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
Year
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338 results found

Morales-Berstein F, Biessy C, Viallon V, Goncalves-Soares A, Casagrande C, Hemon B, Kliemann N, Cairat M, Blanco Lopez J, Al Nahas A, Chang C-M, Vamos E, Rauber F, Bertazzi Levy R, Barbosa Cunha D, Jakszyn P, ferrari P, Vineis P, Masala G, Catalano A, Sonestedt E, Borne Y, Katzke V, Bajracharya R, on behalf of the EPIC Networket al., 2024, Ultra-processed foods, adiposity and risk of head and neck cancer and oesophageal adenocarcinoma in the European Prospective Investigation into Cancer and Nutrition study: a mediation analysis, European Journal of Nutrition, Vol: 63, Pages: 377-396, ISSN: 0044-264X

Purpose:To investigate the role of adiposity in the associations between ultra-processed food (UPF) consumption and head and neck cancer (HNC) and oesophageal adenocarcinoma (OAC) in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort.Methods:Our study included 450,111 EPIC participants. We used Cox regressions to investigate the associations between the consumption of UPFs and HNC and OAC risk. A mediation analysis was performed to assess the role of body mass index (BMI) and waist-to-hip ratio (WHR) in these associations. In sensitivity analyses, we investigated accidental death as a negative control outcome.Results:During a mean follow-up of 14.13 ± 3.98 years, 910 and 215 participants developed HNC and OAC, respectively. A 10% g/d higher consumption of UPFs was associated with an increased risk of HNC (hazard ratio [HR] = 1.23, 95% confidence interval [CI] 1.14–1.34) and OAC (HR = 1.24, 95% CI 1.05–1.47). WHR mediated 5% (95% CI 3–10%) of the association between the consumption of UPFs and HNC risk, while BMI and WHR, respectively, mediated 13% (95% CI 6–53%) and 15% (95% CI 8–72%) of the association between the consumption of UPFs and OAC risk. UPF consumption was positively associated with accidental death in the negative control analysis.Conclusions:We reaffirmed that higher UPF consumption is associated with greater risk of HNC and OAC in EPIC. The proportion mediated via adiposity was small. Further research is required to investigate other mechanisms that may be at play (if there is indeed any causal effect of UPF consumption on these cancers).

Journal article

Escher N, Calixto Andrade G, Ghosh-Jerath S, Millett C, Seferidi Pet al., 2024, The effect of nutrition-specific and nutrition-sensitiveinterventions on the double burden of malnutrition in lowincome and middle-income countries: a systematic review, The Lancet Global Health, Vol: 12, Pages: E419-E432, ISSN: 2214-109X

Background:Low- and middle-income countries (LMICs) experiencing nutrition transition face an increasing double burden of malnutrition (DBM). The World Health Organization has urged the identification of risks and opportunities in nutrition interventions to mitigate the DBM, but robust evidence is missing. This review summarises the impact of nutrition-specific and nutrition-sensitive interventions on under- and overnutrition simultaneously in LMICs.Methods:We searched four major databases and grey literature for publications in English, French, Portuguese, and Spanish from January 1, 2000, to August 14, 2023. Eligible studies evaluated nutrition-specific and/or nutrition-sensitive interventions on both under- and overnutrition, employing robust study designs (individually-, cluster- and non-randomised trials, interrupted time series, controlled before-after and prospective cohort studies). Studies were synthesised narratively, and classified as DBM-beneficial, potentially DBM-beneficial, DBM-neutral, potentially DBM-harmful, and DBM-harmful, using vote counting. The review is registered with PROSPERO, CRD42022320131. Findings:We identified 26 studies evaluating 20 nutrition-specific (maternal and child health (MCH) and school-based programmes) and six nutrition-sensitive interventions (conditional cash transfers and other social policies). Seven out of eight MCH interventions providing food-based or nutritional supplements indicated possible DBM-harmful impacts, associated with increased maternal or child overweight. Most school-based programmes and behavioural change MCH interventions were considered potentially DBM-beneficial. Two evaluations of conditional cash transfers suggested DBM-beneficial impacts in children, while one indicated potentially harmful effects on maternal overweight. Evaluations of a family planning service and an education reform revealed possible long-term harmful impacts on obesity.Interpretation:There is considerable scope to repurpose ex

Journal article

Hone T, Gonçalves J, Seferidi P, Moreno-Serra R, Rocha R, Gupta I, Bhardwaj V, Hidayat T, Cai C, Suhrcke M, Millett Cet al., 2024, Progress towards universal health coverage and inequalities in infant mortality: An analysis of 4.1 million births from 60 low- and middle-income countries between 2000-2019, The Lancet Global Health, ISSN: 2214-109X

Background:Expanding universal health coverage (UHC) may not be inherently pro-poor without explicit targeting and prioritising of low-income populations. This study examines whether expansion of UHC is associated with reduced socio-economic inequalities in infant mortality in low- and middle-income countries (LMICs).Methods:Data on 4,065,868 live births were compiled from 177 Demographic and Health Surveys from 60 LMICs covering the period 2000-2019. Logistic regression models with country and year fixed effects assessed associations between country-level progress to UHC (using WHO’s UHC service coverage index) and infant mortality (overall and by wealth quintile), adjusting for infant-, mother-, and country-level variables. Findings:A one unit increase in the UHC index was associated with a 1.2% reduction in the risk of infant death (AOR: 0.988 95%CI: 0.981,0.995; absolute: 0.57 deaths per 1000 live births). An estimated 16 million infant deaths were averted between 2000-2019 due to increases in UHC. However, richer wealth quintiles had larger associated reductions in infant mortality from UHC (Q5: AOR: 0.983 95%CI: 0.973,0.993) than poorer quintiles (Q1: AOR: 0.991 95%CI: 0.985,0.998). In the early stages of UHC, UHC expansion was generally pro-poor (i.e. larger reductions in infant mortality for poorer households), but became less so as overall coverage increased. Interpretation:Since UHC expansion in LMICs appears to become less pro-poor as coverage increases, UHC policies should be explicitly designed to ensure lower income groups continue to benefit as coverage expands.Funding:NIHR: NIHR133252 and NIHR150067

