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. 2023 Dec;29(37):1–32. doi: 10.3310/NMFG0214

The potential impact of policies and structural interventions in reducing cardiovascular disease and mortality: a systematic review of simulation-based studies.

Olalekan A Uthman, Rachel Court, Seun Anjorin, Jodie Enderby, Lena Al-Khudairy, Chidozie Nduka, Hema Mistry, G J Melendez-Torres, Sian Taylor-Phillips, Aileen Clarke
PMCID: PMC12434559  PMID: 38140927

Abstract

BACKGROUND

The aim of the study was to investigate the potential effect of different structural interventions for preventing cardiovascular disease.

METHODS

Medline and EMBASE were searched for peer-reviewed simulation-based studies of structural interventions for prevention of cardiovascular disease. We performed a systematic narrative synthesis.

RESULTS

A total of 54 studies met the inclusion criteria. Diet, nutrition, tobacco and alcohol control and other programmes are among the policy simulation models explored. Food tax and subsidies, healthy food and lifestyles policies, palm oil tax, processed meat tax, reduction in ultra-processed foods, supplementary nutrition assistance programmes, stricter food policy and subsidised community-supported agriculture were among the diet and nutrition initiatives. Initiatives to reduce tobacco and alcohol use included a smoking ban, a national tobacco control initiative and a tax on alcohol. Others included the NHS Health Check, WHO 25 × 25 and air quality management policy.

FUTURE WORK AND LIMITATIONS

There is significant heterogeneity in simulation models, making comparisons of output data impossible. While policy interventions typically include a variety of strategies, none of the models considered possible interrelationships between multiple policies or potential interactions. Research that investigates dose-response interactions between numerous modifications as well as longer-term clinical outcomes can help us better understand the potential impact of policy-level interventions.

CONCLUSIONS

The reviewed studies underscore the potential of structural interventions in addressing cardiovascular diseases. Notably, interventions in areas such as diet, tobacco, and alcohol control demonstrate a prospective decrease in cardiovascular incidents. However, to realize the full potential of such interventions, there is a pressing need for models that consider the interplay and cumulative impacts of multiple policies. Rigorous research into holistic and interconnected interventions will pave the way for more effective policy strategies in the future.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42019154836.

FUNDING

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/148/05.

Plain language summary

This study aimed to explore the potential effects of various policy changes on the prevention of heart disease. By searching two large medical databases, we identified studies that employed computer models to estimate the impact of these policies on heart disease rates. In total, 54 studies matched our criteria. These studies considered a diverse range of policy interventions. Some delved into food and nutrition, investigating aspects like unhealthy food taxes, healthy food subsidies, stricter food regulations, and nutritional assistance programs. Others examined the impact of policies targeting tobacco and alcohol, encompassing smoking bans, nationwide tobacco control measures, and alcohol taxation. Further policies assessed included routine health checkups, global health goals, and measures to enhance air quality. One significant challenge lies in the varied approaches and models each study employed, making direct comparisons difficult. Furthermore, there's a gap in understanding how these policies might influence one another, as the studies did not consider potential interactions between them. While these policies show promise in the computer models, more comprehensive research is needed to fully appreciate their combined and long-term effects on heart health in real-world scenarios. As of now, we recognize the potential of these interventions, but further studies will determine their true impact on reducing heart disease rates.

