Promoting physical activity is a global initiative. However, published systematic syntheses regarding physical activity among children and young people with chronic kidney disease (CKD) are limited. The aim of this review was to determine the evidence relating to physical activity among children and young people with CKD and identify research gaps. A comprehensive search across seven databases was conducted, and two reviewers screened and synthesised the data. Fifty-seven primary studies were included. Most studies were observational, conducted in Europe and North America, and focused on kidney transplant recipients. Physical activity levels measured by various parameters, tools, and reporting methods showed children with CKD had a lower or similar percentage of physical activity participation, intensity, frequency, duration, and overall activeness compared with healthy controls. Associations between physical activity and sex, age, CKD stages, and outcomes varied in size, direction, and strength among studies. No prospective longitudinal studies have examined the associations between physical activity and CKD progression. Nor did any explicitly describe children’s/carer’s experience of engaging in physical activity, although five qualitative studies reported impacts and adaptations in children with different CKD stages. Most interventions described were short-term (<6 months) home-based exercise training programmes incorporating endurance, resistance, or flexibility elements. In conclusion, evidence on physical activity in children with CKD is predominantly quantitative, cross-sectional, relying on self-reported data, and focusing primarily on adolescents and kidney transplant recipients. Further research should establish more precise physical activity estimates using validated, standardised measures across CKD stages and diverse populations. A higher resolution version of the Graphical abstract is available as Supplementary information

Abstract Background Over half of UK adults eat food prepared out-of-home (OOH) weekly and the poor nutritional profile of OOH food contributes to ill health. Nutri-Score is a form of interpretative labelling which assigns food products a value of A (healthiest) to E (least healthy) based on nutritional quality, and inclusion on menus could be a public health policy option to reduce obesity. This is the first real-world Randomised Control Trial to test the effectiveness of Nutri-Score alongside calorie labelling on food menus in UK OOH settings. Methods Adult participants (N=672), majority White (80%) female (63%), with a mean age of 47(±18) years, were recruited from the local community to visit OOH food businesses to order, consume, and pay for meals. Data collection days were randomised to be control (calorie labelling) or Nutri-Score (calorie labelling with Nutri-Score). Linear mixed models assessed impacts of labelling condition on perceived effectiveness of menu labelling and nutritional quality of food orders. Findings Scores for perceived effectiveness of labelling were significantly greater in the Nutri-Score condition compared to control (B = 0.21, p=0.010; 95% CI 0.05, 0.37) and food orders were significantly better nutritional quality, indicated by lower Nutrient Profiling Model scores in the Nutri-Score vs. control condition (B = -0.89, p=0.003; 95% CI -1.48, -0.31). Interpretation Compared to providing calorie labelling alone, inclusion of Nutri-Score could be an effective policy approach to improve nutritional quality of diet and reduce diet-related disease. Funding This research was funded by the Economic and Social Research Council (ESRC;Reference ES/W007932/1). Research in context Evidence before this study PubMed was searched for all research into Nutri-Score food labelling, published between June 2016 (earliest available result), and February 24, 2026, using the search terms: (((((Nutri-Score)) OR (Nutriscore)) OR (Nutri-Score label*)) OR (Nutriscore label*)) with no language restrictions. The search returned n=354 articles deemed relevant according to title and abstract content. Nutri-Score labelling has been adopted as a front-of-pack food labelling policy in several European countries. Systematic reviews and meta-analyses have explored the impact of Nutri-Score labelling, primarily on food packaging, through both real world and experimental evidence. Findings suggest that Nutri-Score is effective in helping consumers to identify healthier foods, and rank foods in order of healthiness. Additionally, Nutri-Score labelling is associated with improved nutritional quality of food selection, by facilitating the selection of healthier food choices and the avoidance of less-healthy food choices. However, most studies to date have been conducted in experimental settings, and only n=2 studies have tested Nutri-Score in out-of-home (OOH) settings. The two studies conducted in the OOH food sector were conducted in France and differed in design (e.g., non-randomized). Findings have suggested that Nutri-Score is associated with food choices of greater nutritional quality, although effects may not be consistent across socioeconomic status. Added value of this study No research has examined the effectiveness of Nutri-Score on food choices with a UK population or the impact of Nutri-Score on nutrient consumption (as opposed to purchase or selection). Inclusion of interpretive labelling (i.e., Nutri-Score) for OOH food menus is a potential avenue for national government policy, however research to assess effectiveness and guide implementation of such policy is limited. In the present real-world randomised controlled trial, participants visited an OOH food business in Liverpool city centre and selected a meal from a control menu (calorie labelling only) or a Nutri-Score intervention menu (calorie labelling with Nutri-Score). Primary outcomes of interest were perceived message effectiveness and nutritional quality of meal ordered. Implications of all the available evidence The evidence suggests that Nutri-Score labelling combined with calorie labelling on food menus is perceived to be effective by consumers and may prompt healthier food choices than calorie labelling alone. The inclusion of interpretative nutrition information, such as Nutri-Score, should be considered for OOH settings as a public health policy.

