Imperial College London

ProfessorChristopherMillett

Faculty of MedicineSchool of Public Health

Professor of Public Health
 
 
 
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Contact

 

c.millett Website

 
 
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Location

 

Reynolds BuildingCharing Cross Campus

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Summary

 

Publications

Publication Type
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309 results found

Parnham J, Chang C-M, Rauber F, Levy RB, Millett C, Laverty AA, von Hinke S, Vamos EPet al., 2022, The ultra-processed food content of school meals and packed lunches in the United Kingdom, Nutrients, ISSN: 2072-6643

British children have the highest levels of ultra-processed food (UPF) consumption in Europe. Schools are posited as a positive setting for impacting dietary intake but the level of UPFs consumed at schools is currently unknown. This study determined the UPF content of school food in the UK. We conducted a pooled cross-sectional analysis of primary (4-11 years, n=1,895) and secondary schoolchildren (11-18 years, n=1,408) from the UK’s National Diet and Nutrition Survey (2008-2017). Multivariable quantile regression models determined the association between meal-type (school meal or packed lunch) and lunchtime UPF intake (NOVA food classification system). We showed that on average UPF intake was high in both primary (72.6% total lunch Kcal) and secondary schoolchildren (77.8 % total lunch Kcal). Higher UPF intakes were observed in packed lunch consumers, secondary schoolchildren, and those in lower income households. This study highlights the need for a renewed focus on school food. Better guidance and policies which consider levels of industrial processing in food served in schools is needed to ensure the dual benefit of encouraging school meal uptake and equitably improving children’s diet.

Journal article

Radó MK, van Lenthe FJ, Laverty AA, Filippidis FT, Millett C, Sheikh A, Been JVet al., 2022, Effect of comprehensive smoke-free legislation on neonatal mortality and infant mortality across 106 middle-income countries: a synthetic control study, The Lancet Public Health, Vol: 7, Pages: 1-10, ISSN: 2468-2667

BackgroundThere are few quantitative studies into the effect of comprehensive smoke-free legislation on neonatal and infant mortality in middle-income countries. We aimed to estimate the effects of implementing comprehensive smoke-free legislation on neonatal mortality and infant mortality across all middle-income countries.MethodsWe applied the synthetic control method using 1990–2018 country-level panel data for 106 middle-income countries from the WHO, World Bank, and Penn World datasets. Outcome variables were neonatal (age 0–28 days) mortality and infant (age 0–12 months) mortality rates per 1000 livebirths per year. For each middle-income country with comprehensive smoke-free legislation, a synthetic control country was constructed from middle-income countries without comprehensive smoke-free legislation, but with similar prelegislation trends in the outcome and predictor variables. Overall legislation effect was the mean average of country-specific effects weighted by the number of livebirths. We compared the distribution of the legislation effects with that of the placebo effects to assess the likelihood that the observed effect was related to the implementation of smoke-free legislation and not merely influenced by other processes.Findings31 (29%) of 106 middle-income countries introduced comprehensive smoke-free legislation and had outcome data for at least 3 years after the intervention. We were able to construct a synthetic control country for 18 countries for neonatal mortality and for 15 countries for infant mortality. Comprehensive smoke-free legislation was followed by a mean yearly decrease of 1·63% in neonatal mortality and a mean yearly decrease of 1·33% in infant mortality. An estimated 12 392 neonatal deaths in 18 countries and 8932 infant deaths in 15 countries were avoided over 3 years following the implementation of comprehensive smoke-free legislation. We estimated that an additional 104 063 infant deaths (inc

Journal article

Haney E, Parnham JC, Chang K, Laverty AA, von Hinke S, Pearson-Stuttard J, White M, Millett C, Vamos EPet al., 2022, Dietary quality of school meals and packed lunches: a national study of primary and secondary school children in the UK., Public Health Nutr, Pages: 1-30

OBJECTIVE: School lunches represent a key opportunity to improve diets and health of schoolchildren. No recent nationally representative studies have examined the nutritional differences between school meals and packed lunches in the UK. This study aimed to characterise and compare the nutritional quality of school meals and packed lunches among primary and secondary school-aged children. DESIGN: A pooled cross-sectional analysis of the UK's National Diet and Nutrition Survey (2008-2017). SETTING: United Kingdom. PARTICIPANTS: 3,001 children (aged 4-16 years) who completed a 3/4-day food diary which recorded meal-type (school meal/packed lunch). Multivariable logistic regression models assessed associations of meeting food and nutrient recommendations by meal type. Analyses were stratified by academic key stages (KS). RESULTS: KS-1 (4-7y) and 2 (8-11y) children consuming school meals were more likely to meet minimum recommendations for vegetables, protein-rich foods, and fibre, and not exceed maximum recommendations for salt, savoury and sweet snacks compared with pupils consuming packed lunches. However, in KS-3 (12-14y) and 4 (14-16y), these effects were reduced. As children aged, the median weight of fruits, vegetables, protein-rich foods, and dairy products consumed typically decreased for both school meals and packed lunches, and generally an increasing proportion of school meals contained sweet and savoury snacks. CONCLUSION: These findings suggest school meals are nutritionally superior to packed lunches but are not yet optimal. Quality declined at higher key stages. Actions to improve lunches of primary and secondary schoolchildren across the UK are needed, with attention to KS-3 and 4 in secondary schools.