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References

  1. BHF. Facts and Figures. 2022. URL: https://www.bhf.org.uk/what-we-do/news-from-the-bhf/contact-the-press-office/facts-and-figures#:~:text=Heart%20and%20circulatory%20diseases%20cause,men%20and%203.6%20million%20women (accessed 20 January 2023).
  2. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. Global burden of cardiovascular diseases and risk factors, 1990–2019: update from the GBD 2019 study. J Am Coll Cardiol 2020;76:2982–3021. https://doi.org/10.1016/j.jacc.2020.11.010 doi: 10.1016/j.jacc.2020.11.010. [DOI] [PMC free article] [PubMed]
  3. Feigin VL, Brainin M, Norrving B, Gorelick PB, Dichgans M, Wang W, et al. What is the best mix of population-wide and high-risk targeted strategies of primary stroke and cardiovascular disease prevention? J Am Heart Assoc 2020;9:e014494. https://doi.org/10.1161/jaha.119.014494 doi: 10.1161/JAHA.119.014494. [DOI] [PMC free article] [PubMed]
  4. Freebairn L, Atkinson J, Kelly P, McDonnell G, Rychetnik L. Simulation modelling as a tool for knowledge mobilisation in health policy settings: a case study protocol. Health Res Policy Syst 2016;14:71. https://doi.org/10.1186/s12961-016-0143-y doi: 10.1186/s12961-016-0143-y. [DOI] [PMC free article] [PubMed]
  5. Salleh S, Thokala P, Brennan A, Hughes R, Booth A. Simulation modelling in healthcare: an umbrella review of systematic literature reviews. PharmacoEconomics 2017;35:937–49. https://doi.org/10.1007/s40273-017-0523-3 doi: 10.1007/s40273-017-0523-3. [DOI] [PubMed]
  6. Xue H, Slivka L, Igusa T, Huang TT, Wang Y. Applications of systems modelling in obesity research. Obes Rev 2018;19:1293–308. https://doi.org/10.1111/obr.12695 doi: 10.1111/obr.12695. [DOI] [PubMed]
  7. Eddy DM, Hollingworth W, Caro JJ, Tsevat J, McDonald KM, Wong JB; ISPOR−SMDM Modeling Good Research Practices Task Force. Model transparency and validation: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force–7. Value Health 2012;15:843–50. https://doi.org/10.1016/j.jval.2012.04.012 doi: 10.1016/j.jval.2012.04.012. [DOI] [PubMed]
  8. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilisation of health research in policy-making: concepts, examples and methods of assessment. Health Res Policy Syst 2003;1:2. https://doi.org/10.1186/1478-4505-1-2 doi: 10.1186/1478-4505-1-2. [DOI] [PMC free article] [PubMed]
  9. Moberg J, Oxman AD, Rosenbaum S, Schünemann HJ, Guyatt G, Flottorp S, et al.; GRADE Working Group. The GRADE Evidence to Decision (EtD) framework for health system and public health decisions. Health Res Policy Syst 2018;16:45. https://doi.org/10.1186/s12961-018-0320-2 doi: 10.1186/s12961-018-0320-2. [DOI] [PMC free article] [PubMed]
  10. Meyers DG, Neuberger JS, He J. Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis. J Am Coll Cardiol 2009;54:1249–55. https://doi.org/10.1016/j.jacc.2009.07.022 doi: 10.1016/j.jacc.2009.07.022. [DOI] [PubMed]
  11. Downs SM, Bloem MZ, Zheng M, Catterall E, Thomas B, Veerman L, Wu Jason HY. The impact of policies to reduce trans fat consumption: a systematic review of the evidence. Curr Dev Nutr 2017;1:cdn.117.000778. https://doi.org/10.3945/cdn.117.000778 doi: 10.3945/cdn.117.000778. [DOI] [PMC free article] [PubMed]
  12. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev 2021;10:89. https://doi.org/10.1186/s13643-021-01626-4 doi: 10.1186/s13643-021-01626-4. [DOI] [PMC free article] [PubMed]