Professional sport clubs and organisations (PSCOs) are effective settings for adults' health promotion; however, little insight exists regarding their potential role in children's health promotion. This research sought to explore the role, delivery, and challenges of PSCO health promotion projects delivered in primary schools located in Bristol, England. A qualitative case study methodology was followed, utilising semi-structured interviews and ethnographic observations. Three key themes were identified within our data: (1) PSCOs as more than 'just' PA providers; (2) the importance of partnership and multisectoral working; and (3) the challenges and practical considerations for monitoring and evaluation. Our findings suggest that PSCOs, primary schools, local authorities, and academics should explore how further collaboration and knowledge sharing can inform the delivery and evaluation practices of future health promotion projects in primary schools. Specifically, such collaboration could be used to co-develop project design, recruitment strategies and evaluation frameworks for PSCO health promotion projects.

Background Central Europe carries a substantial global burden of ischaemic heart disease (IHD). We aimed to quantify sex-specific differences in IHD case-fatality across 13 Central European countries and to examine the contribution of metabolic, behavioural, and dietary risk factors to these disparities. Methods We analysed Global Burden of Disease (GBD) data on IHD from 1990 to 2023 across 13 Central European countries. Population-level case-fatality was assessed using sex-specific age-standardised mortality-to-prevalence ratios (MPRs). Mortality attributable to specific risk factors was normalised to prevalence to derive a case-fatality index (CFI). Z-scores (≥1.96) quantified the significance of sex differences. Associations with gross national income (GNI) per capita were evaluated using Pearson correlation. Findings In 2023, there were 6.71 million prevalent IHD cases in the region, of whom 3.01 million (44.8%) were women. From 2011 to 2023, regional MPRs declined from 4.49% to 4.37% in men (2.6% relative decrease) and from 4.59% to 4.42% in women (3.7% relative decrease). However, statistically significant sex disparities persisted in 2023: women had higher MPRs in Croatia (Z = 5.55), Serbia (Z = 2.55), and Czechia (Z = 2.18), whereas men had higher MPRs in Poland (Z = −2.55). Higher GNI per capita was associated with lower MPRs (r = −0.76; p = 0.003). Elevated systolic blood pressure and physical inactivity were prominent (Z > 1.96) contributors to excess female case-fatality, while tobacco use disproportionately (Z > 2.58) affected men, particularly in Poland. Dietary risks contributed to sex disparities: women demonstrated higher CFIs for low intake of fruits, nuts/seeds, vegetables, and seafood omega-3 in several high-disparity countries, while male excess was limited to high sodium and low whole-grain intake in isolated settings. Interpretation Despite overall improvements, significant sex inequalities in IHD case-fatality persist in Central Europe. Differential burdens of metabolic, behavioural, and dietary risks are associated with these disparities, underscoring the importance of sex-specific and country-specific prevention approaches to reduce avoidable cardiovascular mortality. Funding None.

BACKGROUND:The healthcare services for the Rohingya population rely heavily on external aid; however, the recent shifts in the funding landscape have created additional pressures. This study aimed to explore the perspectives of healthcare providers (HCPs) on barriers to implementing nutrition programmes and potential solutions to improve nutrition-related healthcare for Rohingya refugees. METHODS:A qualitative phenomenological study was conducted in 2025. Eleven key informant interviews were carried out with HCPs in the Rohingya refugee camp, Cox's Bazar district, Bangladesh. All interviews were transcribed verbatim and analysed using a hybrid thematic approach combining both deductive and inductive methods. RESULTS:HCPs reported several barriers: structural and operational limitations included safety concerns in the camps and funding shortages; sociocultural and behavioural barriers encompassed cultural norms, gender roles, and low health literacy; and programme implementation-related challenges involved uneven coverage, high staff turnover, and weak coordination. Suggested strategies to address these challenges included empowering communities through livelihood programmes and strengthening sustainable coordination mechanisms. CONCLUSIONS:The fragile funding structures, contextual insecurities, and a lack of coordination can undermine the delivery of essential health and nutrition services. There is a need for initiatives that empower communities to become more self-reliant and on strengthening health systems to deliver nutrition services more effectively.

Non-communicable diseases [NCDs] are an ever-increasing burden globally. Community-based programmes [CBPs] have been identified as a cost-effective prevention and management strategy of NCDs. However, evidence for scaling up and sustaining CBPs remains limited. This study explores stakeholders’ perceptions of the utility of social network analysis (SNA) visuals, the systematic mapping of actors within a network, a growing but underexplored method to strengthen CBPs. Semi-structured interviews were conducted with 14 stakeholders of a complex community-based health programme in South Africa, in which an SNA study had previously taken place. Codebook thematic analysis within a realist paradigm was used to develop a practical understanding of the use of SNA visuals. Four topic summary themes were generated in the interviews: 1) who to include in the network boundary, 2) pros and cons of SNA visuals, 3) what SNA can ideally provide, and 4) use of a ‘live’ map. The findings indicate that, while it has its uses for helping to understand overall network structure, SNA visuals need substantial improvement to have utility in consideration of the constraints that many CBPs experience in conducting SNA research in low-resource settings. This research contributes to the development of a pragmatic ‘live’ mapping SNA approach to strengthen complex CBPs, particularly where resources for research may be low. Further exploration of this approach with participants across different types of CBPs is needed.

