Reducing US cardiovascular disease disparities through food policy

Jonathan Pearson-Stuttard, Piotr Bandosz, Colin Rehm, Jose Penalvo, Laurie Whitsel, Tom Gaziano,

Ffion Lloyd-Williams, Simon, Capewell, DariushMozaffarian, Martin O’Flaherty

Universities of Liverpool, Imperial College London, Harvard & Tufts

Cardiovascular Disease• Huge burden of disease in US and globally

• Mortality rates halved over three decades

• 1.6m CVD cases annually

• 500,000 CVD deaths per year

• Projected 116 million individuals will be coping with CVD by 2030

• Unequal burden, more in deprived & ethnic minorities

Heidenreich et al Circulation 2011

Cardiovascular Disease

• Major Risk Factors:• Diet: added sugar, Fruit & Veg, Salt, Trans Fats

• Tobacco

• Excess Alcohol

• Physical Inactivity

• Potential effectiveness of F&V policies poorly documented

• Potential benefits of population level policies poorly documented

• ↑ 100g daily intake • ↓CHD mortality 1.3-6.1%

• ↓Stroke mortality 1.7-14.4%

BUT

• Potential effectiveness of F&V policies poorly documented

(particularly population level policies)

Fruits & Vegetable benefits

Khatibzadehet al Circulation 2012

Sugar Sweetened Beverages (SSB)

• Consumption falls with age:• 2.8 servings a day (young men)

• 0.4 servings a day (elderly women)

• SSB price increases successfully implemented Mexico, France, Berkeley

BUT

• Potential benefits upon disparities poorly estimated

Bartlet et al, USDA, 2014Conrad et al, in submission

• Aims to prevent food insecurity & hunger and promote diet quality

• Gives food stamps to 46million Americans

BUT

• SNAP recipients have worse cardio-metabolic health than non-eligible population

HENCE

• Healthy Incentive Pilot (HIP)• fruits & veg 30% price cheaper when purchased using EBT card

• Consumption ↑ 27%

Supplemental Nutrition Assistance Programme(SNAP)

Objective

• Estimate effect of• Price changes

• Mass Media Campaign targeting fruits, vegetables and SSB consumption

• on CVD mortality & disparities• in the USA up to 2030

• Stratified by • Age & gender

• SNAP group (proxy for socio-economic status)

Methods• Quantified the population benefits and effects upon

disparities 2015-2030 of contrasting food policiesA) NationalB) Targeting high risk groups

A+B) Combined Approach (National +Targeting high risk groups)

• Estimated cumulative Deaths Prevented or Postponed (DPP)

• Stratified by• age• Gender• SNAP group (SES proxy)• CVD subtype

Dietary policy options to address CVD and disparities?

A. National policies1. Media campaigns

2. SSB tax (10%)

3. Small subsidy on healthy foods (fruits & veg) (10%)

B. Targeted policies• Most deprived groups receive larger subsidy (30%) on healthy foods

A+B = combination of national and targeted policies

Mass Media Campaign

• Mass media campaign ↑ F&V intake by 7% (4%-11%)

Assumed:• Full effect in 2016

• Continued effect to 2030

Afshin et al, In submission

Price Reduction Policies (Subsidies)

• 10% national price reduction ↑ F&V consumption by 14% (11-17%)

Assumed:

• 50% larger effect in most deprived group v. most affluent

• Full effect in baseline year (2015)

• Effect continues to 2030

• 30% targeted price reduction ↑ F&V consumption by 27%

Afshin et al, In submission Bartlet et al, USDA, 2014

Price Increase (Tax)

• 10% national price increase ↓ SSB consumption by 7% (3-10%)

Assumed:

• 50% larger effect in most deprived v most affluent

• Full effect in baseline year (2015)

• Effect continues to 2030

Afshin et al, In submission

Food policy modelling approach

Risk Factor ChangeCVD

Mortality

ChangeFoodPolicy

↑ F&V consumption e.g.

F&V Price reduction

CVD deaths

13

Stratified by age, gender, SES & CVD

subtype

Results

Deaths averted 2015-2030(heart disease and stroke)

Deaths averted 2015-2030(heart disease and stroke)

Deaths averted 2015-2030(heart disease and stroke)

Effects onDisparities?

Types of policy?

• High risk targeted policies?

• Or

• Whole population approach?

• Or Combination

Strengths

• Considers entire US adult population (200 million)

• Reliable datasets

• Novel policy modelling of population level intervention

• Stratification by SES

• APC mortality projections may provide conservative estimates of benefits

Limitations

BUT

• Risk estimates are imperfect

• Coverage not stratified by age or gender

• Assumes instantaneous effect

• No cost estimates

Conclusions

• All policies modelled would reduce CVD mortality

• Targeted subsidy would achieve greatest reduction in disparities

• Combined approach → big reductions in mortality AND disparities

• Cost effectiveness research now required

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Reducing US cardiovascular disease disparities through food policy

Jonathan Pearson-Stuttard, Piotr Bandosz, Colin Rehm, Jose Penalvo, Laurie Whitsel, Tom Gaziano,

Ffion Lloyd-Williams, Simon, Capewell, DariushMozaffarian, Martin O’Flaherty

Thank youj.pearson-stuttard@imperial.ac.uk