Journal article

Ahmed A, Aune D, Vineis P, pescarini J, Millett C, Hone Tet al., 2022, The impact of conditional cash transfers on the control of neglected tropical disease: a systematic review, The Lancet Global Health, Vol: 10, Pages: e640-e648, ISSN: 2214-109X

Background:Neglected tropical diseases (NTDs) are diseases of poverty and affect 1.5 billion people globally. Conditional cash transfer (CCTs) programmes alleviate poverty in many countries, potentially contributing to improved NTD outcomes. This systematic review examines the relationship between CCTs and screening, incidence or treatment outcomes of NTDs.Methods:A systematic review was carried out. MEDLINE, EMBASE, Lilacs, EconLit, Global Health, and grey literature websites were systematically searched in September 2020 with no date or language restrictions. Controlled quantitative studies including randomised controlled trials (RCTs) and observational studies evaluating CCT interventions in low- and middle-income countries (LMICs) were included. Any outcome measures related to the WHO’s 20 diseases classified as NTDs were included. Two authors extracted data from published studies and appraised risk of biases using the Risk of Bias in Non-Randomised Studies of Interventions and Risk of Bias 2 tools. Results were analysed narratively. PROSPERO registration: CRD42020202480.Findings:From the search, 5165 records were identified. Eleven studies were eligible for inclusion covering four CCTs in Brazil, the Philippines, Mexico and Zambia. Most studies were either RCTs or quasi-experimental studies and ten were assessed to be of moderate quality. Seven studies reported improved NTD outcomes associated with CCTs – particularly reduced incidence of leprosy and increased uptake of deworming treatments. There was some evidence of greater benefit in lower socioeconomic groups but sub-group analysis was limited. Methodological weaknesses include self-reported outcomes, missing data, improper randomisation and differences between CCT and comparator populations in observational studies. The available evidence is currently limited, covering a small proportion of CCTs and NTDs. Interpretation:CCTs can be associated with improved NTD outcomes, and could be driven by

Journal article

Seringa J, Pedreiras S, Freitas MJ, De Matos RV, Rocha J, Millett C, Santana Ret al., 2022, Direct Costs of COVID-19 Inpatient Admissions in a Portuguese Tertiary Care University Centre, Portuguese Journal of Public Health, Vol: 40, Pages: 26-34

Background: The COVID-19 pandemic has posed greater financial pressure on health systems and institutions that had to respond to the specific needs of COVID-19 patients while ensuring the safety of the diagnosis and treatment of all patients and healthcare professionals. To assess the financial impact of COVID-19 patients admitted to hospitals, we have characterized the cost of COVID-19 admissions, using inpatient data from a Portuguese Tertiary Care University Centre. Methods: We analysed inpatient data from adult patients diagnosed with COVID-19 who were admitted between March 1, 2020 and May 31, 2020. Admissions were eligible if the ICD-10-CM principal diagnosis was coded U07.1. We excluded admissions from patients under 18 years old, admissions with incomplete records, admissions from patients who had been transferred to or from other hospitals or those whose inpatient stay was under 24 h. Pregnancy, childbirth, and puerperium admissions were also excluded, as well as admissions from patients who had undergone surgery. Results: We identified 223 admissions of patients diagnosed with COVID-19. Most were men (64.1%) and aged 45-64 years (30.5%). Around 13.0% of patients were admitted to intensive care units and 9.9% died in hospital. The average length of hospital stay was 12.7 days (SD = 10.2) and the average estimated cost per admission was EUR 8,177 (SD = 11,534), which represents more than triple the inpatient base price (EUR 2,386). Human resources accounted for the highest proportion of the total costs per admission (50.8%). About 92.4% of the admissions were assigned to Diagnosis Related Group (DRG) 723, whose inpatient price is lower than COVID- 19 inpatient costs for all degrees of severity. Conclusion: COVID-19 admissions represent a substantial financial burden for the Portuguese NHS. For each COVID-19 hospitalized patient it would have been possible to treat three other hospitalized patients. Also, the price set for DRG 723 is not adjusted to the cost

Journal article

Parnham JC, Chang K, Millett C, Laverty A, von Hinke S, Pearson-Stuttard J, de Vocht F, White M, Vamos EPet al., 2022, The impact of the Universal Infant Free School Meal policy on dietary quality in English and Scottish primary school children: evaluation of a natural experiment, Nutrients, Vol: 14, ISSN: 2072-6643

The Universal Infant Free School Meal (UIFSM) policy was introduced in September 2014 in England and January 2015 in Scotland and offered all infant schoolchildren (ages 4-7 years) a free school lunch, regardless of income. Yet, impacts of UIFSM on dietary intakes and or social inequalities are not known. A difference-in-differences study using the National Diet and Nutrition Survey assessed pooled pre-UIFSM (2010-2014) and post-UIFSM (2014-2017) dietary data. English or Scottish infant schoolchildren (4-7 years; N=458) were the intervention group with junior schoolchildren (8-11 years; N=401) as controls. We found that implementation of UIFSM led to an increase in infant schoolchildren having a school meal. Impacts on key food groups such as fruit and vegetables or sweetened beverages were not seen. However, there was evidence that the UIFSM policy lowered consumption of foods associated with packed lunches, such as crisps, and some nutrients, such as total fat and sodium. Policy impacts differed by income group, with larger effect sizes in low-income children. In conclusion, evaluation of UIFSM demonstrated some improvements on dietary quality but the findings suggest school meal quality needs to be improved to fully realise the benefits of UIFSM.

Journal article

Seferidi P, Hone T, Duran AC, Bernabe-Ortiz A, Millett Cet al., 2022, Global inequalities in the double burden of malnutrition and associations with globalisation: a multilevel analysis of Demographic and Health Surveys from 55 low-income and middle-income countries, 1992-2018, The Lancet Global Health, Vol: 10, Pages: e482-e490, ISSN: 2214-109X

BACKGROUND: Low-income and middle-income countries (LMICs) face a double burden of malnutrition (DBM), whereby overnutrition and undernutrition coexist within the same individual, household, or population. This analysis investigates global inequalities in household-level DBM, expressed as a stunted child with an overweight mother, and its association with economic, social, and political globalisation across country income and household wealth. METHODS: We pooled anthropometric and demographic data for 1 132 069 children (aged <5 years) and their mothers (aged 15-49 years) from 189 Demographic and Health Surveys in 55 LMICs between 1992 and 2018. These data were combined with country-level data on economic, social, and political globalisation from the Konjunkturforschungsstelle Globalisation Index and gross national income (GNI) from the World Bank. Multivariate associations between DBM and household wealth, GNI, and globalisation and their interactions were tested using multilevel logistic regression models with country and year fixed-effects and robust standard errors clustered by country. FINDINGS: The probability of DBM was higher among richer households in poorer LMICs and poorer households in richer LMICs. Economic globalisation was associated with higher odds of DBM among the poorest households (odds ratio 1·49, 95% CI 1·20-1·86) compared with the richest households. These associations attenuated as GNI increased. Social globalisation was associated with higher odds of DBM (1·39, 95% CI 1·16-1·65), independently of household wealth or country income. No associations were identified between political globalisation and DBM. INTERPRETATION: Increases in economic and social globalisation were associated with higher DBM, although the impacts of economic globalisation were mostly realised by the world's poorest. The economic patterning of DBM observed in this study calls for subpopulation-specific double-dut