Background: Cervical cancer killed 348,874 women in 2022, with over 90% of fatalities occurring in low- and middle-income countries. The WHO 90–70–90 elimination strategy requires that 70% of women be screened by 45 years, yet coverage data from standardised, population-based surveys in low-income settings remain scarce. We aimed to estimate country-specific and pooled cervical cancer screening prevalence, characterise educational and residential inequalities, and assess progress toward the WHO 2030 target across 58 countries. Methods: We conducted a cross-sectional analysis of the WHO STEPS (WHO STEPwise Approach to Noncommunicable Disease Risk Factor Surveillance) program, drawing on surveys conducted from 2006 to 2024 in 58 countries across seven geographic regions. Women aged 25–65 years who reported ever being screened for cervical cancer were included. Country-specific weighted prevalence estimates with 95% CIs were derived using complex survey-weighted procedures. Educational and urban–rural inequalities were quantified. Findings: Among 130,317 women aged 25–65, screening prevalence ranged from 0·6% (95% CI 0·3–0·9) in Benin to 95·9% (94·4–97·3) in the Cayman Islands. Pooled regional estimates were 79·1% (64·8–88·6) in Latin America and the Caribbean and 75·4% (49·2–90·6) in Central and Eastern Europe the only two regions meeting the WHO 70% threshold compared with 11·0% (1·3–53·1) in South Asia and 11·7% (5·0–25·3) in sub-Saharan Africa. Only 11 of 58 countries (19%) had achieved the WHO target; 31 (53%) were critically below 30% coverage. Six countries required annual coverage gains exceeding 5·0 percentage points to reach 70% by 2030, a pace without precedent in population-level cancer screening. A pronounced pro-education gradient was observed globally, with prevalence rising from 6·0% (5·7–6·4) among women with no formal education to 35·2% (34·7–35·7) among those with tertiary education. The largest relative educational disparity was in sub-Saharan Africa (relative gap 5·63). Urban women screened at consistently higher rates than rural women in most regions, with the largest absolute gap in Latin America and the Caribbean (21·4 percentage points). Interpretation: Cervical cancer screening coverage remains critically inadequate across most of the 58 countries studied and is systematically concentrated among the most educated and urban women. Meeting the WHO elimination targets by 2030 will require an equity-centred program redesign, the deployment of HPV self-sampling, and the explicit monitoring of socioeconomic and residential gradients within national screening strategies.

BACKGROUND AND AIMS:This study aims to provide the most comprehensive assessment to date of interventional cardiology practices across European Society of Cardiology (ESC) national society member countries, with a focus on infrastructure, procedural volumes, temporal trends (2013-22), regional disparities, and adherence to guideline-recommended care. METHODS:The third edition of the ESC-European Association of Percutaneous Cardiovascular Interventions Atlas presents data from 50 ESC national society member countries, collected through a dedicated 2023 survey of national cardiac societies and interventional working groups. Data were subjected to a rigorous multi-step quality control process to ensure consistency and accuracy. Key metrics include interventional resources, such as the number of hospitals with catheterization laboratories, trained personnel, and the proportion of women in the interventional workforce; procedural volumes and types, including percutaneous coronary intervention (PCI), primary PCI, transcatheter aortic valve implantation, transcatheter mitral valve procedures, transcatheter tricuspid valve procedures; and procedural characteristics, including arterial access site, use of intracoronary imaging, physiological lesion assessment, and sex-specific data on patient care delivery. RESULTS:Despite the ongoing expansion of structural heart transcatheter interventions, PCI remains the dominant procedure, accounting for >90% of all percutaneous cardiovascular interventions. Percutaneous coronary intervention volumes showed limited variation across ESC member countries and demonstrated no significant association with gross national income per capita. In contrast, important regional disparities were observed in the use of transcatheter aortic valve implantation, transcatheter mitral valve procedures, and transcatheter tricuspid valve procedures with procedure rates strongly correlated with gross national income (r = .86; r = .63; and r = .64). Workforce data revealed that while women constitute 39% of all cardiologists, they represent only 10% of interventional cardiologists across ESC member countries. Although interventional cardiology has helped reduce female disparity in access compared with cardiac surgery, inequalities persist, e.g. <30% of PCI recipients are women, despite women representing >40% of patients with ischaemic heart disease. Temporal trend analysis showed a narrowing gap in PCI and primary PCI volumes between regions, reflecting improved access across all economic strata. However, growth in structural valve interventions remained disproportionately concentrated in wealthier countries. CONCLUSIONS:The third edition of the ESC-European Association of Percutaneous Cardiovascular Interventions Atlas highlights significant progress in percutaneous cardiovascular interventions across Europe but also underscores persistent disparities. These findings reinforce the need for balanced investment strategies, harmonized training, greater sex equity, and enhanced data infrastructures to support more equitable and evidence-based cardiovascular care.

