Showing papers in "Circulation-cardiovascular Quality and Outcomes in 2020"
TL;DR: The impact of the COVID-19 outbreak on STEMI care in Hong Kong is described through a handful of recent cases of patients with STEMI who underwent PPCI at a single center.
Abstract: Acute ST-segment–elevation myocardial infarction (STEMI) is a disease of high mortality and morbidity, and primary percutaneous coronary intervention (PPCI) is the typical recommended therapy.1,2 Systems of care have been established to expedite PPCI workflow to minimize ischemic time from symptom onset to definitive treatment in the catheterization laboratory. Little is known about the impact of public health emergencies like a community outbreak of infectious disease on STEMI systems of care. Since December 2019, the emergence of Coronavirus disease 2019 (COVID-19) in Wuhan, China, has evolved into a regional epidemic, including in Hong Kong, a city in Southern China. We describe the impact of the COVID-19 outbreak on STEMI care in Hong Kong through a handful of recent cases of patients with STEMI who underwent PPCI at a single center. We included patients with STEMI admitted via the Accident and Emergency Department and in whom PPCI was performed. We focus on the time period since January 25, 2020, when hospitals in the city started to institute emergency infection protocols to contain COVID-19. This required hospitals to suspend all nonessential visits and adjust clinical in-patient and out-patient services. Indications for PPCI were according to the international guidelines.1,2 Study exclusion criteria included inpatient STEMI (n=1), STEMI with unknown symptom onset time (n=3), and cardiac arrest patients (n=2). Our hospital has offered 24/7 PPCI service to all eligible patients presenting with acute STEMI since 2010 per standard Accident and Emergency Department protocol. When STEMI is diagnosed, a PPCI team is activated after cardiology evaluation. Data on key time points in STEMI care are recorded in a clinical registry. Symptom-onset-to-first-medicalcontact time is defined as the time from patient-reported chest discomfort onset time to the time of first medical contact. Door-to-device time is defined as the time from Accident and Emergency Department arrival to successful wire crossing time during PPCI. Catheterization laboratory arrival-to-device time is defined as the time from patient arrival in the catheterization laboratory to successful wire crossing time. From January 25, 2020, to February 10, 2020, we observed changes in time components of STEMI care among the aggregate group of 7 consecutive patients who underwent PPCI. We compared these with data from 108 patients with STEMI treated with PPCI in the prior year from February 1, 2018, to January 31, 2019 (N=108). These 7 patients did not suffer from COVID-19 infection, and 6 out of 7 presented to our hospital during regular work hours (8 am–8 pm weekdays, excluding public holidays). The Table shows numerically longer median times in all components when compared with historical data from the prior year. The largest time difference was in the time from symptom onset to first medical contact. Circulation: Cardiovascular Quality and Outcomes
850 citations
TL;DR: Only 1 in 4 CR-eligible Medicare beneficiaries participated in CR and marked disparities were observed, indicating reinforcement of current effective strategies and development of new strategies will be critical to address the noted disparities and achieve the 70% participation goal.
Abstract: Background: Despite cardiac rehabilitation (CR) being shown to improve health outcomes among patients with heart disease, its use has been suboptimal. In response, the Million Hearts Cardiac Rehabi...
291 citations
TL;DR: A recommendation for transparent and structured reporting of ML analysis results specifically directed at clinical researchers and a list of key reporting elements with examples that can be used as a template when preparing and submitting ML-based manuscripts for the same audience are provided.
Abstract: Use of machine learning (ML) in clinical research is growing steadily given the increasing availability of complex clinical data sets. ML presents important advantages in terms of predictive performance and identifying undiscovered subpopulations of patients with specific physiology and prognoses. Despite this popularity, many clinicians and researchers are not yet familiar with evaluating and interpreting ML analyses. Consequently, readers and peer-reviewers alike may either overestimate or underestimate the validity and credibility of an ML-based model. Conversely, ML experts without clinical experience may present details of the analysis that are too granular for a clinical readership to assess. Overwhelming evidence has shown poor reproducibility and reporting of ML models in clinical research suggesting the need for ML analyses to be presented in a clear, concise, and comprehensible manner to facilitate understanding and critical evaluation. We present a recommendation for transparent and structured reporting of ML analysis results specifically directed at clinical researchers. Furthermore, we provide a list of key reporting elements with examples that can be used as a template when preparing and submitting ML-based manuscripts for the same audience.
