poor health in the US are not established. Objective: To estimate the burdens of 12 key dietary factors on major chronic diseases in the US, overall and by age, sex, and disease. Methods: We used a comparative risk assessment framework to develop consistent and comparable methods to identify specific dietary factors with evidence for etiologic effects on coronary heart disease (CHD), stroke, diabetes, and cancers; estimate current national intake levels and their uncertainty, by age and sex; quantify etiologic effects of each diet-disease relationship, by age; and characterize optimal consumption levels of each dietary factor. We combined these inputs with national disease-specific deaths and disability-adjusted life-years (DALYs) to estimate burdens attributable to each dietary factor overall, and by age, sex, and disease. We quantified uncertainty using probabilistic simulation analyses for all our estimates. Results: In 2010, the 5 leading dietary causes of chronic disease mortality and morbidity in the US were low fruits, low nuts/seeds, high sodium, low vegetables, and high processed meats ( Figure ). Most dietary factors contributed to CHD burden. Leading causes of cancer mortality were low fruits, high processed meats, low milk, low vegetables, and high red meats. Leading causes of diabetes morbidity were high sugar-sweetened beverages, high processed meats, low whole grains, and high red meats. Conclusions: Our findings revealed a major impact of specific dietary factors on poor health in the US. Our study calls for policies and coordinated, multi-stakeholder efforts to improve diet in the US.

Background: Global quality and trends over time of dietary patterns, a priority for reducing chronic diseases, are unknown. Methods: We evaluated age- and sex-specific energy-adjusted consumption, derived from 325 national surveys covering 88.7% of the global adult population, of 17 key foods and nutrients in 187 countries in 1990 and 2010. Diet patterns were assessed by two distinct scales, one based on higher intakes of healthful items (higher intakes=higher scores), and the other on lower intakes of unhealthful items (lower intakes=higher scores), by country, age, sex, and national income. Results: In 2010, global diet patterns varied substantially ( Figure ). African and South Asian nations had low scores based on more healthful items, but high scores based on fewer unhealthful items. In contrast, Western countries had moderate scores based on healthful items and very poor scores based on unhealthful items. This distinction between more healthful items and fewer unhealthful items was largely masked if we aggregated the two pattern scores, which were weakly correlated ( r =-0.08). By age and sex, women and older adults had higher scores based on either healthful or unhealthful items ( p <0.05). Compared to low-income countries, high-income countries had higher scores based on more healthful items (+4.4 [95% uncertainty interval: 3.8, 5.0]), but substantially lower scores based on fewer unhealthful items (-28.1 [-27.3, -28.9]). From 1990 to 2010, most regions improved their diets based on more healthful items (global average=+2.2 [2.0, 2.4]), except for poorest nations; conversely, nearly all regions worsened their diets based on fewer unhealthful items (-2.5 [-2.8, -2.2]), with marked heterogeneity across global regions. Conclusions: Diet quality varies substantially worldwide, with important differences by higher intakes of healthier foods vs. lower intakes of unhealthy foods. The findings emphasize distinct, nation-specific policy priorities for increasing healthful and decreasing unhealthful foods.

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.

BACKGROUNDHigh sodium intake increases blood pressure, a risk factor for cardiovascular disease, but the effects of sodium intake on global cardiovascular mortality are uncertain.METHODSWe 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.RESULTSIn 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.CONCLUSIONSIn 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.).

Excessive sodium consumption is both prevalent and very costly in many countries around the world. Recent research has found that more than 90% of the world's adult population live in countries with mean intakes exceeding the World Health Organization's recommendation, and that more than a million deaths every year may be attributable to excess sodium. This study uses a simulation model to estimate, for the first time, the costeffectiveness of government interventions to reduce population sodium consumption in every country in the world. It reveals substantial heterogeneity in cost-effectiveness by country that has never before been identified, and illustrates, also for the first time, the sensitivity of intervention efficacy to the theoretical-minimum-risk exposure distribution of sodium intake. The study makes a number of additional contributions. It offers a comprehensive appraisal of the methodological strengths and limitations of the surveys, imputation models, randomized controlled trials, prospective cohort studies, meta-analyses, and simulation models that together constitute the evidence base for public health recommendations on sodium intake, as well as for this study's own analysis. These methodological issues, some raised for the first time, are evaluated systematically to allow the relative quality of each input to be assessed and to inform prioritization of further research. The study also uses economic theory to ground a discussion of the proper nature and scope of government policies targeting population sodium consumption, and presents an up-to-date survey of sodium reduction initiatives around the world. Thesis Supervisor: David Andrew Singer Title: Associate Professor

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.