Journal article

Radó MK, Laverty AA, Hone T, Chang K, Jawad M, Millett C, Been JV, Filippidis FTet al., 2022, Cigarette taxation and neonatal and infant mortality: a longitudinal analysis of 159 countries, PLOS Global Public Health, Vol: 2, ISSN: 2767-3375

Previous studies on the associations between cigarette taxes and infant survival have all been in high-income countries and did not examine the relative benefits of different taxation levels and structures. We evaluated longitudinal associations of cigarette taxes with neonatal and infant mortality globally. We applied country-level panel regressions using 2008–2018 annual mortality and biennial WHO tobacco taxation data. Complete data was available for 159 countries. Outcomes were neonatal and infant mortality. We conducted analyses by type of taxes (i.e. specific cigarette taxes, ad valorem taxes, and other taxes, import duties and VAT) and the income group classification of countries. Covariates included scores for other WHO recommended tobacco control policies, socioeconomic, health-care, and air quality measures. Secondary analyses investigated the associations between cigarette tax and cigarette consumption. We found that a 10 percentage-point increase in total cigarette tax as a percentage of the retail price was associated with a 2.6% (95% Confidence Interval [CI]: 1.9% to 3.2%) decrease in neonatal mortality and a 1.9% (95% CI: 1.3% to 2.6%) decrease in infant mortality globally. Estimates were similar for both excise and ad valorem taxes. We estimated that 231,220 (95% CI: 152,658 to 307,655) infant deaths could have been averted in 2018 if all countries had total cigarette tax at least 75%. 99.2% of these averted deaths would have been in low- and middle-income countries (LMICs). The secondary analysis supported causal interpretation of results by finding that a 10 percentage-point increase in taxes was associated with a reduction of 94.6 (95% CI: 32.7 to 156.5) in annual cigarette consumption per capita. Although causal inference is precarious due to the quasi-experimental design, we used a robust analytical approach and focused on within-country changes. Limitations include an inability to include data on roll-your-own tobacco, other forms of toba

Journal article

Palladino R, Alfano R, Moccia M, Barone-Adesi F, Majeed A, Triassi M, Millett Cet al., 2022, Association Between Institutional Affiliations of Academic Editors and Authors in Medical Journals, JOURNAL OF GENERAL INTERNAL MEDICINE, ISSN: 0884-8734

Journal article

Kliemann N, Al Nahas A, Vamos EP, Touvier M, Kesse-Guyot E, Gunter MJ, Millett C, Huybrechts Iet al., 2022, Ultra-processed foods and cancer risk: from global food systems to individual exposures and mechanisms, BRITISH JOURNAL OF CANCER, Vol: 127, Pages: 14-20, ISSN: 0007-0920

Journal article

Stratakis N, Siskos AP, Papadopoulou E, Nguyen AN, Zhao Y, Margetaki K, Lau C-HE, Coen M, Maitre L, Fernández-Barrés S, Agier L, Andrusaityte S, Basagaña X, Brantsaeter AL, Casas M, Fossati S, Grazuleviciene R, Heude B, McEachan RRC, Meltzer HM, Millett C, Rauber F, Robinson O, Roumeliotaki T, Borras E, Sabidó E, Urquiza J, Vafeiadi M, Vineis P, Voortman T, Wright J, Conti DV, Vrijheid M, Keun HC, Chatzi Let al., 2022, Urinary metabolic biomarkers of diet quality in European children are associated with metabolic health, eLife, Vol: 11, Pages: 1-20, ISSN: 2050-084X

Urinary metabolic profiling is a promising powerful tool to reflect dietary intake and can help understand metabolic alterations in response to diet quality. Here, we used 1H NMR spectroscopy in a multicountry study in European children (1147 children from 6 different cohorts) and identified a common panel of 4 urinary metabolites (hippurate, N-methylnicotinic acid, urea, and sucrose) that was predictive of Mediterranean diet adherence (KIDMED) and ultra-processed food consumption and also had higher capacity in discriminating children’s diet quality than that of established sociodemographic determinants. Further, we showed that the identified metabolite panel also reflected the associations of these diet quality indicators with C-peptide, a stable and accurate marker of insulin resistance and future risk of metabolic disease. This methodology enables objective assessment of dietary patterns in European child populations, complementary to traditional questionary methods, and can be used in future studies to evaluate diet quality. Moreover, this knowledge can provide mechanistic evidence of common biological pathways that characterize healthy and unhealthy dietary patterns, and diet-related molecular alterations that could associate to metabolic disease.

Journal article

Basu S, Hone T, Villela D, Saraceni V, Trajman A, Durovni B, Millett C, Rasella Det al., 2022, The contribution of primary care expansion to sustainable development goal three for health: a microsimulation of the fifteen largest cities in Brazil, BMJ Open, Vol: 12, ISSN: 2044-6055

