Potential cardiovascular mortality reductions with stricter food policies in the United Kingdom of Great Britain and Northern Ireland
Cardiovascular diseases (CVDs) are the leading cause of death in the United Kingdom, where coronary heart disease (CHD) and stroke cause 150 000 deaths every year. Of these CVD deaths, more than 40 000 occur prematurely, in people younger than 75 years.1 Apart from smoking, the main risk factors for CVD are elevated blood cholesterol, elevated blood pressure, obesity and diabetes, all related to poor eating habits. from olive oil), whole grains, pulses, nuts and fish have consistently shown a protective effect against CVD.2 4
In the United Kingdom and the United States of America, processed foods and fast, takeaway foods are the main dietary sources of excess salt, saturated fats, trans fats and excess calories. In 2001 the Food Standards Agency (FSA) of the United Kingdom began working with industry to develop a range of healthy food strategies,5 including voluntary product reformulation, clearer (traffic light) package labelling of nutrient levels and media campaigns. The FSA’s salt strategy helped reduce the average daily salt intake by nearly 1 g between 2001 and 2008 (from 9.5 to 8.6 g, respectively).6 However, outside the United Kingdom stricter regulatory policies have resulted in much greater reductions.7 For instance, between 1979 and 2002 Finland’s daily average salt intake fell from 12 g to 9 g.7
The FSA’s strategy in the United Kingdom also sought to reduce the daily average intake of saturated fat from 13.3% to 11% of total food energy by 2010,5 yet currently the figure stands at 12.8%.6 Finland and Iceland, on the other hand, reduced saturated fat intake by 5% of total energy in one or two decades.4,8 Furthermore, in the traditional Italian and Japanese diets and the successful DASH and OMNI diets, 6% of total energy comes from saturated fats.9
Dietary industrial trans fats, resulting from the partial hydrogenation of vegetable oils, are particularly toxic. By raising serum low density lipoprotein (LDL or «bad» cholesterol) and reducing high density lipoprotein (HDL or «good» cholesterol), they substantially increase the risk of CHD and stroke.10 The Government of the United Kingdom currently recommends consuming less than 2% of total energy in the form of trans fats. Average trans fat intake for adults in the United Kingdom reportedly represents only 0.8% of total energy consumption.6,11 However, the true value is probably closer to 1% because routine surveys tend to underestimate consumption outside the home, particularly from fast foods. Furthermore, ethnic minorities, low income adults and children probably consume substantially more.12 In contrast, Denmark’s 2004 legislative ban eliminated the consumption of dietary industrial trans fats within a year (from a baseline of 4%).13 Currently Austria, Canada, Iceland, Switzerland and several states in the United States are cheap jerseys aggressively working to eliminate trans fats.10
Finally, the average quantity of fruit and vegetables eaten daily in the United Kingdom has levelled at about 245 g since 2003.6 This is much lower than the pragmatic target of 400 g (five portions) and less than half of the 600 g per day already achieved in much of France, Greece and Italy and now recommended for the entire European Union.14
The FSA reasonably estimated that approximately 7000 CVD deaths would be averted annually if people in the United Kingdom reached the current (modest) dietary targets for saturated fat and trans fats.5,11 However, the potential benefit of more ambitious dietary targets remains unclear. We therefore estimated the potential reduction in CVD mortality achievable in the United Kingdom if stricter, yet feasible food policies were established, as in other countries, to further decrease the intake of salt, saturated fats and trans fats and increase fruit and vegetable consumption.
We first assumed, under the conservative policy scenario, that by 2015 the fraction of total energy derived from trans fats would have decreased by an additional 0.5%. We subsequently assumed, under the aggressive policy scenario, that a legislative ban on industrial trans fats would essentially eliminate their intake, as witnessed in Denmark,13 and would further decrease trans fats intake by approximately 1% of total energy.
We then used the RR from the largest meta analysis to estimate the CVD deaths that would be averted under the aggressive scenario.15 If the 2% total energy derived from industrial trans fats were completely replaced by monounsaturated and polyunsaturated fats, mortality from CHD would drop by approximately 23%.15 Thus, if the total energy derived from trans fats were reduced by 0.5%, the number of CHD deaths would drop by approximately 6%.15
The number of CHD deaths averted under the aggressive scenario was then calculated by multiplying by 0.06 the number of deaths from CHD in the United Kingdom in 2006 in each age group. For example, in 2006 11 947 CHD deaths occurred among men aged 65 to 74 years. The estimated number of CHD deaths averted in this group would thus be approximately:
This process was repeated for all other age groups and for both men and women.