OBJECTIVE:To quantify ultra-processed food (UPF) intake in Scotland, identify key contributing food groups and examine sociodemographic associations using nationally representative data. DESIGN:Cross-sectional analysis of 2021 Scottish Health Survey data using 2-d dietary recalls via Intake24 classified by NOVA. UPF intake was calculated as percentage of total energy intake (%TEI) and grams per day (g/d). Multivariable linear regression assessed associations with sex, age, ethnicity, income, socio-economic classification, highest educational qualification, urban-rural location, region and Scottish Index of Multiple Deprivation (SIMD) quintiles. SETTING:Nationally representative sample of Scottish households. PARTICIPANTS:Individuals aged 16 years or over with complete dietary and sociodemographic data (n 2645). RESULTS:Mean energy intake was 1637·8 kcal/d (95 % CI 1615·8, 1659·8). Mean UPF consumption was 666·9 g/d (95 % CI 647·9, 685·9), amounting to 919·9 kcal/d (95 % CI 901·1, 938·6), representing 55·4 % of TEI (95 % CI 54·7, 56·2) and 28·2 % of total food weight. The main contributors to UPF intake were cereal products (244·8 kcal/d, 27·0 % of UPF kcal), confectionery (170·3 kcal/d, 17·9 %) and meats (153·6 kcal/d, 16·2 %). Sandwiches (99·9 % UPF), salty snacks (94·1 %) and dietary supplements (90·5 %) showed highest UPF proportions by food groups. Adjusted analyses revealed greater UPF consumption (%TEI) among males (β = -3·3, P < 0·001), younger adults (β = -2·8 per decade, P < 0·001), White participants (β = +12·9 v. non-White, P < 0·001) and lower SIMD quintile (β = -1·8 per quintile, P < 0·001). Similar patterns emerged for absolute intake (g/d). CONCLUSIONS:UPF dominates Scotland's diet, with inequitable distribution across sociodemographic groups. Policy actions - such as adopting NOVA in dietary guidelines and restricting UPF marketing - are urgently needed to address this public health crisis.

This 2025 report from the ESC Atlas project is the fifth in a biennial series. It presents and compares updated cardiovascular disease (CVD) statistics for more than 50 of the ESC member countries. The statistics are for 2024 or latest available year and are stratified by sex and World Bank national income status to identify inequalities in the risk, management, and outcomes of CVD across ESC member countries. A key objective of the ESC Atlas project has been to inform EU-level policy initiatives aimed at reducing the burden of CVD, contributing to the evidence base underpinning the European Union's cardiovascular health plan ("Safe Hearts Plan"), adopted in December 2025. Population ageing is a major contributor to the continuing high prevalence of CVD across ESC member countries. The Atlas reports 68 million disability-adjusted life years attributable to CVD in association with more than 3 million deaths per year. These statistics identify CVD as the leading cause of death across ESC member countries. However, substantial variation exists by national income status, with middle-income countries exhibiting age-standardized mortality rates that are roughly twice those observed in high-income countries. Marked disparities in healthcare delivery-particularly in workforce capacity and access to advanced interventions-are also evident. These inequalities by national income status are recurrent throughout this Atlas report. They highlight clear priorities for policymakers as they develop strategies to reduce the burden of CVD in the regions where the need is greatest. This 2025 report provides a detailed picture of the complex interplay between demography, the environment, socio-economic status, and clinical factors in shaping cardiovascular (CV) risk. It underscores how the progress that has been made in reducing the CVD burden across ESC member countries is at risk of being offset by new challenges, particularly the epidemic of obesity and diabetes that continues to undermine CV health. The findings presented in this report emphasize the need for coordinated policies to combat these challenges in order to sustain the progress that has been made in reducing the burden of CVD across ESC member countries.

The ageing population in Europe is contributing to a growing proportion of older people affected by cardiovascular disease (CVD). Older adults account for most of the CVD burden and face unique challenges, complicated by age-related physiological changes and comorbidities. Older patients are underrepresented in clinical trials, leading to scientific and clinical equipoise, and inequities in care. Managing CVD in this age group is complex. Despite the availability of guideline-directed therapies, older adults often do not receive optimal treatment due to the complexity of their conditions and are at higher risk of complications. Strategies for the treatment and management of CVD in older individuals should be driven by patient centred outcomes relating to functional capacity and quality of life. Social and economic factors, such as financial limitations and isolation, further exacerbate age-related CVD inequalities and highlight the need for a holistic approach to care. To address this challenge, The Lancet Regional Health-Europe convened experts to evaluate the current state of knowledge on inequalities and disparities in cardiovascular health among older adults and propose recommendations to address these disparities. This Series paper aims to explore inequalities in, and the escalating burden of, CVD for older adults, with a focus on treatment, prevention, and strategies to support their physical and mental well-being.