ObjectivesAs middle-income countries strive to achieve the Sustainable Development Goals (SDGs), it remains unclear to what degree expanding primary care coverage can help achieve those goals and reduce within-country inequalities in mortality. Our objective was to estimate the potential impact of primary care expansion on cause-specific mortality in the 15 largest Brazilian cities.DesignMicrosimulation modelSetting15 largest cities by population size in BrazilParticipantsSimulated populationsInterventionsWe performed survival analysis to estimate hazard ratios of death by cause and by demographic group, from a national administrative database linked to the Estratégia de Saúde da Família (Family Health Strategy, FHS) electronic health and death records among 1.2 million residents of Rio de Janeiro (2010-2016). We incorporated the hazard ratios into a microsimulation to estimate the impact of changing primary care coverage in the 15 largest cities by population size in Brazil.Primary and secondary outcome measuresCrude and age-standardized mortality by cause, infant mortality, and under-5 mortality.ResultsIncreased FHS coverage would be expected to reduce inequalities in mortality among cities (from 2.8 to 2.4 deaths per 1,000 between the highest- and lowest-mortality city, given a 40-percentage point increase in coverage), between welfare recipients and non-recipients (from 1.3 to 1.0 deaths per 1,000), and among race/ethnic groups (between Black and White Brazilians from 1.0 to 0.8 deaths per 1,000). Even a 40-percentage point increase in coverage, however, would be insufficient to reach SDG targets alone, as it would be expected to reduce premature mortality from non-communicable diseases by 20% (versus the target of 33%), and communicable diseases by 15% (versus 100%).ConclusionsFHS primary care coverage may be critically beneficial to reducing within-country health inequalities, but reaching SDG targets will likely require coordination betwe

Journal article

Goel R, Oyebode O, Foley L, Tatah L, Millett C, Woodcock Jet al., 2022, Gender differences in active travel in major cities across the world, TRANSPORTATION, ISSN: 0049-4488

Journal article

Parnham J, Millett C, Chang K, Laverty A, von Hinke S, Pearson-Stuttard J, Vamos Eet al., 2021, Is the Healthy Start scheme associated with increased food expenditure in low-income families with young children in the United Kingdom?, BMC Public Health, Vol: 21, Pages: 1-11, ISSN: 1471-2458

Introduction: Healthy Start is a food assistance programme in the United Kingdom (UK) which aims to provide a nutritional safety-net and enable low-income families on welfare benefits to access a healthier diet through the provision of food vouchers. Healthy Start was launched in 2006 but remains under-evaluated. This study aims to determine whether participation in the Healthy Start scheme is associated with differences in food expenditure in a nationally representative sample of households in the UK. Methods: Cross-sectional analyses of the Living Costs and Food Survey dataset (2010-2017). All households with a child (0-3 years) or pregnant woman were included in the analysis (n=4,869). Multivariable quantile regression compared the expenditure and quantity of fruit and vegetables (FV), infant formula and total food purchases. Four exposure groups were defined based on eligibility, participation and income (Healthy Start Participating, Eligible Non-participating, Nearly Eligible low-income and Ineligible high-income households).Results: Of 876 eligible households, 54% participated in Healthy Start. No significant differences were found in FV or total food purchases between participating and eligible non-participating households, but infant formula purchases were lower in Healthy Start participating households. Ineligible higher-income households had higher purchases of FV. Conclusion: This study did not find evidence of an association between Healthy Start participation and FV expenditure. Moreover, inequalities in FV purchasing persist in the UK. Higher participation and increased voucher value may be needed to improve programme performance and counteract the harmful effects of poverty on diet.

Journal article

Seferidi P, Hone T, Duran AC, Bernabé-Ortiz A, Millett Cet al., 2021, Global inequalities in the double burden of malnutrition and associations with globalisation: a multilevel analysis of 55 low- and middle-income countries 1992-2018, The Lancet Global Health, ISSN: 2214-109X

BackgroundLow- and middle-income countries (LMIC) face a double burden of malnutrition (DBM), where overnutrition and undernutrition co-exist within the same individual, household, or population. This analysis investigates global inequalities in household-level DBM, expressed as a stunted child with an overweight mother, and its association with economic, social, and political globalisation across country income and household wealth.MethodsWe pooled anthropometric and demographic data for 1,131,069 children (<5 years) and their mothers (15-49 years), from 189 Demographic and Healthy Surveys in 55 LMICs between 1992-2018. These were combined with country-level data on economic, social, and political globalisation from KOF and gross national income (GNI) from the World Bank. Multi-variate associations between DBM and household wealth, GNI, and globalisation and their interactions were tested using multilevel logistic regression models with country and year fixed-effects and robust standard errors clustered by country.FindingsThe probability of DBM was higher among richer households in poorer LMICs and poorer households in richer LMICs. Economic globalisation was associated with higher odds of DBM among the poorest households (OR: 1.49; 95% CI: 1.20-1.86) compared with the richest. These associations attenuated as GNI increased. Social globalisation was associated with higher odds of DBM (OR: 1.39; 95% CI: 1.16-1.65), independently of household wealth or country income. No associations were identified between political globalisation and DBM.InterpretationIncreases in economic and social globalisation were associated with higher DBM, although the impacts of economic globalisation were mostly realised by the world’s poorest.

Journal article

Neri D, Steele EM, Khandpur N, Cediel G, Zapata ME, Rauber F, Marron-Ponce JA, Machado P, da Costa Louzada ML, Andrade GC, Batis C, Babio N, Salas-Salvado J, Millett C, Monteiro CA, Levy RBet al., 2021, Ultraprocessed food consumption and dietary nutrient profiles associated with obesity: A multicountry study of children and adolescents, OBESITY REVIEWS, Vol: 23, ISSN: 1467-7881

Journal article

Mrejen M, Rocha R, Millett C, Hone Tet al., 2021, The quality of alternative models of primary health care and morbidity and mortality in Brazil: a national longitudinal analysis, The Lancet Regional Health - Americas, Vol: 4, Pages: 1-9, ISSN: 2667-193X