Journal article

Medeiros S, Coelho R, Millett C, Sacareni V, Medina Coeli C, Trajman A, Rasella D, Durovni B, Hone Tet al., 2023, Racial inequalities in mental healthcare use and mortality: a cross-sectional analysis of 1.2 million low-income individuals in Rio de Janeiro, Brazil 2010-16, BMJ Global Health, Vol: 8, ISSN: 2059-7908

IntroductionMental health inequalities across racial and ethnic groups are large and unjust in many countries, yet these inequalities remain under-researched, particularly in low- and middle-income countries such as Brazil. This study investigates racial and socioeconomic inequalities in primary healthcare utilisation, hospitalisation, and mortality for mental health disorders in Rio de Janeiro, Brazil.MethodsA cohort of 1.2 million low-income adults from Rio de Janeiro, Brazil with linked socioeconomic, demographic, healthcare use and mortality records was cross-sectionally analysed. Poisson regression models were used to investigate associations between self-defined race/colour and primary healthcare (PHC) utilisation, hospitalisation, and mortality due to mental disorders, adjusting for socioeconomic factors. Interactions between race/colour and socioeconomic characteristics (sex, education level, income) explored if Black and Pardo (mixed race) individuals faced compounded risk of adverse mental health outcomes.ResultsThere were 272,532 PHC consultations, 10,970 hospitalisations, and 259 deaths due to mental disorders between 2010–2016. After adjusting for a wide range of socioeconomic factors, the lowest PHC utilisation rates were observed in Black (adjusted rate ratio [ARR]:0.64; 95% CI:0.60–0.68; compared to White) and Pardo individuals (ARR:0.87; 95% CI:0.83–0.92;). Black individuals were more likely to die from mental disorders (ARR:1.68; 95% CI:1.19–2.37; compared to White), as were those with lower educational attainment and household income. In interaction models, being Black or Pardo conferred additional disadvantage across mental health outcomes. The highest educated Black (ARR:0.56; 95% CI:0.47–0.66) and Pardo (ARR:0.75; 95% CI:0.66–0.87) individuals had lower rates of PHC utilisation for mental disorders compared to the least educated White individuals. Black individuals were 3.7 times (ARR:3.67; 95% CI:1.29–

Journal article

Cordova R, Viallon V, Fontvielle E, Peruchet-Noray L, Jansana A, Wagner K-H, Kyrø C, Tjønneland A, Katzke V, Bajracharya R, Schulze MB, Masala G, Sieri S, Panico S, Ricceri F, Tumino R, Boer JMA, Verschuren WMM, van der Schouw YT, Jakszyn P, Redondo-Sánchez D, Amiano P, Huerta JM, Guevara M, Borné Y, Sonestedt E, Tsilidis KK, Millett C, Heath AK, Aglago EK, Aune D, Gunter MJ, Ferrari P, Huybrechts I, Freisling Het al., 2023, Consumption of ultra-processed foods and risk of multimorbidity of cancer and cardiometabolic diseases: a multinational cohort study, The Lancet Regional Health. Europe, Vol: 35, Pages: 100771-100771, ISSN: 2666-7762

BackgroundIt is currently unknown whether ultra-processed foods (UPFs) consumption is associated with a higher incidence of multimorbidity. We examined the relationship of total and subgroup consumption of UPFs with the risk of multimorbidity defined as the co-occurrence of at least two chronic diseases in an individual among first cancer at any site, cardiovascular disease, and type 2 diabetes.MethodsThis was a prospective cohort study including 266,666 participants (60% women) free of cancer, cardiovascular disease, and type 2 diabetes at recruitment from seven European countries in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Foods and drinks consumed over the previous 12 months were assessed at baseline by food-frequency questionnaires and classified according to their degree of processing using Nova classification. We used multistate modelling based on Cox regression to estimate cause-specific hazard ratios (HR) and their 95% confidence intervals (CI) for associations of total and subgroups of UPFs with the risk of multimorbidity of cancer and cardiometabolic diseases.FindingsAfter a median of 11.2 years of follow-up, 4461 participants (39% women) developed multimorbidity of cancer and cardiometabolic diseases. Higher UPF consumption (per 1 standard deviation increment, ∼260 g/day without alcoholic drinks) was associated with an increased risk of multimorbidity of cancer and cardiometabolic diseases (HR: 1.09, 95% CI: 1.05, 1.12). Among UPF subgroups, associations were most notable for animal-based products (HR: 1.09, 95% CI: 1.05, 1.12), and artificially and sugar-sweetened beverages (HR: 1.09, 95% CI: 1.06, 1.12). Other subgroups such as ultra-processed breads and cereals (HR: 0.97, 95% CI: 0.94, 1.00) or plant-based alternatives (HR: 0.97, 95% CI: 0.91, 1.02) were not associated with risk.InterpretationOur findings suggest that higher consumption of UPFs increases the risk of cancer and cardiometabolic multimorbidity.Fun

Journal article

Cai C, Xiong S, Millett C, Xu J, Tian M, Hone Tet al., 2023, The health and health system impacts of China's comprehensive primary health care reforms: a systematic review., Health Policy and Planning, Vol: 38, Pages: 1064-1078, ISSN: 0268-1080

