BackgroundNon-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.MethodsWe 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.ResultsAfter 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.ConclusionsComprehensive 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 emph...

Background Accurate forecasting of cardiovascular disease (CVD) mortality is crucial to guide policy and programming efforts. Prior forecasts have often not incorporated past trends in rates of reduction in CVD mortality. This creates uncertainties about future trends in CVD mortality and disparities. Methods and Results To forecast US CVD mortality and disparities to 2030, we developed a hierarchical Bayesian model to determine and incorporate prior age, period and cohort (APC) effects from 1979–2012, stratified by age, gender and race; which we combined with expected demographic shifts to 2030. Data sources included the National Vital Statistics System, SEER single year population estimates, and US Bureau of Statistics 2012 National Population projections. We projected coronary disease and stroke deaths to 2030, first based on constant APC effects at 2012 values, as most commonly done (conventional); and then using more rigorous projections incorporating expected trends in APC effects (trend-based). We primarily evaluated absolute mortality. The conventional model projected total coronary and stroke deaths by 2030 to increase by approximately 18% (67,000 additional coronary deaths/year) and 50% (64,000 additional stroke deaths/year). Conversely, the trend-based model projected that coronary mortality would fall by 2030 by approximately 27% (79,000 fewer deaths/year); and stroke mortality would remain unchanged (200 fewer deaths/year). Health disparities will be improved in stroke deaths, but not coronary deaths. Conclusions After accounting for prior mortality trends and expected demographic shifts, total US coronary deaths are expected to decline, while stroke mortality will remain relatively constant. Health disparities in stroke, but not coronary, deaths will be improved but not eliminated. These APC approaches offer more plausible predictions than conventional estimates.

Background The increasing burden of multimorbidity and its socioeconomic gradient poses unique challenges to the provision and structure of health care. We aimed to describe inequalities and trends over time in multimorbidity prevalence, incidence, and case fatality among adults of all ages in England using primary care electronic health records. MethodsWe used a random sample of 991 243 individuals from the Clinical Practice Research Datalink Aurum database registered at participating general practices within England between Jan 1, 2004, and Dec 31, 2019, linked to the 2015 English Index of Multiple Deprivation (IMD). We used the following two outcome measures: basic multimorbidity, comprising two or more chronic conditions; and complex multimorbidity, comprising at least three chronic conditions affecting at least three body systems. We calculated crude, age-standardised, and age-sexstandardised annual incidence, prevalence, and case fatality rates, along with median age of onset for both multimorbidity types. We calculated absolute and relative inequalities for each outcome.Findings In 2004, 30•8% of our study population had basic multimorbidity and 15•1% had complex multimorbidity. This increased to 52•8% and 32•7%, respectively, in 2019. Although the overall incidence of basic multimorbidity remained stable over the 16-year study period, the incidence among people of working age and the incidence of complex multimorbidity increased gradually. Socioeconomic deprivation was associated with an increased incidence of both multimorbidity types in working-age adults. The median age at onset of complex multimorbidity was 7 years younger for the most deprived quintile of the IMD compared with the least deprived quintile.Interpretation The burden of multimorbidity in England has increased substantially over the past 16 years with persistent inequalities, which are worse in working-age adults and for complex multimorbidity. Prevention efforts to reduce the onset and slow the progression of multimorbidity are essential to reduce the increasing impact on patients and health systems alike.