BackgroundEvidence is limited on health benefits from quality improvement of primary healthcare (PHC) in low- and middle-income countries (LMICs). This study investigated whether increasing PHC quality in Brazil with highly-skilled health professionals and integrated community health workers (CHWs) was associated with reductions in hospitalizations and mortality beyond benefits derived from increasing access.MethodsAnnual municipal-level data for 5,411 municipalities between 2000 and 2014 were analysed using fixed effects panel regressions. PHC quality was measured as: i) the proportion of consultations provided by highly-skilled health professionals (doctors and nurses); and ii) the proportion of visits provided by CHWs from multidisciplinary PHC teams. Models assessed associations between PHC quality and hospitalization and mortality from diabetes, cardiovascular disease (CVD), tuberculosis, leprosy, perinatal and maternal causes, and adjusted for PHC access, utilisation, presence of secondary care services, and socioeconomic factors.FindingsA one percentage point increase in the proportion of consultations provided by highly-skilled health professionals was associated with 0•019 fewer deaths from diabetes per 100,000 population (95%CI: -0•034, -0•003; p-value: 0.0167) and 0•029 fewer hospitalizations per 100,000 from leprosy (95%CI: -0•055, -0•002; p-value: 0.0321). A one percentage point increase in the proportion of care provided by CHWs from multidisciplinary PHC teams was associated with 0•025 fewer deaths from CVD per 100,000 (95%CI: -0•050, -0•001; p-value: 0.0442) and 0•148 fewer maternal hospital admissions per 100,000 (95%CI: -0•286, -0•010; p-value: 0.0356). No significant associations were found for the other twenty pairs of exposures and outcomes analysed.InterpretationInvesting in higher-quality PHC models with highly-skilled health professionals and integrated CHWs can deliver reductions in

Journal article

Shimizu H, Pacheco Santos L, Sanchez M, Hone T, Millett C, Harris Met al., 2021, Challenges facing the more doctors program (Programa Mais Médicos) in vulnerable and peri-urban areas in Greater Brasilia, Brazil, Human Resources for Health, Vol: 19, Pages: 1-8, ISSN: 1478-4491

BackgroundA shortage of physicians, especially in vulnerable and peri-urban areas, is a global phenomenon that has serious implications for health systems, demanding policies to assure the provision and retention of health workers. The aim of this study was to analyze the strategies employed by the More Doctors Program (Programa Mais Médicos) to provide primary care physicians in vulnerable and peri-urban parts of Greater Brasilia.MethodsThe study used a qualitative approach based on the precepts of social constructivism. Forty-nine semi-structured interviews were conducted: 24 with physicians employed as part of the More Doctors program, five with program medical supervisors, seven with secondary care physicians, twelve with primary care coordinators, and one federal administrator. The interviews occurred between March and September 2019. The transcripts of the interviews were submitted to thematic content analysis.ResultsThe partnership between the Ministry of Health and local authorities was essential for the provision of doctors—especially foreign doctors, most from Cuba, to assist vulnerable population groups previously without access to the health system. There was a notable presence of doctors with experience working with socioeconomically disadvantaged populations, which was important for gaining a better understanding of the effects of the endemic urban violence in the region. The incentives and other institutional support, such as enhanced salaries, training, and housing, transportation, and food allowances, were factors that helped provide a satisfactory working environment. However, the poor state of the infrastructure at some of the primary care units and limitations of the health service as a whole were factors that hampered the provision of comprehensive care, constituting a cause of dissatisfaction.ConclusionsMore Doctors introduced a range of novel strategies that helped ensure a supply of primary care doctors in vulnerable and peri-urb

Journal article

Laverty AA, Li CR, Chang KC-M, Millett C, Filippidis FTet al., 2021, Cigarette taxation and price differentials in 195 countries during 2014-2018, Tobacco Control, ISSN: 0964-4563

INTRODUCTION: Raising tobacco prices via increased taxation may be undermined by tobacco industry tactics to keep budget cigarettes on the market. Price differentials between budget and premium cigarettes allow smokers to trade down in the face of average price rises thus attenuating health benefits. This study examines global trends of price differentials and associations with taxation. METHODS: Ecological analysis of country-level panel data of 195 countries' price differentials was performed and compared against total, specific excise, ad valorem and other taxation. Price differentials were expressed as the difference between budget cigarette and premium pack prices (as % of premium pack prices). Two-level linear regression models with repeated measurements (2014, 2016 and 2018) nested within each country assessed the association between country-level taxation structures and price differentials, adjusted for year, geographical region and income group. RESULTS: Worldwide, median price differential between budget and premium 20-cigarette packs was 49.4% (IQR 25.9%-70.0%) in 2014 and 44.4% (IQR 22.5%-69.4%) in 2018 with significant regional variation. The largest price differentials in 2018 were in Africa, with the lowest in Europe. Total taxation was negatively associated with price differentials (-1.5%, 95% CI -2.5% to -0.4% per +10% total taxation) as was specific excise taxation (-2.5%, 95% CI -3.7% to -1.2% per +10% specific excise tax). We found no statistically significant association between ad valorem taxation and price differentials. CONCLUSION: Total levels of taxation and specific excise taxes were associated with smaller price differentials. Implementing high specific excise taxes may reduce price differentials and improve health outcomes.

Journal article

Hanley-Cook GT, Huybrechts I, Biessy C, Remans R, Kennedy G, Deschasaux-Tanguy M, Murray KA, Touvier M, Skeie G, Kesse-Guyot E, Argaw A, Casagrande C, Nicolas G, Vineis P, Millett CJ, Weiderpass E, Ferrari P, Dahm CC, Bueno-de-Mesquita HB, Sandanger TM, Ibsen DB, Freisling H, Ramne S, Jannasch F, van der Schouw YT, Schulze MB, Tsilidis KK, Tjonneland A, Ardanaz E, Boden S, Cirera L, Gargano G, Halkjaer J, Jakszyn P, Johansson I, Katzke V, Masala G, Panico S, Rodriguez-Barranco M, Sacerdote C, Srour B, Tumino R, Riboli E, Gunter MJ, Jones AD, Lachat Cet al., 2021, Food biodiversity and total and cause-specific mortality in 9 European countries: An analysis of a prospective cohort study, PLoS Medicine, Vol: 18, ISSN: 1549-1277