  13. Lee Y, Mozaffarian D, Sy S, Liu J, Wilde PE, Marklund M, et al. Health impact and cost-effectiveness of volume, tiered, and absolute sugar content sugar-sweetened beverage tax policies in the United States: a microsimulation study. Circulation 2020;142:523–34. https://doi.org/10.1161/circulationaha.119.042956 doi: 10.1161/CIRCULATIONAHA.119.042956. [DOI] [PMC free article] [PubMed]
  14. Liu J, Mozaffarian D, Sy S, Lee Y, Wilde PE, Abrahams-Gessel S, et al.; FOOD-PRICE (Policy Review and Intervention Cost-Effectiveness) Project. Health and economic impacts of the National Menu Calorie Labeling Law in the United States: a microsimulation study. Circ Cardiovasc Qual Outcomes 2020;13:e006313. https://doi.org/10.1161/circoutcomes.119.006313 doi: 10.1161/CIRCOUTCOMES.119.006313. [DOI] [PMC free article] [PubMed]
  15. Mozaffarian D, Liu J, Sy S, Huang Y, Rehm C, Lee Y, et al. Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the US Supplemental Nutrition Assistance Program (SNAP): a microsimulation study. PLOS Med 2018;15:e1002661. https://doi.org/10.1371/journal.pmed.1002661 doi: 10.1371/journal.pmed.1002661. [DOI] [PMC free article] [PubMed]
  16. Wilde P, Huang Y, Sy S, Abrahams-Gessel S, Jardim TV, Paarlberg R, et al. Cost-effectiveness of a US national sugar-sweetened beverage tax with a multistakeholder approach: who pays and who benefits. Am J Public Health 2019;109:276–84. https://doi.org/10.2105/ajph.2018.304803 doi: 10.2105/AJPH.2018.304803. [DOI] [PMC free article] [PubMed]
  17. Wilde P, Huang Y, Sy S, Abrahams-Gessel S, Jardim TV, Paarlberg R, et al. Abstract P229: cost-effectiveness of a US national sugar-sweetened beverage tax using a multi-stakeholder approach. Circulation 2018;137:AP229-AP. https://doi.org/10.1161/circ.137.suppl_1.p229
  18. Collins M, Mason H, O’Flaherty M, Guzman-Castillo M, Critchley J, Capewell S. An economic evaluation of salt reduction policies to reduce coronary heart disease in England: a policy modeling study. Value Health 2014;17:517–24. https://doi.org/10.1016/j.jval.2014.03.1722 doi: 10.1016/j.jval.2014.03.1722. [DOI] [PubMed]
  19. Gillespie DO, Allen K, Guzman-Castillo M, Bandosz P, Moreira P, McGill R, et al. The health equity and effectiveness of policy options to reduce dietary salt intake in England: policy forecast. PLOS ONE 2015;10:e0127927. https://doi.org/10.1371/journal.pone.0127927 doi: 10.1371/journal.pone.0127927. [DOI] [PMC free article] [PubMed]
  20. Kypridemos C, Collins B, McHale P, Bromley H, Parvulescu P, Capewell S, O’Flaherty M. Future cost-effectiveness and equity of the NHS Health Check cardiovascular disease prevention programme: Microsimulation modelling using data from Liverpool, UK. PLOS Med 2018;15:e1002573. https://doi.org/10.1371/journal.pmed.1002573 doi: 10.1371/journal.pmed.1002573. [DOI] [PMC free article] [PubMed]
  21. Kypridemos C, Guzman-Castillo M, Hyseni L, Hickey GL, Bandosz P, Buchan I, et al. Estimated reductions in cardiovascular and gastric cancer disease burden through salt policies in England: an IMPACTNCD microsimulation study. BMJ Open 2017;7:e013791. https://doi.org/10.1136/bmjopen-2016-013791 doi: 10.1136/bmjopen-2016-013791. [DOI] [PMC free article] [PubMed]