China's comprehensive primary health care (PHC) reforms since 2009 aimed to deliver accessible, efficient, equitable and high-quality health care services. However, knowledge on the system-wide effectiveness of these reforms is limited. This systematic review synthesizes evidence on the reforms' health and health system impacts. In August 2022, 13 international databases and three Chinese databases were searched for randomised controlled trials, quasi-experimental studies and controlled before-after studies. Included studies assessed large-scale PHC policies since 2009; had a temporal comparator and a control group; and assessed impacts on expenditures, utilisation, care quality, and health outcomes. Study quality was assessed using ROBINS-I and results were synthesized narratively. From 49,174 identified records, 42 studies were included - all with quasi-experimental designs, except for one randomised control trial. Nine studies assessed as at low risk of bias. Only five low to moderate quality studies assessed the comprehensive reforms as a whole and found associated increases in health service utilisation, whilst the other 37 studies examined single-component policies. The National Essential Medicine Policy (N=15) and financing reforms (N=11) were the most studied policies, whilst policies on primary care provision (i.e., family physician policy and the National Essential Public Health Services) were poorly evaluated. The PHC reforms were associated with increased primary care utilisation (N=17) and improved health outcomes in people with non-communicable diseases (N=8). Evidence on healthcare costs was unclear and impacts on patients' financial burden and care quality were understudied. Some studies showed disadvantaged regions and groups accrued greater benefits (N=8). China's comprehensive PHC reforms have made some progress in achieving their policy objectives including increasing primary care utilisation, improving some health outcomes, and reducing health i

Journal article

Abu Hamad B, Jamaluddine Z, Safadi G, Ragi ME, Ahmad RES, Vamos E, Basu S, Yudkin J, Jawad M, Millett C, Ghattas Het al., 2023, The hypertension cascade of care in the midst of conflict: the case of the Gaza Strip, Journal of Human Hypertension, Vol: 37, Pages: 957-968, ISSN: 0950-9240

Although hypertension constitutes a substantial burden in conflict-affected areas, little is known about its prevalence, control, and management in Gaza. This study aims to estimate the prevalence and correlates of hypertension, its diagnosis and control among adults in Gaza. We conducted a representative, cross-sectional, anonymous, household survey of 4576 persons older than 40 years in Gaza in mid-2020. Data were collected through face-to-face interviews, anthropometric, and blood pressure measurements. Hypertension was defined in anyone with an average systolic blood pressure ≥140 mmHg or average diastolic blood pressure ≥90 mmHg from two consecutive readings or a hypertension diagnosis. The mean age of participants was 56.9 ± 10.5 years, 54.0% were female and 68.5% were Palestinian refugees. The prevalence of hypertension was 56.5%, of whom 71.5% had been diagnosed. Hypertension was significantly higher among older participants, refugees, ex-smokers, those who were overweight or obese, and had other co-morbidities including mental illnesses. Two-thirds (68.3%) of those with hypertension were on treatment with one in three (35.6%) having their hypertension controlled. Having controlled hypertension was significantly higher in females, those receiving all medications for high blood pressure and those who never or rarely added salt to food. Investing in comprehensive but cost-effective initiatives that strengthen the prevention, early detection and timely treatment of hypertension in conflict settings is critical. It is essential to better understand the underlying barriers behind the lack of control and develop multi-sectoral programs to address these barriers.

Journal article

Costa E, Conceição D, Von Hafe F, Millett Cet al., 2023, The First Quantification of the Carbon Footprint of the Portuguese National Health Service: A Positive but Insufficient Step Forward, Portuguese Journal of Public Health, Vol: 41, Pages: 81-82

Journal article

McKevitt S, White M, Petticrew M, Summerbell C, Vasiljevic M, Boyland E, Cummins S, Laverty AA, Millett C, de Vocht F, Junghans C, Vamos EPet al., 2023, Characterizing restrictions on commercial advertising and sponsorship of harmful commodities in local government policies: a nationwide study in England, JOURNAL OF PUBLIC HEALTH, ISSN: 1741-3842

Journal article

Lai HTM, Chang K, Sharabiani MTA, Valabhji J, Gregg EW, Middleton L, Majeed A, Pearson-Stuttard J, Millett C, Bottle A, Vamos EPet al., 2023, Twenty-year trajectories of cardio-metabolic factors among people with type 2 diabetes by dementia status in England: a retrospective cohort study, European Journal of Epidemiology, Vol: 38, Pages: 733-744, ISSN: 0393-2990

To assess 20-year retrospective trajectories of cardio-metabolic factors preceding dementia diagnosis among people with type 2 diabetes (T2D). We identified 227,145 people with T2D aged > 42 years between 1999 and 2018. Annual mean levels of eight routinely measured cardio-metabolic factors were extracted from the Clinical Practice Research Datalink. Multivariable multilevel piecewise and non-piecewise growth curve models assessed retrospective trajectories of cardio-metabolic factors by dementia status from up to 19 years preceding dementia diagnosis (dementia) or last contact with healthcare (no dementia). 23,546 patients developed dementia; mean (SD) follow-up was 10.0 (5.8) years. In the dementia group, mean systolic blood pressure increased 16-19 years before dementia diagnosis compared with patients without dementia, but declined more steeply from 16 years before diagnosis, while diastolic blood pressure generally declined at similar rates. Mean body mass index followed a steeper non-linear decline from 11 years before diagnosis in the dementia group. Mean blood lipid levels (total cholesterol, LDL, HDL) and glycaemic measures (fasting plasma glucose and HbA1c) were generally higher in the dementia group compared with those without dementia and followed similar patterns of change. However, absolute group differences were small. Differences in levels of cardio-metabolic factors were observed up to two decades prior to dementia diagnosis. Our findings suggest that a long follow-up is crucial to minimise reverse causation arising from changes in cardio-metabolic factors during preclinical dementia. Future investigations which address associations between cardiometabolic factors and dementia should account for potential non-linear relationships and consider the timeframe when measurements are taken.