Background: There is a high prevalence of the double burden of malnutrition (DBM) in children and adolescents in South Asia. This research aims to explore which sociodemographic factors are attributed to DBM in urban Bangladesh, a South Asian country. Methods: We conducted secondary analyses of data obtained from the national survey of childhood obesity among school-age children in Bangladesh (2012-2013). The sample includes 4140 children (aged 5-9 years) and adolescents (10-19 years) randomly recruited from the city corporation (urban) areas in all administrative divisions. At the population level, DBM was defined as the coexistence of underweight and overweight/obesity among children and adolescents. At the household level, DBM was defined as maternal underweight co-occurring with child overweight/obesity within the same mother-child dyad. A multivariable logistic regression model was fitted to estimate odds ratios and 95% confidence intervals. A rapid policy review was conducted to understand the implication of the results obtained from the analysis. Results: The prevalence of DBM at the population level was 45.2% (95% CI: 42.5-45.5%), ranging between 40.0% and 47.6% across seven divisions (p < 0.001). At the household level, DBM prevalence was 16.6% (95% CI: 14.7-18.7%), ranging between 14.0% and 19.0% across seven divisions (p = 0.015). At the population level, DBM odds were 56% higher among younger children (5-9 years) than adolescents (10-19 years) (OR: 1.56; 95% CI: 1.37-1.78), and this association was found in four divisions. At the household level (mother-child pairs), DBM odds were 64% higher in younger children than adolescents (OR: 1.64; 95% CI:1.38-1.95); and higher in children living at a lower-middle socioeconomic status (SES) and middle SES, than upper SES. The policy review revealed that Bangladesh has made substantial commitments to improve nutrition; however, reference to DBM is absent from policy documents. Conclusions: The prevalence of DBM is high among children in urban areas in Bangladesh, disproportionately affecting younger children and households with low SES. In the current policy space, Bangladesh should revise national nutrition frameworks to recognize DBM as a public health priority and implement region-sensitive strategies for preventing and reducing malnutrition among school-aged children.

AIM:To a) evaluate the impact of Making Every Contact Count Healthy Conversation Skills (MECC HCS) training on the confidence and competence of physiotherapists in supporting patient behaviour change, and b) evaluate perceived acceptability, barriers and facilitators to implementing MECC HCS, following training. METHODS:A before and after evaluation design was employed. MECC HCS training took place in October and December 2021. A range of measures were taken directly before training, directly after training, at 6- to 12- week follow-up and at 6- month follow-up. These measures related to confidence in delivering MECC HCS and supporting behaviour change in patients, competence in doing so, and perceived acceptability of utilising MECC HCS as a brief intervention to support behaviour change in practice. RESULTS:MECC HCS training had significant positive impacts on the confidence and competence of physiotherapists in using MECC HCS skills to support patient behaviour change. Physiotherapists found training highly valuable and felt that implementing MECC HCS was acceptable within their practice. 'Intentions' and 'Social/ Professional Role and Identity' were key enablers to MECC HCS implementation at 6 months post- training. CONCLUSIONS:MECC HCS training may contribute to closing the gap between evidence-based recommendations and the practice of physiotherapists in relation to health promotion and supporting patient behaviour change and self-management.

Charitable arms of professional sports clubs and organizations (PSCOs) offer a range of health promotion (HP) programmes within communities, yet little is known about their role within approaches to HP, particularly from the view of key intersectoral partners. Our study explored the perceptions of the role of PSCOs within local approaches to HP from the perspective of multisectoral stakeholders in a southwest region of England. A qualitative single case study approach was implemented, undertaking semi-structured interviews (n = 23) with intersectoral stakeholders spanning the sport, public, voluntary, and health sectors. Findings suggest PSCOs were viewed as important organizations for provision of local HP due to their unique assets, such as stadia, branding, coaching staff and their presence within communities. However, their aims and objectives were unclear to stakeholders and often perceived as motivated by 'brand drivers' of the elite club, despite holding independent charitable status. Moreover, stakeholders were generally unaware of evaluation materials created by PSCOs and favoured the development of a co-produced evaluation framework for PSCOs. In conclusion, PSCOs should utilize existing community forums, networks, and working groups to better communicate organizational structure, aims, and provision amongst prospective partners. Better understanding of PSCOs structures and aims would support understanding of organizational readiness and requirements for future collaboration in intersectoral approaches to local HP. Moreover, local policymakers should consider how mutually beneficial partnerships with PSCOs could be formed, and how the unique assets, and reach, of PSCOs can be best utilized within intersectoral approaches to local HP.

Understanding socio-economic differences in the factors influencing physical activity among older adults is essential for developing comprehensive interventions. We aimed to quantify the associations of modifiable correlates and determinants with physical activity among UK-based older adults of low versus high socio-economic status (SES). In this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, CENTRAL, and Scopus from inception to December 2023, for peer-reviewed studies published in English, investigating associations between a modifiable factor as an independent variable and physical activity as a dependent variable, by SES, in community-dwelling UK older adults aged 60+ years. Random effects meta-analyses were performed separately for people of low and high SES. Risk of bias was assessed with the Mixed Methods Appraisal Tool. This study was registered with PROSPERO (CRD42022351708). Searches identified 11,472 references; seventy-seven studies met the selection criteria, of which fifty-one contributed to meta-analyses (N range = 134–29,280). Of the exposures positively associated with physical activity, physical function, social participation, and perceived general health had the largest effect sizes (standardised mean difference [SMD] range = 0.53–0.81; I-squared statistic range = 54.81–91.00%). Estimates were comparable among low- and high-SES older adults, except for built physical activity facilities, walking and cycling infrastructure, and less smoking, which were positively associated with physical activity only among low-SES individuals. Our results suggest researchers need to better understand discrepancies in the prevalence of the assessed correlates (e.g., fewer low-SES participants reported good physical function) to inform policies that reduce inequalities in older adults’ physical activity levels.