  22. Moreira PV, Baraldi LG, Moubarac JC, Monteiro CA, Newton A, Capewell S, O’Flaherty M. Comparing different policy scenarios to reduce the consumption of ultra-processed foods in UK: impact on cardiovascular disease mortality using a modelling approach. PLOS ONE 2015;10:e0118353. https://doi.org/10.1371/journal.pone.0118353 doi: 10.1371/journal.pone.0118353. [DOI] [PMC free article] [PubMed]
  23. O’Keeffe C, Kabir Z, O’Flaherty M, Walton J, Capewell S, Perry IJ. Modelling the impact of specific food policy options on coronary heart disease and stroke deaths in Ireland. BMJ Open 2013;3:e002837. https://doi.org/10.1136/bmjopen-2013-002837 doi: 10.1136/bmjopen-2013-002837. [DOI] [PMC free article] [PubMed]
  24. Seferidi P, Laverty AA, Pearson-Stuttard J, Guzman-Castillo M, Collins B, Capewell S, et al. Implications of Brexit on the effectiveness of the UK soft drinks industry levy upon CHD in England: a modelling study. Public Health Nutr 2018;21:3431–9. https://doi.org/10.1017/s1368980018002367 doi: 10.1017/S1368980018002367. [DOI] [PMC free article] [PubMed]
  25. Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007;370:2044–53. https://doi.org/10.1016/s0140-6736(07)61698-5 doi: 10.1016/S0140-6736(07)61698-5. [DOI] [PubMed]
  26. Basu S, O’Neill J, Sayer E, Petrie M, Bellin R, Berkowitz SA. Population health impact and cost-effectiveness of community-supported agriculture among low-income US adults: a microsimulation analysis. Am J Public Health 2020;110:119–26. https://doi.org/10.2105/ajph.2019.305364 doi: 10.2105/AJPH.2019.305364. [DOI] [PMC free article] [PubMed]
  27. Basu S, Babiarz KS, Ebrahim S, Vellakkal S, Stuckler D, Goldhaber-Fiebert JD. Palm oil taxes and cardiovascular disease mortality in India: economic-epidemiologic model. BMJ 2013;347:f6048. https://doi.org/10.1136/bmj.f6048 doi: 10.1136/bmj.f6048. [DOI] [PMC free article] [PubMed]
  28. Basu S, Glantz S, Bitton A, Millett C. The effect of tobacco control measures during a period of rising cardiovascular disease risk in India: a mathematical model of myocardial infarction and stroke. PLOS Med 2013;10:e1001480. https://doi.org/10.1371/journal.pmed.1001480 doi: 10.1371/journal.pmed.1001480. [DOI] [PMC free article] [PubMed]
  29. Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A, Lightwood JM, Pletcher MJ, Goldman L. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362:590–9. https://doi.org/10.1056/NEJMoa0907355 doi: 10.1056/NEJMoa0907355. [DOI] [PMC free article] [PubMed]
  30. Choi SE, Brandeau ML, Basu S. Expansion of the national salt reduction initiative: a mathematical model of benefits and risks of population-level sodium reduction. Med Decis Making 2016;36:72–85. https://doi.org/10.1177/0272989x15583846 doi: 10.1177/0272989X15583846. [DOI] [PMC free article] [PubMed]
  31. Choi SE, Seligman H, Basu S. Cost effectiveness of subsidizing fruit and vegetable purchases through the supplemental nutrition assistance program. Am J Prev Med 2017;52:e147–55. https://doi.org/10.1016/j.amepre.2016.12.013 doi: 10.1016/j.amepre.2016.12.013. [DOI] [PMC free article] [PubMed]
  32. Cobiac LJ, Scarborough P. Translating the WHO 25 × 25 goals into a UK context: the PROMISE modelling study. BMJ Open 2017;7:e012805. https://doi.org/10.1136/bmjopen-2016-012805 doi: 10.1136/bmjopen-2016-012805. [DOI] [PMC free article] [PubMed]
  33. Dehmer SP, Cogswell ME, Ritchey MD, Hong Y, Maciosek MV, LaFrance AB, Roy K. Health and budgetary impact of achieving 10-year U.S. sodium reduction targets. Am J Prev Med 2020;59:211–8. https://doi.org/10.1016/j.amepre.2020.03.010 doi: 10.1016/j.amepre.2020.03.010. [DOI] [PMC free article] [PubMed]