Journal article

Albers PN, Rinaldi C, Brown H, Mason KE, d'Apice K, McGill E, McQuire C, Craig P, Laverty AA, Beeson M, Campbell M, Egan M, Gibson M, Fuller M, Dillon A, Taylor-Robinson D, Jago R, Tilling K, Barr B, Sniehotta FF, Hickman M, Millett CJ, de Vocht Fet al., 2023, Natural experiments for the evaluation of place-based public health interventions: a methodology scoping review, Frontiers in Public Health, Vol: 11, Pages: 1-13, ISSN: 2296-2565

INTRODUCTION: Place-based public health evaluations are increasingly making use of natural experiments. This scoping review aimed to provide an overview of the design and use of natural experiment evaluations (NEEs), and an assessment of the plausibility of the as-if randomization assumption. METHODS: A systematic search of three bibliographic databases (Pubmed, Web of Science and Ovid-Medline) was conducted in January 2020 to capture publications that reported a natural experiment of a place-based public health intervention or outcome. For each, study design elements were extracted. An additional evaluation of as-if randomization was conducted by 12 of this paper's authors who evaluated the same set of 20 randomly selected studies and assessed 'as-if ' randomization for each. RESULTS: 366 NEE studies of place-based public health interventions were identified. The most commonly used NEE approach was a Difference-in-Differences study design (25%), followed by before-after studies (23%) and regression analysis studies. 42% of NEEs had likely or probable as-if randomization of exposure (the intervention), while for 25% this was implausible. An inter-rater agreement exercise indicated poor reliability of as-if randomization assignment. Only about half of NEEs reported some form of sensitivity or falsification analysis to support inferences. CONCLUSION: NEEs are conducted using many different designs and statistical methods and encompass various definitions of a natural experiment, while it is questionable whether all evaluations reported as natural experiments should be considered as such. The likelihood of as-if randomization should be specifically reported, and primary analyses should be supported by sensitivity analyses and/or falsification tests. Transparent reporting of NEE designs and evaluation methods will contribute to the optimum use of place-based NEEs.

Journal article

Hone T, Millett C, 2023, Associations between primary healthcare and infant health outcomes: a cohort analysis of low-income mothers in Rio de Janeiro, Brazil, The Lancet Regional Health. Americas, Vol: 22, Pages: 1-12, ISSN: 2667-193X

BackgroundExpanding primary healthcare to urban poor populations is a priority in many low-and middle-income countries and is essential to achieve universal health coverage (UHC). Between 2008 and 2016 the city of Rio de Janeiro undertook an ambitious programme to rapidly expand primary care to low-income areas through the family health strategy (FHS). Infant health impacts of this roll out are unknown. This study examines associations between maternal FHS utilisation and birth outcomes, neonatal and infant mortality.MethodsA cohort of 75,339 live births (January 2009–December 2014) to low-income mothers in Rio de Janeiro was linked to primary care, birth, hospital and death records. The relationship between maternal FHS use and infant health outcomes was assessed through logistic regression with inverse probability treatment weighting and regression adjustment. Socioeconomic inequalities in the associations between FHS use and outcomes were explored through interactions. Primary outcomes were neonatal and infant death. Thirteen secondary outcomes were also examined to explore other important health outcomes and potential mechanisms.ResultsA total of 9002 (12.0%) infants were born to mothers in the cohort who used FHS services either before pregnancy or in the first two trimesters. There was a total of 527 neonatal and 893 infant deaths. Maternal FHS usage during the first two trimesters was associated with substantial reductions in neonatal [adjusted odds ratio (aOR): 0.527, 95% confidence interval (95% CI): 0.345; 0.806] and infant mortality (aOR: 0.672, 95% CI: 0.48; 0.924). Infants born to lower-income mothers and those without formal employment had larger reductions in neonatal and infant mortality associated with FHS use. Maternal FHS in the first two trimesters use was also associated with more antenatal care consultations and a lower risk of low birth weight and preterm birth.InterpretationExpanding primary care to low-income populations in Rio de Jane

Journal article

Flores-Ortiz R, Fiaccone RL, Leyland A, Millett C, Hone T, Schmidt MI, Ferreira AJF, Ichihara MY, Teixeira C, Sanchez MN, Pescarini J, Aquino EML, Malta DC, Velasquez-Melendez G, de Oliveira JF, Craig P, Ribeiro-Silva RC, Barreto ML, Katikireddi SVet al., 2023, Subsidised housing and diabetes mortality: a retrospective cohort study of 10 million low-income adults in Brazil, BMJ OPEN DIABETES RESEARCH & CARE, Vol: 11

Journal article

Vineis P, Handakas E, Alfano R, Millett C, Fecht D, Chatzi L, Plusquin M, Nawrot T, Richiardi L, Barros H, Vrijheid M, Sassi F, Robinson Oet al., 2023, The contribution to policies of an exposome-based approach to childhood obesity, Exposome, Vol: https://academic.oup.com/exposome/advance-article/doi/10.1093/exposome/osad006/7180277, ISSN: 2635-2265

Childhood obesity is an increasingly severe public health problem, with a prospective impact on health. We propose an exposome approach to identifying actionable risk factors for this condition. Our assumption is that relationships between external exposures and outcomes such as rapid growth, overweight or obesity in children can be better understood through a “meet-in-the-middle” model. This is based on a combination of external and internal exposome-based approaches, i.e. the study of multiple exposures (in our case dietary patterns) and molecular pathways (metabolomics and epigenetics). This may strengthen causal reasoning by identifying intermediate markers that are associated with both exposures and outcomes. Our biomarker-based studies in the STOP consortium suggest (in several ways, including mediation analysis) that Branched-Chain Amino Acids (BCAAs) could be mediators of the effect of dietary risk factors on childhood overweight/obesity. This is consistent with intervention and animal studies showing that higher intake of BCAAs has a positive impact on body composition, glycemia and satiety. Concerning food, of particular concern is the trend of increasing intake of ultra-processed food (UPF), including among children. Several mechanisms have been proposed to explain the impact of UPF on obesity and overweight, including nutrient intake (particularly proteins), changes in appetite or the role of additives. Research from the ALSPAC cohort has shown a relationship between UPF intake and trajectories in childhood adiposity, while UPF was related to lower blood levels of BCAAs. We suggest that an exposome-based approach can help strengthening causal reasoning and support policies. Intake of UPF in children should be restricted to prevent obesity.