BackgroundFood biodiversity, encompassing the variety of plants, animals, and other organisms consumed as food and drink, has intrinsic potential to underpin diverse, nutritious diets and improve Earth system resilience. Dietary species richness (DSR), which is recommended as a crosscutting measure of food biodiversity, has been positively associated with the micronutrient adequacy of diets in women and young children in low- and middle-income countries (LMICs). However, the relationships between DSR and major health outcomes have yet to be assessed in any population.Methods and findingsWe examined the associations between DSR and subsequent total and cause-specific mortality among 451,390 adults enrolled in the European Prospective Investigation into Cancer and Nutrition (EPIC) study (1992 to 2014, median follow-up: 17 years), free of cancer, diabetes, heart attack, or stroke at baseline. Usual dietary intakes were assessed at recruitment with country-specific dietary questionnaires (DQs). DSR of an individual’s yearly diet was calculated based on the absolute number of unique biological species in each (composite) food and drink. Associations were assessed by fitting multivariable-adjusted Cox proportional hazards regression models. In the EPIC cohort, 2 crops (common wheat and potato) and 2 animal species (cow and pig) accounted for approximately 45% of self-reported total dietary energy intake [median (P10–P90): 68 (40 to 83) species consumed per year]. Overall, higher DSR was inversely associated with all-cause mortality rate. Hazard ratios (HRs) and 95% confidence intervals (CIs) comparing total mortality in the second, third, fourth, and fifth (highest) quintiles (Qs) of DSR to the first (lowest) Q indicate significant inverse associations, after stratification by sex, age, and study center and adjustment for smoking status, educational level, marital status, physical activity, alcohol intake, and total energy intake, Mediterranean diet score, red

Journal article

Jawad M, Hone T, Vamos EP, Cetorelli V, Millett Cet al., 2021, Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000-2019, PLoS Medicine, Vol: 18, ISSN: 1549-1277

BACKGROUND: Armed conflicts have major indirect health impacts in addition to the direct harms from violence. They create enduring political instability, destabilise health systems, and foster negative socioeconomic and environmental conditions-all of which constrain efforts to reduce maternal and child mortality. The detrimental impacts of conflict on global maternal and child health are not robustly quantified. This study assesses the association between conflict and maternal and child health globally. METHODS AND FINDINGS: Data for 181 countries (2000-2019) from the Uppsala Conflict Data Program and World Bank were analysed using panel regression models. Primary outcomes were maternal, under-5, infant, and neonatal mortality rates. Secondary outcomes were delivery by a skilled birth attendant and diphtheria, pertussis, and tetanus (DPT) and measles vaccination coverage. Models were adjusted for 10 confounders, country and year fixed effects, and conflict lagged by 1 year. Further lagged associations up to 10 years post-conflict were tested. The number of excess deaths due to conflict was estimated. Out of 3,718 country-year observations, 522 (14.0%) had minor conflicts and 148 (4.0%) had wars. In adjusted models, conflicts classified as wars were associated with an increase in maternal mortality of 36.9 maternal deaths per 100,000 live births (95% CI 1.9-72.0; 0.3 million excess deaths [95% CI 0.2 million-0.4 million] over the study period), an increase in infant mortality of 2.8 per 1,000 live births (95% CI 0.1-5.5; 2.0 million excess deaths [95% CI 1.6 million-2.5 million]), a decrease in DPT vaccination coverage of 4.9% (95% CI 1.5%-8.3%), and a decrease in measles vaccination coverage of 7.3% (95% CI 2.7%-11.8%). The long-term impacts of war were demonstrated by associated increases in maternal mortality observed for up to 7 years, in under-5 mortality for 3-5 years, in infant mortality for up to 8 years, in DPT vaccination coverage for up to 3 years, and in

Journal article

Laverty AA, Millett C, 2021, A respiratory pandemic should focus the mind on tobacco control, Thorax, Vol: 77, Pages: 7-8, ISSN: 0040-6376

Journal article

Chang K, Khandpur N, Neri D, Touvier M, Huybrechts I, Millett C, Vamos Eet al., 2021, Association between childhood consumption of ultraprocessed food and adiposity trajectories in the Avon Longitudinal Study of Parents and Children birth cohort, JAMA Pediatrics, Vol: 175, ISSN: 2168-6211

Importance Reports of associations between higher consumption of ultraprocessed foods (UPF) and elevated risks of obesity, noncommunicable diseases, and mortality in adults are increasing. However, associations of UPF consumption with long-term adiposity trajectories have never been investigated in children.Objective To assess longitudinal associations between UPF consumption and adiposity trajectories from childhood to early adulthood.Design, Setting, and Participants This prospective birth cohort study included children who participated in the Avon Longitudinal Study of Parents and Children (ALSPAC) in Avon County, southwest England. Children were followed up from 7 to 24 years of age during the study period from September 1, 1998, to October 31, 2017. Data were analyzed from March 1, 2020, to January 31, 2021.Exposures Baseline dietary intake data were collected using 3-day food diaries. Consumption of UPF (applying the NOVA food classification system) was computed as a percentage of weight contribution in the total daily food intake for each participant and categorized into quintiles.Main Outcomes and Measures Repeated recordings of objectively assessed anthropometrics (body mass index [BMI; calculated as weight in kilograms divided by height in meters squared], weight, and waist circumference) and dual-energy x-ray absorptiometry measurements (fat and lean mass indexes [calculated as fat and lean mass, respectively, divided by height in meters squared] and body fat percentage). Associations were evaluated using linear growth curve models and were adjusted for study covariates.Results A total of 9025 children (4481 [49.7%] female and 4544 [50.3%] male) were followed up for a median of 10.2 (interquartile range, 5.2-16.4) years. The mean (SD) UPF consumption at baseline was 23.2% (5.0%) in quintile 1, 34.7% (2.5%) in quintile 2, 43.4% (2.5%) in quintile 3, 52.7% (2.8%) in quintile 4, and 67.8% (8.1%) in quintile 5. Among those in the highest quintile of UPF

Journal article

Cordova R, Kliemann N, Huybrechts I, Rauber F, Vamos EP, Levy RB, Wagner K-H, Viallon V, Casagrande C, Nicolas G, Dahm CC, Zhang J, Halkjær J, Tjønneland A, Boutron-Ruault M-C, Mancini FR, Laouali N, Katzke V, Srour B, Jannasch F, Schulze MB, Masala G, Grioni S, Panico S, van der Schouw YT, Derksen JWG, Rylander C, Skeie G, Jakszyn P, Rodriguez-Barranco M, Huerta JM, Barricarte A, Brunkwall L, Ramne S, Bodén S, Perez-Cornago A, Heath AK, Vineis P, Weiderpass E, Monteiro CA, Gunter MJ, Millett C, Freisling Het al., 2021, Consumption of ultra-processed foods associated with weight gain and obesity in adults: A multi-national cohort study, Clinical Nutrition, Vol: 40, Pages: 5079-5088, ISSN: 0261-5614