198 citations
TL;DR: This analysis includes data from the recently presented International Study of Comparative Health Effectiveness with Medical and Invasive Approaches and Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI (COMPLETE) trials.
Abstract: Background: In patients presenting with ST-segment–elevation myocardial infarction, percutaneous coronary intervention (PCI) reduces mortality when compared with fibrinolysis. In other forms of cor...
142 citations
TL;DR: Housing is a prominent social determinant of cardiovascular health and well-being and should be considered in the evaluation of prevention efforts to reduce and eliminate racial/ethnic and socioeconomic disparities.
Abstract: Cardiovascular disease disparities are shaped by differences in risk factors across racial and ethnic groups. Housing remains an important social determinant of health. The objective of this statement is to review and summarize research that has examined the associations of housing status with cardiovascular health and overall health. PubMed/Medline, Centers for Disease Control and Prevention data, US Census data, Cochrane Library reviews, and the annual Heart Disease and Stroke Statistics report from the American Heart Association were used to identify empirical research studies that examined associations of housing with cardiovascular health and overall well-being. Health is affected by 4 prominent dimensions of housing: stability, quality and safety, affordability and accessibility, and neighborhood environment. Vulnerable and underserved populations are adversely affected by housing insecurity and homelessness, are at risk for lower-quality and unsafe housing conditions, confront structural barriers that limit access to affordable housing, and are at risk for living in areas with substandard built environment features that are linked to cardiovascular disease. Research linking select pathways to cardiovascular health is relatively strong, but research gaps in other housing pathways and cardiovascular health remain. Efforts to eliminate cardiovascular disease disparities have recently emphasized the importance of social determinants of health. Housing is a prominent social determinant of cardiovascular health and well-being and should be considered in the evaluation of prevention efforts to reduce and eliminate racial/ethnic and socioeconomic disparities.
117 citations
TL;DR: In this article, the American Heart Association provides rationale for the widespread adoption of rapid diet screener tools in primary care and relevant specialty care prevention settings, discuss the theory and practice-based criteria of a rapid diet assessment and counseling in clinical settings, review existing tools, and discuss opportunities and challenges for integrating a rapid Diet Screener tool into clinician workflows through the electronic health record.
Abstract: It is critical that diet quality be assessed and discussed at the point of care with clinicians and other members of the healthcare team to reduce the incidence and improve the management of diet-related chronic disease, especially cardiovascular disease. Dietary screening or counseling is not usually a component of routine medical visits. Moreover, numerous barriers exist to the implementation of screening and counseling, including lack of training and knowledge, lack of time, sense of futility, lack of reimbursement, competing demands during the visit, and absence of validated rapid diet screener tools with coupled clinical decision support to identify actionable modifications for improvement. With more widespread use of electronic health records, there is an enormous unmet opportunity to provide evidence-based clinician-delivered dietary guidance using rapid diet screener tools that must be addressed. In this scientific statement from the American Heart Association, we provide rationale for the widespread adoption of rapid diet screener tools in primary care and relevant specialty care prevention settings, discuss the theory- and practice-based criteria of a rapid diet screener tool that supports valid and feasible diet assessment and counseling in clinical settings, review existing tools, and discuss opportunities and challenges for integrating a rapid diet screener tool into clinician workflows through the electronic health record.
89 citations
TL;DR: Over-testing for PE in American EDs remains a major public health problem, and the potential for implementation of D-dimer based protocols to reduce low-yield CTPA ordering is suggested.