Journal article

Huybrechts I, Rauber F, Nicolas G, Casagrande C, Kliemann N, Wedekind R, Biessy C, Scalbert A, Touvier M, Aleksandrova K, Jakszyn P, Skeie G, Bajracharya R, Boer JMA, Borné Y, Chajes V, Dahm CC, Dansero L, Guevara M, Heath AK, Ibsen DB, Papier K, Katzke V, Kyrø C, Masala G, Molina-Montes E, Robinson OJK, Santiuste de Pablos C, Schulze MB, Simeon V, Sonestedt E, Tjønneland A, Tumino R, van der Schouw YT, Verschuren WMM, Vozar B, Winkvist A, Gunter MJ, Monteiro CA, Millett C, Levy RBet al., 2023, Corrigendum: characterization of the degree of food processing in the European Prospective Investigation into Cancer and Nutrition: application of the Nova classification and validation using selected biomarkers of food processing, Frontiers in Nutrition, Vol: 10, Pages: 1-4, ISSN: 2296-861X

[This corrects the article DOI: 10.3389/fnut.2022.1035580.]

Journal article

Laverty AA, Li CR, Chang KC-M, Millett C, Filippidis FTet al., 2023, Cigarette taxation and price differentials in 195 countries during 2014-2018, Tobacco Control, Vol: 32, Pages: 359-365, 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

Goel R, Oyebode O, Foley L, Tatah L, Millett C, Woodcock Jet al., 2023, Gender differences in active travel in major cities across the world, TRANSPORTATION, Vol: 50, Pages: 733-749, ISSN: 0049-4488

Journal article

Kliemann N, Rauber F, Levy R, Viallon V, Vamos E, Cordova R, Freisling H, Casagrande C, Nicolas G, Aune D, Tsilidis K, Heath A, Schulze MB, Jannasch F, Srour B, Kaaks R, Rodriguez-Barranco M, Tagliabue G, Agudo A, Panico S, Ardanaz E, Chirlaque MD, Vineis P, Tumino R, Perez-Cornago A, Munk Andersen JL, Tjønneland A, Skeie G, Weiderpass E, Monteiro CA, Gunter M, Millett CJ, Huybrechts Iet al., 2023, Food processing and cancer risk in Europe: results from the prospective EPIC cohort study, The Lancet Planetary Health, Vol: 7, Pages: E219-E232, ISSN: 2542-5196

BackgroundFood processing has been hypothesised to play a role in cancer development; however, data from large-scale epidemiological studies are scarce. This study investigated the association between dietary intake according to amount of food processing and risk of cancer at 25 anatomical sites using data from the European Prospective Investigation into Cancer and Nutrition (EPIC) study.MethodsThis study used data from the prospective EPIC cohort study, which recruited participants between March 18, 1991, and July 2, 2001, from 23 centres in ten European countries. Participant eligibility within each cohort was based on geographical or administrative boundaries. Participants were excluded if they had a cancer diagnosis before recruitment, had missing information for the NOVA food processing classification, or were within the top and bottom 1% for ratio of energy intake to energy requirement. Validated dietary questionnaires were used to obtain information on food and drink consumption. Participants with cancer were identified using cancer registries or during follow-up from a combination of sources, including cancer and pathology centres, health insurance records, and active follow-up of participants. We performed a substitution analysis to assess the effect of replacing 10% of processed foods and ultra-processed foods with 10% of minimally processed foods on cancer risk at 25 anatomical sites using Cox proportional hazard models.Findings521 324 participants were recruited into EPIC, and 450 111 were included in this analysis (318 686 [70·8%] participants were female individuals and 131 425 [29·2%] were male individuals). In a multivariate model adjusted for sex, smoking, education, physical activity, height, and diabetes, a substitution of 10% of processed foods with an equal amount of minimally processed foods was associated with reduced risk of overall cancer (hazard ratio 0·96, 95% CI 0·95–0·9

Journal article

Pineda E, Barbosa Cunha D, Taghavi Azar Sharabiani M, Millett Cet al., 2023, Association of the retail food environment, BMI, dietary patterns, and socioeconomic position in urban areas of Mexico, PLOS Global Public Health, Vol: 3, ISSN: 2767-3375

The retail food environment is a key modifiable driver of food choice and the risk of non-communicable diseases (NCDs). This study aimed to assess the relationship between the density of food retailers, body mass index (BMI), dietary patterns, and socioeconomic position in Mexico. Cross-sectional dietary data, BMI and socioeconomic characteristics of adult participants came from the nationally representative 2012 National Health and Nutrition Survey in Mexico. Geographical and food outlet data were obtained from official statistics. Densities of food outlets per census tract area (CTA) were calculated. Dietary patterns were determined using exploratory factor analysis and principal component analysis. The association of food environment variables, socioeconomic position, BMI, and dietary patterns was assessed using two-level multilevel linear regression models. Three dietary patterns were identified-the healthy, the unhealthy and the carbohydrates-and-drinks dietary pattern. Lower availability of fruit and vegetable stores was associated with an unhealthier dietary pattern whilst a higher restaurant density was associated with a carbohydrates-and-drinks pattern. A graded and inverse association was observed for fruit and vegetable store density and socioeconomic position (SEP)-lower-income populations had a reduced availability of fruit and vegetable stores, compared with higher-income populations. A higher density of convenience stores was associated with a higher BMI when adjusting for unhealthy dietary patterns. Upper-income households were more likely to consume healthy dietary patterns and middle-upper-income households were less likely to consume unhealthy dietary patterns when exposed to high densities of fruit and vegetable stores. When exposed to a high concentration of convenience stores, lower and upper-lower-income households were more likely to consume unhealthy dietary patterns. Food environment and sociodemographic conditions within neighbourhoods may