  34. Dilley JA, Harris JR, Boysun MJ, Reid TR. Program, policy, and price interventions for tobacco control: quantifying the return on investment of a state tobacco control program. Am J Public Health 2012;102:e22–8. https://doi.org/10.2105/ajph.2011.300506 doi: 10.2105/AJPH.2011.300506. [DOI] [PMC free article] [PubMed]
  35. Han C, Lim YH, Yorifuji T, Hong YC. Air quality management policy and reduced mortality rates in Seoul metropolitan area: a quasi-experimental study. Environ Int 2018;121:600–9. https://doi.org/10.1016/j.envint.2018.09.047 doi: 10.1016/j.envint.2018.09.047. [DOI] [PubMed]
  36. Homer J, Milstein B, Wile K, Trogdon J, Huang P, Labarthe D, Orenstein D. Simulating and evaluating local interventions to improve cardiovascular health. Prev Chronic Dis 2010;7:A18. [PMC free article] [PubMed]
  37. Hurley SF, Matthews JP. Cost-effectiveness of the Australian National Tobacco Campaign. Tob Control 2008;17:379–84. https://doi.org/10.1136/tc.2008.025213 doi: 10.1136/tc.2008.025213. [DOI] [PubMed]
  38. Konfino J, Mekonnen TA, Coxson PG, Ferrante D, Bibbins-Domingo K. Projected impact of a sodium consumption reduction initiative in Argentina: an analysis from the CVD policy model–Argentina. PLOS ONE 2013;8:e73824. https://doi.org/10.1371/journal.pone.0073824 doi: 10.1371/journal.pone.0073824. [DOI] [PMC free article] [PubMed]
  39. Konfino J, Ferrante D, Mejia R, Coxson P, Moran A, Goldman L, Pérez-Stable EJ. Impact on cardiovascular disease events of the implementation of Argentina’s national tobacco control law. Tob Control 2014;23:e6. https://doi.org/10.1136/tobaccocontrol-2012-050599 doi: 10.1136/tobaccocontrol-2012-050599. [DOI] [PMC free article] [PubMed]
  40. Lloyd-Williams F, O’Flaherty M, Mwatsama M, Birt C, Ireland R, Capewell S. Estimating the cardiovascular mortality burden attributable to the European Common Agricultural Policy on dietary saturated fats. Bull World Health Organ 2008;86:535–41a. https://doi.org/10.2471/blt.08.053728 doi: 10.2471/BLT.08.053728. [DOI] [PMC free article] [PubMed]
  41. Manyema M, Veerman LJ, Tugendhaft A, Labadarios D, Hofman KJ. Modelling the potential impact of a sugar-sweetened beverage tax on stroke mortality, costs and health-adjusted life years in South Africa. BMC Public Health 2016;16:405. https://doi.org/10.1186/s12889-016-3085-y doi: 10.1186/s12889-016-3085-y. [DOI] [PMC free article] [PubMed]
  42. Marklund M, Zheng M, Veerman JL, Wu JHY. Estimated health benefits, costs, and cost-effectiveness of eliminating industrial trans-fatty acids in Australia: a modelling study. PLOS Med 2020;17:e1003407. https://doi.org/10.1371/journal.pmed.1003407 doi: 10.1371/journal.pmed.1003407. [DOI] [PMC free article] [PubMed]
  43. Mason H, Shoaibi A, Ghandour R, O’Flaherty M, Capewell S, Khatib R, et al.; MedCHAMPS project team. A cost effectiveness analysis of salt reduction policies to reduce coronary heart disease in four Eastern Mediterranean countries. PLOS ONE 2014;9:e84445. https://doi.org/10.1371/journal.pone.0084445 doi: 10.1371/journal.pone.0084445. [DOI] [PMC free article] [PubMed]