Professional sports clubs and organisations (PSCOs) have been identified as effective organisations for health promotion (HP); however, their position and connectivity within local HP systems is largely unknown. Our research aimed to explore (i) who identifies PSCOs as a key partner within the delivery of local HP projects, (ii) who they collaborate with, and (iii) their perceived importance by network members. A social network analysis survey was completed by eighteen stakeholders within a South West region of England. Few organisations identified PSCOs as a key partner; however, influential organisations, such as the local authority, reported ties to them. Generally, PSCOs were not identified by network stakeholders as key organisations in the dissemination of HP knowledge or resources, such as project delivery or staffing. Limited relationships with voluntary and health sector organisations existed, and fostering such multisectoral relationships should be a priority for PSCOs in the future. PSCOs were not clearly integrated within the local HP system sampled and are siloed within their local HP activities and delivery. Future research and practice should explore how PSCOs’ assets could be best utilised with local HP and contribute towards local and national health priorities.

Understanding digital exclusion in older adults during the COVID-19 pandemic could help tailor responses to future outbreaks. This cohort study used data from older adults aged 60+ years in England who participated in wave nine (2018/2019) of the main English Longitudinal Study of Ageing (ELSA) survey, and/or wave one of the ELSA COVID-19 sub-study (June/July 2020). Using latent class analysis and latent transition analysis, we aimed to identify distinct subgroups of older adults characterised by different patterns of internet use pre- and intra-pandemic, explore the extent to which individuals remained in the same subgroup or transitioned to a different subgroup during the COVID-19 pandemic, and examine longitudinal associations of socio-economic factors (education, occupational class, and wealth) with latent class membership. Preliminary tests showed that the types of internet activities differed between men and women; therefore, subsequent analyses were stratified by biological sex. Three clusters (low, medium, and high) were identified in male participants at both timepoints. Among female participants, three clusters were distinguished pre-pandemic and two (low versus high) during the pandemic. The latent classes were characterised by participants’ breadth of internet use. Higher education, occupational class, and wealth were associated with greater odds of membership in the medium and/or high classes, versus the low class, in men and women. A high degree of stability in latent class membership was observed over time. However, men experienced a stark decrease in online health information-seeking. Our results highlight that inequality regarding the range of functional and social opportunities provided by the internet prevailed during the pandemic. Policymakers should ensure that digital access and upskilling initiatives are equitable for all.