Journal article

Chang C-M, Gunter M, Rauber F, Levy R, Huybrechts I, Kliemann N, Millett C, Vamos Eet al., 2023, Ultra-processed food consumption, cancer risk and cancer mortality: a large-scale prospective analysis within the UK Biobank, EClinicalMedicine, Vol: 56, Pages: 1-12, ISSN: 2589-5370

BackgroundGlobal dietary patterns are increasingly dominated by relatively cheap, highly palatable, and ready-to-eat ultra-processed foods (UPFs). However, prospective evidence is limited on cancer development and mortality in relation to UPF consumption. This study examines associations between UPF consumption and risk of cancer and associated mortality for 34 site-specific cancers in a large cohort of British adults.MethodsThis study included a prospective cohort of UK Biobank participants (aged 40–69 years) who completed 24-h dietary recalls between 2009 and 2012 (N = 197426, 54.6% women) and were followed up until Jan 31, 2021. Food items consumed were categorised according to their degree of food processing using the NOVA food classification system. Individuals’ UPF consumption was expressed as a percentage of total food intake (g/day). Prospective associations were assessed using multivariable Cox proportional hazards models adjusted for baseline socio-demographic characteristics, smoking status, physical activity, body mass index, alcohol and total energy intake.FindingsThe mean UPF consumption was 22.9% (SD 13.3%) in the total diet. During a median follow-up time of 9.8 years, 15,921 individuals developed cancer and 4009 cancer-related deaths occurred. Every 10 percentage points increment in UPF consumption was associated with an increased incidence of overall (hazard ratio, 1.02; 95% CI, 1.01–1.04) and specifically ovarian (1.19; 1.08–1.30) cancer. Furthermore, every 10 percentage points increment in UPF consumption was associated with an increased risk of overall (1.06; 1.03–1.09), ovarian (1.30; 1.13–1.50), and breast (1.16; 1.02–1.32) cancer-related mortality.InterpretationOur UK-based cohort study suggests that higher UPF consumption may be linked to an increased burden and mortality for overall and certain site-specific cancers especially ovarian cancer in women.FundingThe Cancer Research UK and World Cancer Re

Journal article

Chang K, Gunter MJ, Rauber F, Levy RB, Huybrechts I, Kliemann N, Millett C, Vamos EPet al., 2023, Ultra-processed food consumption, cancer risk and cancer mortality: a large-scale prospective analysis within the UK Biobank, ECLINICALMEDICINE, Vol: 56, Pages: 1-12

Journal article

McKevitt S, White M, Petticrew M, Summerbell C, Vasiljevic M, Boyland E, Cummins S, Laverty AA, Junghans C, Millett C, de Vocht F, Hrobonova E, Vamos EPet al., 2023, Typology of how ‘harmful commodity industries’ interact with local governments in England: a critical interpretive synthesis, BMJ Global Health, Vol: 8, Pages: 1-13, ISSN: 2059-7908

Introduction Industries that produce and market potentially harmful commodities or services (eg, tobacco, alcohol, gambling, less healthy foods and beverages) are a major influence on the drivers of behavioural risk factors for non-communicable diseases. The nature and impact of interactions between public bodies and ‘harmful commodity industries’ (HCIs) has been widely recognised and discussed at national and international levels, but to date little is known about such interactions at local or regional government levels. This study aimed to identify and characterise actual and potential interactions and proposes a typology of interactions between HCIs and English local authorities (LAs).Methods Five electronic databases covering international literature (PubMed, EBSCO, OVID, Scopus and Web of Science) were searched up to June 2021. We also performed online searches for publicly available, web-based grey literature and documented examples of interactions in an English LA context. We conducted a critical interpretive synthesis of the published and grey literature to integrate and conceptualise the data in the context of English LAs.Results We included 47 published papers to provide the frame for the typology, which was refined and contextualised for English LAs through the available grey literature. Three categories were developed, describing the medium through which interactions occur: (1) direct involvement with LAs, (2) involvement through intermediaries and (3) involvement through the local knowledge space. Within these, we grouped interactions into 10 themes defining their nature and identified illustrative examples.Conclusion Our typology identifies complex inter-relationships and characterises interactions between HCIs and LAs, with illustrative examples from English LAs. Drawn from well-established theories and frameworks in combination with contextual information on English LAs, this typology explores the LA perspective and could help local decis

Journal article

Parnham J, Millett C, Vamos E, 2023, School meals in the UK: ultra-processed, unequal, and inadequate, Public Health Nutrition, Vol: 26, Pages: 297-301, ISSN: 1368-9800

Recent research paints an alarming picture of the school food system in the UK. This commentary discusses the issues that undermine healthy school meals and considers the actions required to ensure the school food system can meet the challenges ahead.