  44. Mekonnen TA, Odden MC, Coxson PG, Guzman D, Lightwood J, Wang YC, Bibbins-Domingo K. Health benefits of reducing sugar-sweetened beverage intake in high risk populations of California: results from the cardiovascular disease (CVD) policy model. PLOS ONE 2013;8:e81723. https://doi.org/10.1371/journal.pone.0081723 doi: 10.1371/journal.pone.0081723. [DOI] [PMC free article] [PubMed]
  45. Ni Mhurchu C, Eyles H, Genc M, Scarborough P, Rayner M, Mizdrak A, et al. Effects of health-related food taxes and subsidies on mortality from diet-related disease in New Zealand: an econometric-epidemiologic modelling study. PLOS ONE 2015;10:e0128477. https://doi.org/10.1371/journal.pone.0128477 doi: 10.1371/journal.pone.0128477. [DOI] [PMC free article] [PubMed]
  46. Nilson EAF, Metlzer AB, Labonté ME, Jaime PC. Modelling the effect of compliance with WHO salt recommendations on cardiovascular disease mortality and costs in Brazil. PLOS ONE 2020;15:e0235514. https://doi.org/10.1371/journal.pone.0235514 doi: 10.1371/journal.pone.0235514. [DOI] [PMC free article] [PubMed]
  47. Nnoaham KE, Sacks G, Rayner M, Mytton O, Gray A. Modelling income group differences in the health and economic impacts of targeted food taxes and subsidies. Int J Epidemiol 2009;38:1324–33. https://doi.org/10.1093/ije/dyp214 doi: 10.1093/ije/dyp214. [DOI] [PubMed]
  48. O’Flaherty M, Flores-Mateo G, Nnoaham K, Lloyd-Williams F, Capewell S. Potential cardiovascular mortality reductions with stricter food policies in the United Kingdom of Great Britain and Northern Ireland. Bull World Health Organ 2012;90:522–31. https://doi.org/10.2471/blt.11.092643 doi: 10.2471/BLT.11.092643. [DOI] [PMC free article] [PubMed]
  49. Pearson-Stuttard J, Bandosz P, Rehm CD, Penalvo J, Whitsel L, Gaziano T, et al. Reducing US cardiovascular disease burden and disparities through national and targeted dietary policies: a modelling study. PLOS Med 2017;14:e1002311. https://doi.org/10.1371/journal.pmed.1002311 doi: 10.1371/journal.pmed.1002311. [DOI] [PMC free article] [PubMed]
  50. Pearson-Stuttard J, Bandosz P, Rehm CD, Afshin A, Peñalvo JL, Whitsel L, et al. Comparing effectiveness of mass media campaigns with price reductions targeting fruit and vegetable intake on US cardiovascular disease mortality and race disparities. Am J Clin Nutr 2017;106:199–206. https://doi.org/10.3945/ajcn.116.143925 doi: 10.3945/ajcn.116.143925. [DOI] [PMC free article] [PubMed]
  51. Eom H, Yi SS, Bu D, Russo R, Bellows B, Zhang Y, et al. Abstract MP76: assessing the impact of the ‘Health Bucks’ program on cardiovascular disease in New York city: a modeling study. Circulation 2020;141:AMP76–AMP. https://doi.org/10.1161/circ.141.suppl_1.MP76
  52. Garney WR, Garcia KM. Abstract P003: evaluating comprehensive smoke free policy at the community level using systems modeling. Circulation 2019;139:AP003-AP. https://doi.org/10.1161/circ.139.suppl_1.P003
  53. Sy S, Peñalvo J, Abrahams-Gessel S, Alam S, Pandya A, Mozaffarian D, et al. Abstract P280: changes in food prices improve Cardiovascular Disease (CVD) outcomes. Circulation 2016;133:AP280-AP. https://doi.org/10.1161/circ.133.suppl_1.p280
  54. Pearson-Stuttard J, Kypridemos C, Collins B, Mozaffarian D, Huang Y, Bandosz P, et al. Estimating the health and economic effects of the proposed US Food and Drug Administration voluntary sodium reformulation: Microsimulation cost-effectiveness analysis. PLOS Med 2018;15:e1002551. https://doi.org/10.1371/journal.pmed.1002551 doi: 10.1371/journal.pmed.1002551. [DOI] [PMC free article] [PubMed]