BackgroundThere is a worldwide shift towards increased consumption of ultra-processed foods (UPF) with concurrent rising prevalence of obesity. We examined the relationship between the consumption of UPF and weight gain and risk of obesity.MethodsThis prospective cohort included 348 748 men and women aged 25–70 years. Participants were recruited between 1992 and 2000 from 9 European countries in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Two body weight measures were available, at baseline and after a median follow-up time of 5 years. Foods and drinks were assessed at baseline by dietary questionnaires and classified according to their degree of processing using NOVA classification. Multilevel mixed linear regression was used to estimate the association between UPF consumption and body weight change (kg/5 years). To estimate the relative risk of becoming overweight or obese after 5 years we used Poisson regression stratified according to baseline body mass index (BMI).ResultsAfter multivariable adjustment, higher UPF consumption (per 1 SD increment) was positively associated with weight gain (0·12 kg/5 years, 95% CI 0·09 to 0·15). Comparing highest vs. lowest quintile of UPF consumption was associated with a 15% greater risk (95% CI 1·11, 1·19) of becoming overweight or obese in normal weight participants, and with a 16% greater risk (95% CI 1·09, 1·23) of becoming obese in participants who were overweight at baseline.ConclusionsThese results are supportive of public health campaigns to substitute UPF for less processed alternatives for obesity prevention and weight management.

Journal article

Bexson C, Millett C, Pacheco Santos LM, de Sousa Soares R, Proenço de Oliveira F, Hone Tet al., 2021, Brazil’s more doctors programme and infant health outcomes: a longitudinal analysis, Human Resources for Health, Vol: 19, Pages: 1-10, ISSN: 1478-4491

BackgroundProviding sufficient numbers of human resources for health is essential for effective and accessible health services. Between 2013 and 2018, the Brazilian Ministry of Health implemented the Programa Mais Médicos (PMM) (More Doctors Programme) to increase the supply of primary care doctors in underserved areas of the country. This study investigated the association between PMM and infant health outcomes and assessed if heterogeneity in the impact of PMM varied by municipal socioeconomic factors and health indicators.MethodsAn ecological longitudinal (panel) study design was employed to analyse data from 5,565 Brazilian municipalities over a 12-year period between 2007 and 2018. A differences-in-differences approach was implemented using longitudinal fixed effect regression models to compare infant health outcomes in municipalities receiving a PMM doctor with those that did not receive a PMM doctor. The impact of PMM was assessed on aggregate and in municipality subgroups. ResultsOn aggregate, the PMM was not significantly associated with changes in infant or neonatal mortality, but the PMM was associated with reductions in IMR (of -0.21; 95% CI: -0.38,-0.03) in municipalities with highest IMR prior to the programme’s implementation (where IMR >25.2 infant deaths per 1,000 live births). The PMM was also associated with an increase in the proportion of expectant mothers receiving seven or more prenatal care visits but only in municipalities with a lower IMR at baseline and high density of non-PMM doctors and community health workers before the PMM.ConclusionsThe PMM was associated with reduced infant mortality in municipalities with the highest infant mortality rate prior to the programme. This suggests effectiveness of the PMM was limited only to the areas of greatest need. New programmes to improve the equitable provision of human resources for health should employ comprehensive targeting approaches balancing health needs and socioeconomic

Journal article

Radó MK, Mölenberg FJM, Westenberg LEH, Sheikh A, Millett C, Burdorf A, van Lenthe FJ, Been JVet al., 2021, Effect of smoke-free policies in outdoor areas and private places on children's tobacco smoke exposure and respiratory health: a systematic review and meta-analysis, The Lancet Public Health, Vol: 6, Pages: e566-e578, ISSN: 2468-2667

BACKGROUND: Smoke-free policies in outdoor areas and semi-private and private places (eg, cars) might reduce the health harms caused by tobacco smoke exposure (TSE). We aimed to investigate the effect of smoke-free policies covering outdoor areas or semi-private and private places on TSE and respiratory health in children, to inform policy. METHODS: In this systematic review and meta-analysis, we searched 13 electronic databases from date of inception to Jan 29, 2021, for published studies that assessed the effects of smoke-free policies in outdoor areas or semi-private or private places on TSE, respiratory health outcomes, or both, in children. Non-randomised and randomised trials, interrupted time series, and controlled before-after studies, without restrictions to the observational period, publication date, or language, were eligible for the main analysis. Two reviewers independently extracted data, including adjusted test statistics from each study using a prespecified form, and assessed risk of bias for effect estimates from each study using the Risk of Bias in Non-Randomised Studies of Interventions tool. Primary outcomes were TSE in places covered by the policy, unplanned hospital attendance for wheezing or asthma, and unplanned hospital attendance for respiratory tract infections, in children younger than 17 years. Random-effects meta-analyses were done when at least two studies evaluated policies that regulated smoking in similar places and reported on the same outcome. This study is registered with PROSPERO, CRD42020190563. FINDINGS: We identified 5745 records and assessed 204 full-text articles for eligibility, of which 11 studies met the inclusion criteria and were included in the qualitative synthesis. Of these studies, seven fit prespecified robustness criteria as recommended by the Cochrane Effective Practice and Organization of Care group, assessing smoke-free cars (n=5), schools (n=1), and a comprehensive policy covering multiple areas (n=1). Risk o

Journal article

Monteiro CA, Lawrence M, Millett C, Nestle M, Popkin BM, Scrinis G, Swinburn Bet al., 2021, The need to reshape global food processing: a call to the United Nations Food Systems Summit., BMJ Glob Health, Vol: 6, Pages: 1-3, ISSN: 2059-7908

In the modern, globalised food system, useful types of industrial food processing that preserve foods, enhance their sensory properties and make their culinary preparation easier and more diverse, have been and are being replaced by food ultra-processing.The main purpose of food ultra-processing is to increase profits by creating hyperpalatable and convenient food products that are grossly inferior imitations of minimally processed foods and freshly prepared dishes and meals.In the last decades, obesity, type 2 diabetes and related diseases have become global epidemics, leading the health systems of many countries to or beyond breaking point.Taken together, the totality of evidence summarised here shows beyond reasonable doubt that increased consumption of ultra-processed foods is a major contributor to the pandemic of obesity, type 2 diabetes and related diseases.The 2021 UN Food System has a unique opportunity to urge countries to implement policy interventions required to reduce ultra-processed food production, distribution and consumption, while simultaneously making fresh or minimally processed foods more available, accessible and affordable.