Journal article

Huybrechts I, Rauber F, Nicolas G, Casagrande C, Kliemann N, Wedekind R, Biessy C, Scalbert A, Touvier M, Aleksandrova K, Jakszyn P, Skeie G, Bajracharya R, Boer JMA, Borné Y, Chajes V, Dahm CC, Dansero L, Guevara M, Heath AK, Ibsen DB, Papier K, Katzke V, Kyrø C, Masala G, Molina-Montes E, Robinson OJK, Santiuste de Pablos C, Schulze MB, Simeon V, Sonestedt E, Tjønneland A, Tumino R, van der Schouw YT, Verschuren WMM, Vozar B, Winkvist A, Gunter MJ, Monteiro CA, Millett C, Levy RBet al., 2022, Characterization of the degree of food processing in the European Prospective Investigation into Cancer and Nutrition: Application of the Nova classification and validation using selected biomarkers of food processing, Frontiers in Nutrition, Vol: 9, ISSN: 2296-861X

Background: Epidemiological studies have demonstrated an association between the degree of food processing in our diet and the risk of various chronic diseases. Much of this evidence is based on the international Nova classification system, which classifies food into four groups based on the type of processing: (1) Unprocessed and minimally processed foods, (2) Processed culinary ingredients, (3) Processed foods, and (4) “Ultra-processed” foods (UPF). The ability of the Nova classification to accurately characterise the degree of food processing across consumption patterns in various European populations has not been investigated so far. Therefore, we applied the Nova coding to data from the European Prospective Investigation into Cancer and Nutrition (EPIC) in order to characterize the degree of food processing in our diet across European populations with diverse cultural and socio-economic backgrounds and to validate this Nova classification through comparison with objective biomarker measurements.Methods: After grouping foods in the EPIC dataset according to the Nova classification, a total of 476,768 participants in the EPIC cohort (71.5% women; mean age 51 [standard deviation (SD) 9.93]; median age 52 [percentile (p)25–p75: 58–66] years) were included in the cross-sectional analysis that characterised consumption patterns based on the Nova classification. The consumption of food products classified as different Nova categories were compared to relevant circulating biomarkers denoting food processing, measured in various subsamples (N between 417 and 9,460) within the EPIC cohort via (partial) correlation analyses (unadjusted and adjusted by sex, age, BMI and country). These biomarkers included an industrial transfatty acid (ITFA) isomer (elaidic acid; exogenous fatty acid generated during oil hydrogenation and heating) and urinary 4-methyl syringol sulfate (an indicator for the consumption of smoked food and a component of liquid smoke u

Journal article

Lee TY, Anindya K, Marthias T, Zulfikar Biruni M, Hage S, Ng N, Laverty A, McPake B, Millett C, Haregu TN, Hulse ESG, Cao Yet al., 2022, Low physical activity is associated with adverse health outcome and higher costs in Indonesia: a national panel study, Frontiers in Cardiovascular Medicine, Vol: 9, Pages: 1-11, ISSN: 2297-055X

Aims: To assess the association between low physical activity, cardiovascular disease (CVD) and risk factors, health service utilization, risk of catastrophic health expenditure, and work productivity in Indonesia.Methods: In this population-based, panel data analysis, we used data from two waves of the Indonesian Family Life Survey (IFLS) for 2007/2008 and 2014/2015. Respondents aged 40–80 years who participated in both waves were included in this study (n = 5,936). Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ-SF). Multinomial logistic regression model was used to examine factors associated with physical activity levels (low, moderate, and high). We applied a series of multilevel mixed-effect panel regression to examine the associations between physical activity and outcome variables.Results: The prevalence of low physical activity increased from 18.2% in 2007 to 39.6% in 2014. Compared with those with high physical activity, respondents with low physical activity were more likely to have a 10-year high CVD risk (AOR: 2.11, 95% CI: 1.51–2.95), use outpatient care (AOR: 1.26, 95% CI: 1.07–1.96) and inpatient care (AOR 1.45, 95% CI: 1.07–1.96), experience catastrophic health expenditure of 10% of total household expenditure (AOR: 1.66, 95% CI: 1.21–2.28), and have lower labor participation (AOR: 0.24, 95% 0.20–0.28).Conclusions: Low physical activity is associated with adverse health outcomes and considerable costs to the health system and wider society. Accelerated implementation of public health policies to reduce physical inactivity is likely to result in substantial population health and economic benefits.

Journal article

Harding D, Pitcairn CFM, Machado DB, De Araujo LFSC, Millett C, Hone Tet al., 2022, Interpersonal violence and depression in Brazil: A cross-sectional analysis of the 2019 National Health Survey, PLOS Global Public Health, Vol: 2, Pages: 1-16, ISSN: 2767-3375

Depression and interpersonal violence are issues of increasing public health concern globally, especially in low-and-middle income countries. Despite the known relationship between interpersonal violence and an increased risk of depression, there is a need to further characterise the experience of depression in those who have experienced violence, to better develop screening and treatment interventions. A cross-sectional analysis was conducted on responses from the 2019 Brazilian National Health Survey. The prevalence of depression (both clinician-diagnosed, and Patient Health Questionnaire (PHQ-9) screened) were estimated by type of violence experienced in the preceding 12 months (none, physical violence, sexual violence, physical and sexual violence, or threat of violence). Logistic regression models assessed the associations between violence and depression after adjusting for socioeconomic and demographic factors. Of 88,531 respondents, 8.1% experienced any type of violence. Compared to those not experiencing violence, those who experienced any type of violence had a higher prevalence of clinician-diagnosed or PHQ-9-screened depression (e.g. the prevalence of clinician-diagnosed depression was 18.8% for those experiencing sexual violence compared to 9.5% for those not experiencing violence). Both undiagnosed and untreated depression were also more prevalent in those experiencing any type of violence. In logistic regression models, any experience of violence was associated with a higher odds of depression (e.g. aOR = 3.75 (95% CI: 3.06–4.59) for PHQ-9-detected depression). Experiencing violence was also associated with a higher likelihood of having depression which was undiagnosed (e.g. in those who experienced sexual violence: aOR of 3.20, 95% CI 1.81–5.67) or untreated (e.g. in those who experienced physical and sexual violence: aOR = 8.06, 95% CI 3.44–18.9). These findings highlight the need to consider screening for depression in those affect