The continued and widening disparities in cardiovascular health, despite overall declines in cardiovascular mortality, highlight the inequities in the distribution of advancements in cardiovascular care. These inequities disproportionately affect certain groups within the population, underscoring the need for targeted efforts to ensure equitable healthcare access and outcomes for all individuals.1Woodruff R.C. Tong X. Wadhera R.K. Loustalot F. Jackson S.L. Vaughan A.S. Cardiovascular disease mortality disparities in black and white adults, 2010‒2022.Am J Prev Med. 2023; 66: 914Summary Full Text Full Text PDF Scopus (0) Google Scholar Subgroups within the population experiencing relative increases in age-adjusted mortality rates due to heart disease from 2019 to 2022 include the elderly aged 65−74 years (7.6%), those aged ≥85 years (9.2%), women (9.8%), Black adults (10.6%), American Indian or Alaska native (9.6%) and Asian or Pacific islander (12.2%).1Woodruff R.C. Tong X. Wadhera R.K. Loustalot F. Jackson S.L. Vaughan A.S. Cardiovascular disease mortality disparities in black and white adults, 2010‒2022.Am J Prev Med. 2023; 66: 914Summary Full Text Full Text PDF Scopus (0) Google Scholar Moreover, individuals with severe mental illnesses such as depression and psychosis have an approximately 35%2Vaccarino V. Badimon L. Bremner J.D. et al.Depression and coronary heart disease: 2018 position paper of the ESC working group on coronary pathophysiology and microcirculation.Eur Heart J. 2020; 41: 1687-1696Crossref PubMed Scopus (386) Google Scholar higher risk of experiencing a major cardiovascular event, and face up to five times higher risks of cardiovascular mortality and sudden cardiac death.3Nielsen R.E. Banner J. Jensen S.E. Cardiovascular disease in patients with severe mental illness.Nat Rev Cardiol. 2021; 18: 136-145Crossref PubMed Scopus (153) Google Scholar Addressing cardiovascular disease disparities in these subgroups of populations—women, ethnic minorities, elderly and those with mental health conditions—is one of the most important challenges in global public health. To address inequalities and disparities in cardiovascular health among disadvantaged populations, The Lancet Regional Health–Europe has launched a pivotal Commission dedicated to addressing these issues. This Commission is tasked with carrying out an exhaustive assessment of available data on the incidence and outcomes of cardiovascular disease, both at a global and regional level. It will offer a detailed overview of existing gaps in data and pinpoint the most achievable objectives for enhancing health outcomes. Addressing the persistent disparities in cardiovascular health, this endeavour aims to serve as a catalyst for change. It seeks to usher in a new era of equity in cardiovascular health care and research, ensuring that progress benefits all sectors of society, especially those who have been historically underserved. By focusing on comprehensive assessments and targeted interventions, the initiative is dedicated to bridging gaps in treatment and outcomes, making strides toward equal health opportunities for every individual. The decision to focus on women stems from recognizing that cardiovascular diseases often present differently in women compared to men, impacting diagnosis, treatment, and outcomes.4Cenko E. Yoon J. Kedev S. et al.Sex differences in outcomes after STEMI: effect modification by treatment strategy and age.JAMA Intern Med. 2018; 178: 632-639Crossref PubMed Scopus (191) Google Scholar While women are generally perceived to have a lower risk of coronary heart disease mortality due to a lower disease prevalence, data from the past two decades reveal higher mortality rates among women, particularly following myocardial infarction.5Hochman J.S. Tamis J.E. Thompson T.D. et al.Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIb investigators.N Engl J Med. 1999; 341: 226-232Crossref PubMed Scopus (749) Google Scholar Emphasizing women's cardiovascular health is crucial for addressing historical gaps in research and healthcare practices that have overlooked these differences. Identifying the precise causes of outcome disparities between women and men is challenging due to women's underrepresentation in cardiovascular research and clinical trials.6Vogel B. Acevedo M. Appelman Y. et al.The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.Lancet. 2021; 397: 2385-2438Summary Full Text Full Text PDF PubMed Scopus (508) Google Scholar This underrepresentation has resulted in significant sex-based disparities in the treatment of atherosclerotic cardiovascular disease, with research revealing distinct pathophysiological and risk factor profiles for men and women.6Vogel B. Acevedo M. Appelman Y. et al.The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.Lancet. 2021; 397: 2385-2438Summary Full Text Full Text PDF PubMed Scopus (508) Google Scholar The commission will analyse how sex and gender differences influence cardiovascular disease risk factors, comorbidities, symptom presentation, diagnostic methods, treatment approaches, and outcomes. The inclusion of neglected ethnic and racial groups emphasizes the heightened burden of cardiovascular disease they endure.7Anand S.S. Razak F. Davis A.D. et al.Social disadvantage and cardiovascular disease: development of an index and analysis of age, sex, and ethnicity effects.Int J Epidemiol. 2006; 35: 1239-1245Crossref Scopus (66) Google Scholar,8Kist J.M. Smit G.W.G. Mairuhu A.T.A. et al.Large health disparities in cardiovascular death in men and women, by ethnicity and socioeconomic status in an urban based population cohort.eClinicalMedicine. 2021; 40101120Summary Full Text Full Text PDF Scopus (9) Google Scholar In the United States, Black individuals face a disproportionately higher burden of cardiovascular disease risk factors such as hypertension and obesity and are more than twice as likely to die of cardiovascular disease, relative to White adults; American Indians are also at an elevated risk of coronary heart disease.9Health, United States spotlightRace and ethnic disparities in heart disease.2019Google Scholar In Europe, persistent disparities are evident. For instance, Surinamese and Antillean populations in the Netherlands and South Asian individuals in the UK experience higher coronary heart disease mortality rates compared to their White counterparts.7Anand S.S. Razak F. Davis A.D. et al.Social disadvantage and cardiovascular disease: development of an index and analysis of age, sex, and ethnicity effects.Int J Epidemiol. 2006; 35: 1239-1245Crossref Scopus (66) Google Scholar,8Kist J.M. Smit G.W.G. Mairuhu A.T.A. et al.Large health disparities in cardiovascular death in men and women, by ethnicity and socioeconomic status in an urban based population cohort.eClinicalMedicine. 2021; 40101120Summary Full Text Full Text PDF Scopus (9) Google Scholar,10Lee K.K. Norris E.T. Rishishwar L. et al.Ethnic disparities in mortality and group-specific risk factors in the UK Biobank.PLOS Glob Public Health. 2023; 3e0001560Crossref Google Scholar These disparities underscore the critical need for culturally sensitive interventions and the dismantling of systemic barriers to healthcare that perpetuate these inequalities.5Hochman J.S. Tamis J.E. Thompson T.D. et al.Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIb investigators.N Engl J Med. 1999; 341: 226-232Crossref PubMed Scopus (749) Google Scholar Addressing cardiovascular health disparities necessitates a deep understanding of several foundational concepts, including the definitions of ethnicity, race, and indigeneity, and their intersection with social disadvantages, education, and gender. The Commission will provide an overview of inequalities in cardiovascular health screening, diagnosis, and treatment, with a focus on diverse populations distinguished by ethnicity and race. By exploring the intersections of racial or ethnic identity, gender, and social disadvantages, the Commission aims to identify and propose innovative solutions to narrow the health equity gap. Focusing on the elderly addresses the increasing prevalence of cardiovascular disease in aging populations and their specific needs for specialized care.11Rodgers J.L. Jones J. Bolleddu S.I. et al.Cardiovascular risks associated with gender and aging.J Cardiovasc Dev Dis. 2019; 6PubMed Google Scholar Aging significantly increases cardiovascular disease risk, with a notable portion of acute coronary syndrome hospitalizations and deaths occurring in those over 65.11Rodgers J.L. Jones J. Bolleddu S.I. et al.Cardiovascular risks associated with gender and aging.J Cardiovasc Dev Dis. 2019; 6PubMed Google Scholar Age-related changes in cardiovascular physiology and increased comorbidity rates affect disease presentation and treatment responses. As the population ages, the demand on healthcare services and the need for enhanced support and tailored treatment approaches increases. Prioritizing the cardiovascular health of the elderly is crucial to enhance their quality of life as called for by the UN's Decade of Healthy Ageing.12World Health OrganizationUN decade of Healthy ageing: plan of action.2020https://www.who.int/initiatives/decade-of-healthy-ageingGoogle Scholar The commission will explore the escalating cardiovascular disease burden among older adults, with a focus on prevention, treatment, and strategies to uphold their physical and mental well-being. In light of the intricate link between mental well-being and cardiovascular health, this Commission will also focus on individuals with mental health conditions or those exposed to psychological stress.13Song H. Fang F. Arnberg F.K. et al.Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study.BMJ. 2019; 365l1255PubMed Google Scholar Mental health conditions such as depression and anxiety can increase cardiovascular disease risk by influencing behavior, stress responses, and health practices.13Song H. Fang F. Arnberg F.K. et al.Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study.BMJ. 2019; 365l1255PubMed Google Scholar Conversely, experiencing cardiovascular disease is a stress-inducing event, exacerbating pre-existing mental health conditions and/or leading to new conditions such as anxiety disorders, depression. Recognizing stress as a shared risk factor for mental health and cardiovascular issues advocates for integrating stress management into preventive healthcare. The aim of the Commission encompasses summarizing current research to pinpoint gaps in understanding cardiovascular health among those with mental health conditions developing strategies to enhance their cardiovascular outcomes, raising awareness about the unique obstacles they face, and delineating future research priorities. The establishment of a Commission on Inequalities and Disparities in Cardiovascular Health by The Lancet Regional Health–Europe is crucial for several compelling reasons. Firstly, the Commission would provide a vital platform for understanding the root causes of cardiovascular health disparities and identifying the specific needs and barriers faced by various groups, including women, the elderly, specific ethnic/racial groups, and individuals with stress or mental illness. Secondly, it would play a pivotal role in informing policy development aimed at reducing health inequalities. By pinpointing high-impact areas for intervention, policies can be tailored to ensure that funding and resources are directed towards those most in need and where they can have the greatest impact. Thirdly, the commission can serve as a catalyst for collaborative efforts to address cardiovascular health disparities through advocacy and awareness raising. This collaborative approach ensures that policy recommendations are rooted in scientific evidence while also incorporating practical aspects and the lived experiences of those most impacted by health disparities. By tackling the key challenges (Fig. 1) associated with cardiovascular health disparities stemming from sex and gender differences, mental health status, aging, ethnicity, and race, this commission will advance the overarching objective of attaining the three UN Sustainable Development Goals on good health and wellbeing (SDG 3), gender equality (SDG 5), and reduced inequalities (SDG 10). The Lancet Regional Health Europe Commission on Inequities and Disparities in Cardiovascular Health is chaired by Professor Raffaele Bugiardini, University of Bologna (Italy), Co-Chairs are Professor Chris P Gale, Leeds Institute of Cardiovascular and Metabolic Medicine at the University of Leeds (UK), and Dr Martha Gulati, Barbra Streisand Women's Heart Center Smidt Heart Institute, Cedars-Sinai Medical Center Los Angeles CA (US). The Commissioners are grouped in four Working Groups: women, ethnic minorities, elderly, and mental health conditions. Each of the Working Groups has a coordinator. See the list of contributors and Commission organization in the Appendix. RB, SA, AM, NT, VV and PJ contributed to study design and editing of the manuscript. CG, MG, LB, EC and OM contributed to editing of the manuscript. RB reports participation on the data safety monitoring board of Aptabio Therapeutics. CG reports funding from Horizon 2020, grants or contracts from Alan Turing Institute, British Heart Foundation, National Institute for Health Research, Abbott Diabetes, Bristol Myers Squibb and European Society of Cardiology, consulting fees from AI Nexus, AstraZeneca, Amgen, Bayer, Bristol Myers Squibb, Boehrinher-Ingleheim, CardioMatics, Chiesi, Daiichi Sankyo, GPRI Research B.V., Menarini, Novartis, iRhythm, Organon, The Phoenix Group; fees from AstraZeneca, Boston Scientific, Menarini, Novartis, Raisio Group, Wondr Medical and Zydus; participation on the data safety monitoring board or advisory board of DANBLCOK trial and TARGET CTCA trial; fiduciary role as Deputy Editor: EHJ Quality of Care and Clinical Outcomes, NICE Indicator Advisory Committee, and Chair ESC Quality Indicator Committee: stock or stock options of CardioMatics; and receipt of other services from Kosmos device. MG reports unpaid leadership or fiduciary role as President of The American Society for Preventive Cardiology. SSA reports leadership or fiduciary role as Associate Vice-President of Global Health; McMaster University and Department of Medicine's Associate Chair of Equity and Diversity; McMaster University; Other financial or non-financial interests: Tier 1 Canada Research Chair in Ethnicity and CVD, Chair in Population Health of Heart & Stroke Foundation and Foundational and grant from Canadian Institutes of Health Research. AHEMM decares consulting fees from Philips and Organon. The other authors have no relevant conflicts of interest to declare related to this manuscript. Download .docx (6.32 MB) Help with docx files Appendix

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU's total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.