  55. Mejia R, Ferrante D, Perez-Stable EJ, Bibbins-Domingo K, Coxson P, Goldman L, et al. Projected effect of dietary salt reductions on future cardiovascular disease in Argentina Conference: 34th Annual Meeting of the Society of General Internal Medicine. Phoenix, AZ, United States. Conference Publication: (var. pagings). J Gen Intern Med 2011;26(Suppl. 1):S238. https://doi.org/10.1007/s11606-011-1730-9
  56. Pearson-Stuttard J, Bnadosz P, Rehm CD, Afshin A, Penalvo J, Whitsel L, et al. Abstract P281: comparing the impact of price change and mass media campaigns in reducing cardiovascular disease mortality and disparities in the US. Circulation 2016;133:AP281-AP. https://doi.org/10.1161/circ.133.suppl_1.p281
  57. Peñalvo JL, Cudhea F, Micha R, Rehm CD, Afshin A, Whitsel L, et al. The potential impact of food taxes and subsidies on cardiovascular disease and diabetes burden and disparities in the United States. BMC Med 2017;15:208. https://doi.org/10.1186/s12916-017-0971-9 doi: 10.1186/s12916-017-0971-9. [DOI] [PMC free article] [PubMed]
  58. Purshouse RC, Meier PS, Brennan A, Taylor KB, Rafia R. Estimated effect of alcohol pricing policies on health and health economic outcomes in England: an epidemiological model. Lancet 2010;375:1355–64. https://doi.org/10.1016/s0140-6736(10)60058-x doi: 10.1016/S0140-6736(10)60058-X. [DOI] [PubMed]
  59. Sahan C, Sozmen K, Unal B, O’Flaherty M, Critchley J. Potential benefits of healthy food and lifestyle policies for reducing coronary heart disease mortality in Turkish adults by 2025: a modelling study. BMJ Open 2016;6:e011217. https://doi.org/10.1136/bmjopen-2016-011217 doi: 10.1136/bmjopen-2016-011217. [DOI] [PMC free article] [PubMed]
  60. Salgado MV, Penko J, Fernandez A, Konfino J, Coxson PG, Bibbins-Domingo K, Mejia R. Projected impact of a reduction in sugar-sweetened beverage consumption on diabetes and cardiovascular disease in Argentina: a modeling study. PLOS Med 2020;17:e1003224. https://doi.org/10.1371/journal.pmed.1003224 doi: 10.1371/journal.pmed.1003224. [DOI] [PMC free article] [PubMed]
  61. Sánchez-Romero LM, Penko J, Coxson PG, Fernández A, Mason A, Moran AE, et al. Projected impact of Mexico’s sugar-sweetened beverage tax policy on diabetes and cardiovascular disease: a modeling study. PLOS Med 2016;13:e1002158. https://doi.org/10.1371/journal.pmed.1002158 doi: 10.1371/journal.pmed.1002158. [DOI] [PMC free article] [PubMed]
  62. Schönbach JK, Thiele S, Lhachimi SK. What are the potential preventive population-health effects of a tax on processed meat? A quantitative health impact assessment for Germany. Prev Med 2019;118:325–31. https://doi.org/10.1016/j.ypmed.2018.11.011 doi: 10.1016/j.ypmed.2018.11.011. [DOI] [PubMed]
  63. Smith-Spangler CM, Juusola JL, Enns EA, Owens DK, Garber AM. Population strategies to decrease sodium intake and the burden of cardiovascular disease: a cost-effectiveness analysis. Ann Intern Med 2010;152:481–7, w170–3. https://doi.org/10.7326/0003-4819-152-8-201004200-00212 doi: 10.7326/0003-4819-152-8-201004200-00212. [DOI] [PubMed]
  64. Vega-Solano J, Blanco-Metzler A, Madriz-Morales K, Fernandes-Nilson EA, Labonté ME. Impact of salt intake reduction on CVD mortality in Costa Rica: a scenario modelling study. PLOS ONE 2021;16:e0245388. https://doi.org/10.1371/journal.pone.0245388 doi: 10.1371/journal.pone.0245388. [DOI] [PMC free article] [PubMed]