Journal article

Marthias T, McPake B, Carvalho N, Millett C, Anindya K, Saputri N, Trisnantoro L, Lee TYet al., 2022, Associations between Indonesia's national health insurance, effective coverage in maternal health, and neonatal mortality: a multilevel interrupted time-series analysis 2000-2017, Journal of Epidemiology and Community Health, Vol: 76, Pages: 999-1010, ISSN: 0143-005X

Background:We assessed the effect of Indonesia’s national health insurance program (Jaminan Kesehatan Nasional [JKN]) on effective coverage for maternal and child health across geographical regions and population groups. Methods:We utilized four waves of the Indonesia Demographic and Health Survey from 2000–2017, which included 38,880 women aged 15-49 years and 144,000 birth records. Key outcomes included antenatal and delivery care, caesarean section, and neonatal and infant mortality. We used multilevel interrupted time-series regression to examine changes in outcomes after the introduction of the JKN in January 2014. Findings:JKN introduction was associated with significant level increases in (1) antenatal care (ANC) crude coverage (aOR 1.81, 95% CI 1.44–2.27); (2) ANC quality-adjusted coverage (aOR 1.66, 95% CI 1.38-1.98); (3) ANC user-adherence-adjusted coverage (aOR 1.80, 95% CI 1.45-2.25); (4) safe delivery service contact (aOR 1·83 [1·42–2·36]) and; (5) safe delivery crude coverage (aOR 1·45 [1·20–1·75]). We did not find any significant level increase in ANC service contact or caesarean section. Interestingly, increases in ANC service contact and crude coverage, and safe delivery crude coverage were larger among the poorest compared with the most affluent. No statistically significant associations were found between JKN introduction and neonatal and infant mortality (p-value >0·05) in the first three years following implementation. Interpretation:Expansion of social health insurance led to substantial improvements in quality of care for maternal health services but not in child mortality. Concerted efforts are required to equitably improve service quality and child mortality across the population in Indonesia.

Journal article

Handakas E, Chang K, Khandpur N, Vamos EP, Millett C, Sassi F, Vineis P, Robinson Oet al., 2022, Metabolic profiles of ultra-processed food consumption and their role in obesity risk in British children, Clinical Nutrition, Vol: 41, Pages: 2537-2548, ISSN: 0261-5614

Background & aimsHigher consumption of ultra-processed foods (UPF) has been associated with childhood obesity, but underlying mechanisms remain unclear. We investigated plasma nuclear magnetic resonance metabolic profiles of higher UPF consumption and their role in obesity risk in the British ALSPAC cohort.MethodsWe performed cross-sectional and prospective metabolome wide association analyses of UPF, calculated from food diaries using the NOVA classification. In cross-sectional analysis, we tested the association between UPF consumption and metabolic profile at 7 years (N = 4528), and in the prospective analysis we tested the association between UPF consumption at 13 years and metabolic profile at 17 years (N = 3086). Effects of UPF-associated metabolites at 7 years on subsequent fat mass accumulation were assessed using growth curve models.ResultsAt 7 years, UPF was associated with 115 metabolic traits including lower levels of branched-chain and aromatic amino acids and higher levels of citrate, glutamine, and monounsaturated fatty acids, which were also associated with greater fat mass accumulation. Reported intake of nutrients mediated associations with most metabolites, except for citrate.ConclusionsUPF consumption among British children is associated with perturbation of multiple metabolic traits, many of which contribute to child obesity risk.

Journal article

Hone T, Macinko J, Trajman A, Palladino R, Medina Coeli C, Saraceni V, Rasella D, Durovni B, Millett Cet al., 2022, Expansion of primary healthcare and emergency hospital admissions among the urban poor in Rio de Janeiro Brazil: a cohort analysis, Lancet Regional Health Americas, Vol: 15, Pages: 1-13, ISSN: 2667-193X

Background:Robust evidence on the relationship between primary care and emergency admissions is lacking in low- and middle-income countries. This study evaluates how the phased roll out of the family health strategy (FHS) to the urban poor in Rio de Janeiro Brazil affected emergency hospital admissions and readmissions from ambulatory-care sensitives conditions (ACSCs).Methods:A cohort of 1.2 million adults in Rio de Janeiro city were followed for five years (Jan 2012 to Dec 2016). The association between FHS use and the likelihood of emergency hospital admissions and 30-day readmissions were evaluated using multi-level Poisson regression models with inverse probability treatment weighting and regression adjustment (IPTW-RA) for socioeconomic and household characteristics. Inequalities in associations were examined across groups of causes and by key socioeconomic groups. Results:Records from 2,551,934 primary care consultations and 15,627 admissions were analysed. In IPTW-RA analyses, each additional FHS consultation was associated with a 3% lower rate of ACSC admission (RR: 0.97; 95%CI: 0.95, 0.98), a 63% lower rate of 30-day readmissions from any non-birth cause (RR: 0.37; 95%CI: 0.30, 0.46), and an 57% lower rate of 30-day readmissions from ACSCs (RR: 0.43; 95%CI: 0.33, 0.55). Individuals who were older, had the lowest educational attainment, were unemployed, and had higher incomes had larger reductions in ACSC admissions associated with FHS use.Interpretation:Investment in primary care is important for reducing emergency hospital admissions and their associated costs in LMICs. Funding DFID/MRC/Wellcome Trust/ESRC

Journal article

Laverty AA, Millett C, Been JV, Filippidis FT, Rado MKet al., 2022, A healthy future for children and adolescents, LANCET, Vol: 400, Pages: 1100-1100, ISSN: 0140-6736

Journal article

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