We followed a similar procedure to calculate the number of deaths from stroke potentially averted under the aggressive scenario. If the total energy derived from trans fats were reduced by 0.5%, stroke deaths would be reduced by approximately 3% in both men and women (Appendix B).15
We assumed that by 2015 the fraction of total energy derived from saturated fats would have been reduced by an additional 1% under the conservative policy scenario, and by an additional 3% under the aggressive policy scenario (from an average of 12.8%5,6 to 9.8%). Using summary estimates from Mozaffarian et al.’s meta analysis,16 we determined that replacing the 5% of total energy derived from saturated fats with polyunsaturated fats would reduce CHD mortality by approximately 11.5%.16 However, since complete replacement of saturated fats with polyunsaturated fats would be an unrealistic goal, we assumed that only half of the saturated fat would be replaced by polyunsaturated fat and the other half by monounsaturated fat. from 8.6 to 5.6 g).7 The number of CHD deaths preventable by reducing daily salt intake by 1 g and 3 g was then calculated, as for other nutrients, by multiplying the number of deaths from CHD in the United Kingdom in 2006 by the predicted percentage reduction in CHD deaths. Based on a meta analysis by Strazzullo et al., we determined that reducing daily salt intake by 5 g (equivalent to 2000 mg less sodium per day) would translate into approximately 17% fewer CHD deaths and approximately 23% fewer stroke deaths annually.17
We followed the same procedure to calculate the potential reduction in deaths from stroke. to 500 g or about six portions daily) in the aggressive policy.14
One additional portion http://www.cheapjerseys11.com/ a day would reduce CHD deaths by approximately 4% and stroke deaths by approximately 5%, according to Dauchet et al.18,19 To calculate the CHD deaths averted by one and three additional daily portions of fruit and vegetables, we multiplied the number of CHD deaths observed in 2006 by 0.04 and the number of deaths from stroke by 0.05.
We incorporated age attrition into our model using a method followed by leading cardiovascular epidemiologists.20,21 Specifically, we assumed that the reduction in deaths from CVD associated with a change in the intake of specific macronutrients decreased with age. We modelled this age gradient to mirror the age specific decreases in the risk of death from CVD associated with both hypertension and elevated total cholesterol.20,21
Cumulative effects: Like other researchers,8,16,17 we assumed that simultaneous improvements in the intake of all macronutrients would have a cumulative rather than a merely additive effect on mortality. 1 0.20).
We therefore estimated the total benefit using the following standard formula:Total benefit = 1 [(1 a) (1 b) (1 c) (1 d)]where a, b, c and d represent the percentage reductions in deaths for changes in the intake of salt, saturated fat, trans fats and fruit and vegetables, respectively.8,16,17
All modelling involves uncertainty. We therefore explored the effects of changes in food policy on CVD risk factors and deaths by performing a probabilistic sensitivity analysis. The uncertainty of the hazards ratio and the RR parameters were characterized using a log normal distribution. We performed Monte Carlo simulations, allowing the parameters based on the effect sizes obtained from the literature to vary stochastically. All calculations were performed separately for men and women and were stratified by age. Results were rounded to the nearest hundred and summarized as medians; 95% CIs for the median were generated using the bootstrap percentile method in Stata version 9 (StataCorp. LP, College Station, United States of America).22
Our conservative estimates suggest that modest dietary improvements in the United Kingdom could avert approximately 12 000 annual deaths from CVD by 2015. However, more substantial improvements could avert about 30 000 CVD deaths annually (still fewer than recorded elsewhere). This would represent a 20% reduction in CVD deaths in the United Kingdom, almost one third of which would have occurred prematurely (
The more substantial improvements would probably require more radical policy interventions. In a recent US study, approximately 40% of all premature CVD deaths (in people less than 70 years of age) might be avoided by optimizing various dietary risk factors.23 The modest discrepancies between this study’s findings and ours could well reflect methodological differences, since Danaei et al. optimistically assumed ideal dietary intake targets that practically eliminated the risk factor.23 Two recent US studies on salt reduction also reported comparable mortality decreases, along with impressive cost savings.22,24 Furthermore, comparable cost savings might be confidently anticipated for all population wide dietary improvements.25,26
Our estimate of approximately 4700 fewer CVD deaths following trans fat elimination is also reassuringly close to the 7000 quoted in a recent BMJ editorial.10 The benefit for individuals and ethnic groups with insulin resistance may be even greater.10,15 In Denmark, legislation passed in 2004 banning industrial trans fats resulted in a rapid drop to zero consumption.13 After initial opposition, the EU slowly relented and subsequently discussed a ban across Europe.27 Following Denmark, several countries, including Austria, Canada, Iceland and Switzerland (and several US cities and states), have recently taken steps to reduce or ban industrial trans fats in food.10 Canada was the first country to require that the trans fats levels in pre packaged foods be included on the mandatory nutrition facts table. Though less powerful, labelling regulations inform consumers, motivate industry to reformulate its products and favourably influence social norms. Many manufacturers have now reduced trans fat content.28 In Seattle, a programme to phase out industrial trans fats in fast food outlets encountered surprisingly little opposition from commercial interests; most stakeholders apparently considered it a logical step.29.