  65. Wang M, Moran AE, Liu J, Coxson PG, Penko J, Goldman L, et al. Projected impact of salt restriction on prevention of cardiovascular disease in China: a modeling study. PLOS ONE 2016;11:e0146820. https://doi.org/10.1371/journal.pone.0146820 doi: 10.1371/journal.pone.0146820. [DOI] [PMC free article] [PubMed]
  66. Kheirbek I, Haney J, Douglas S, Ito K, Caputo S Jr, Matte T. The public health benefits of reducing fine particulate matter through conversion to cleaner heating fuels in New York City. Environ Sci Technol 2014;48:13573–82. https://doi.org/10.1021/es503587p doi: 10.1021/es503587p. [DOI] [PubMed]
  67. Salgado MV, O’Flaherty M, Mejía R. The role of computer simulation models in the design of public policies. Medicina (B Aires) 2020;80:681–4. [PubMed]
  68. Egger M, Moons KGM, Fletcher CG. GetReal: from efficacy in clinical trials to relative effectiveness in the real world. Res Synth Methods 2016;7:278–81. https://doi.org/10.1002/jrsm.1207 doi: 10.1002/jrsm.1207. [DOI] [PubMed]
  69. Eichler H-G, Abadie E, Breckenridge A, Flamion B, Gustafsson LL, Leufkens H, et al. Bridging the efficacy-effectiveness gap: a regulator’s perspective on addressing variability of drug response. Nat Rev Drug Discovery 2011;10:495–506. https://doi.org/10.1038/nrd3501 doi: 10.1038/nrd3501. [DOI] [PubMed]
  70. Garnett GP, Cousens S, Hallett TB, Steketee R, Walker N. Mathematical models in the evaluation of health programmes. Lancet 2011;378:515–25. https://doi.org/10.1016/s0140-6736(10)61505-x doi: 10.1016/S0140-6736(10)61505-X. [DOI] [PubMed]
  71. Weinstein MC, Toy EL, Sandberg EA, Neumann PJ, Evans JS, Kuntz KM, et al. Modeling for health care and other policy decisions: uses, roles, and validity. Value Health 2001;4:348–61. https://doi.org/10.1046/j.1524-4733.2001.45061.x doi: 10.1046/j.1524-4733.2001.45061.x. [DOI] [PubMed]
  72. Victora CG, Habicht JP, Bryce J. Evidence-based public health: moving beyond randomized trials. Am J Public Health 2004;94:400–5. https://doi.org/10.2105/ajph.94.3.400 doi: 10.2105/ajph.94.3.400. [DOI] [PMC free article] [PubMed]
  73. Boyko EJ. Observational research–opportunities and limitations. J Diabetes Complications 2013;27:642–8. https://doi.org/10.1016/j.jdiacomp.2013.07.007 doi: 10.1016/j.jdiacomp.2013.07.007. [DOI] [PMC free article] [PubMed]
  74. Gueyffier F, Cucherat M. The limitations of observation studies for decision making regarding drugs efficacy and safety. Therapie 2019;74:181–5. https://doi.org/10.1016/j.therap.2018.11.001 doi: 10.1016/j.therap.2018.11.001. [DOI] [PubMed]
  75. Lipsitch M, Tchetgen Tchetgen E, Cohen T. Negative controls: a tool for detecting confounding and bias in observational studies. Epidemiology 2010;21:383–8. https://doi.org/10.1097/EDE.0b013e3181d61eeb doi: 10.1097/EDE.0b013e3181d61eeb. [DOI] [PMC free article] [PubMed]
  76. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al.; American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic impact goal through 2020 and beyond. Circulation 2010;121:586–613. https://doi.org/10.1161/circulationaha.109.192703 doi: 10.1161/CIRCULATIONAHA.109.192703. [DOI] [PubMed]
  77. Metelli S, Chaimani A. Challenges in meta-analyses with observational studies. Evid Based Ment Health 2020;23:83–7. https://doi.org/10.1136/ebmental-2019-300129 doi: 10.1136/ebmental-2019-300129. [DOI] [PMC free article] [PubMed]

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