Journal article

Hone T, Stokes J, Trajman A, Saraceni V, Coeli CM, Rasella D, Durovni B, Millett Cet al., 2021, Racial and socioeconomic disparities in multimorbidity and associated healthcare utilisation and outcomes in Brazil: a cross-sectional analysis of three million individuals, BMC Public Health, Vol: 21, ISSN: 1471-2458

Background:Evidence is limited on racial/ethnic group disparities in multimorbidity and associated health outcomes in low- and middle-income countries hampering effective policies and clinical interventions to address health inequalities.Methods:This study assessed race/ethnic and socioeconomic disparities in the prevalence of multimorbidity and associated healthcare utilisation, costs and death in Rio de Janeiro, Brazil. A cross-sectional analysis was carried out of 3,027,335 individuals registered with primary healthcare (PHC) services. Records included linked data to hospitalisation, mortality, and welfare-claimant (Bolsa Família) records between 1 Jan 2012 and 31 Dec 2016. Logistic and Poisson regression models were carried out to assess the likelihood of multimorbidity (two or more diagnoses out of 53 chronic conditions), PHC use, hospital admissions and mortality from any cause. Interactions were used to assess disparities.Results:In total 13,509,633 healthcare visits were analysed identifying 389,829 multimorbid individuals (13%). In adjusted regression models, multimorbidity was associated with lower education (Adjusted Odds Ratio (AOR): 1.26; 95%CI: 1.23,1.29; compared to higher education), Bolsa Família receipt (AOR: 1.14; 95%CI: 1.13,1.15; compared to non-recipients); and black race/ethnicity (AOR: 1.05; 95%CI: 1.03,1.06; compared to white). Multimorbidity was associated with more hospitalisations (Adjusted Rate Ratio (ARR): 2.75; 95%CI: 2.69,2.81), more PHC visits (ARR: 3.46; 95%CI: 3.44,3.47), and higher likelihood of death (AOR: 1.33; 95%CI: 1.29,1.36). These associations were greater for multimorbid individuals with lower educational attainment (five year probability of death 1.67% (95%CI: 1.61,1.74%) compared to 1.13% (95%CI: 1.02,1.23%) for higher education), individuals of black race/ethnicity (1.48% (95%CI: 1.41,1.55%) compared to 1.35% (95%CI: 1.31,1.40%) for white) and individuals in receipt of welfare (1.89% (95%CI: 1.77,2.00%) co

Journal article

Hunter RF, Garcia L, de Sa TH, Zapata-Diomedi B, Millett C, Woodcock J, Pentland AS, Moro Eet al., 2021, Effect of COVID-19 response policies on walking behavior in US cities, Nature Communications, Vol: 12, ISSN: 2041-1723

The COVID-19 pandemic is causing mass disruption to our daily lives. We integrate mobility data from mobile devices and area-level data to study the walking patterns of 1.62 million anonymous users in 10 metropolitan areas in the United States. The data covers the period from mid-February 2020 (pre-lockdown) to late June 2020 (easing of lockdown restrictions). We detect when users were walking, distance walked and time of the walk, and classify each walk as recreational or utilitarian. Our results reveal dramatic declines in walking, particularly utilitarian walking, while recreational walking has recovered and even surpassed pre-pandemic levels. Our findings also demonstrate important social patterns, widening existing inequalities in walking behavior. COVID-19 response measures have a larger impact on walking behavior for those from low-income areas and high use of public transportation. Provision of equal opportunities to support walking is key to opening up our society and economy.

Journal article

Coeli CM, Saraceni V, Mota Medeiros Jr P, Santos HPDS, Guillen LCT, Alves LGSB, Hone T, Millett C, Trajman A, Durovni Bet al., 2021, Record linkage under suboptimal conditions for data-intensive evaluation of primary care in Rio de Janeiro, Brazil, BMC Medical Informatics and Decision Making, Vol: 21, Pages: 1-13, ISSN: 1472-6947

BackgroundLinking Brazilian databases demands the development of algorithms and processes to deal with various challenges including the large size of the databases, the low number and poor quality of personal identifiers available to be compared (national security number not mandatory), and some characteristics of Brazilian names that make the linkage process prone to errors. This study aims to describe and evaluate the quality of the processes used to create an individual-linked database for data-intensive research on the impacts on health indicators of the expansion of primary care in Rio de Janeiro City, Brazil.MethodsWe created an individual-level dataset linking social benefits recipients, primary health care, hospital admission and mortality data. The databases were pre-processed, and we adopted a multiple approach strategy combining deterministic and probabilistic record linkage techniques, and an extensive clerical review of the potential matches. Relying on manual review as the gold standard, we estimated the false match (false-positive) proportion of each approach (deterministic, probabilistic, clerical review) and the missed match proportion (false-negative) of the clerical review approach. To assess the sensitivity (recall) to identifying social benefits recipients’ deaths, we used their vital status registered on the primary care database as the gold standard.ResultsIn all linkage processes, the deterministic approach identified most of the matches. However, the proportion of matches identified in each approach varied. The false match proportion was around 1% or less in almost all approaches. The missed match proportion in the clerical review approach of all linkage processes were under 3%. We estimated a recall of 93.6% (95% CI 92.8–94.3) for the linkage between social benefits recipients and mortality data.ConclusionThe adoption of a linkage strategy combining pre-processing routines, deterministic, and probabilistic strategies, as well as

Journal article

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