Abstract: Background: No recent data have investigated rates of diagnostic testing for pulmonary embolism (PE) in US emergency departments (EDs), and no data have examined computed tomographic pulmonary angi...
87 citations
TL;DR: Nonelderly patients with diabetes mellitus have a high prevalence of financial hardship from medical bills, with deleterious consequences, according to the National Health Interview Survey from 2013 to 2017.
Abstract: Background: The trend of increasing total and out-of-pocket expenditure among patients with diabetes mellitus represents a risk of financial hardship for Americans and a threat to medical and nonme...
82 citations
TL;DR: This article describes a doubly robust estimator which combines both models propitiously to offer analysts 2 chances for obtaining a valid causal estimate and demonstrates its use through a data set from the Lindner Center Study.
Abstract: Propensity score-based methods or multiple regressions of the outcome are often used for confounding adjustment in analysis of observational studies. In either approach, a model is needed: A model describing the relationship between the treatment assignment and covariates in the propensity score-based method or a model for the outcome and covariates in the multiple regressions. The 2 models are usually unknown to the investigators and must be estimated. The correct model specification, therefore, is essential for the validity of the final causal estimate. We describe in this article a doubly robust estimator which combines both models propitiously to offer analysts 2 chances for obtaining a valid causal estimate and demonstrate its use through a data set from the Lindner Center Study.
80 citations
TL;DR: The presence of SIRS identified CICU patients at increased risk of short-term and long-term mortality and these patients have higher illness severity and worse outcomes across the spectrum of SCAI shock stages.
Abstract: Background: The systemic inflammatory response syndrome (SIRS) frequently occurs in patients with cardiogenic shock and may aggravate shock severity and organ failure. We sought to determine the as...
79 citations
TL;DR: Although designed according to the best available evidence with input from various stakeholders and consistent with Centers for Medicare and Medicaid Services TC policies, the COMPASS model of TC was not consistently incorporated into real-world health care.
Abstract: Background The objectives of this study were to develop and test in real-world clinical practice the effectiveness of a comprehensive postacute stroke transitional care (TC) management program. Methods and Results The COMPASS study (Comprehensive Post-Acute Stroke Services) was a pragmatic cluster-randomized trial where the hospital was the unit of randomization. The intervention (COMPASS-TC) was initiated at 20 hospitals, and 20 hospitals provided their usual care. Hospital staff enrolled 6024 adult stroke and transient ischemic attack patients discharged home between 2016 and 2018. COMPASS-TC was patient-centered and assessed social and functional determinates of health to inform individualized care plans. Ninety-day outcomes were evaluated by blinded telephone interviewers. The primary outcome was functional status (Stroke Impact Scale-16); secondary outcomes were mortality, disability, medication adherence, depression, cognition, self-rated health, fatigue, care satisfaction, home blood pressure monitoring, and falls. The primary analysis was intention to treat. Of intervention hospitals, 58% had uninterrupted intervention delivery. Thirty-five percent of patients at intervention hospitals attended a COMPASS clinic visit. The primary outcome was measured for 59% of patients and was not significantly influenced by the intervention. Mean Stroke Impact Scale-16 (±SD) was 80.6±21.1 in TC versus 79.9±21.4 in usual care. Home blood pressure monitoring was self-reported by 72% of intervention patients versus 64% of usual care patients (adjusted odds ratio, 1.43 [95% CI, 1.21-1.70]). No other secondary outcomes differed. Conclusions Although designed according to the best available evidence with input from various stakeholders and consistent with Centers for Medicare and Medicaid Services TC policies, the COMPASS model of TC was not consistently incorporated into real-world health care. We found no significant effect of the intervention on functional status at 90 days post-discharge. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
TL;DR: Major deficiencies in the old allocation system are reviewed, new changes in the new system are summarized, and their potential impact on the landscape of transplant medicine is discussed.
Abstract: In 1984, the National Organ Transplant Act was passed, which led to establishment of the Organ Procurement and Transplantation Network (OPTN) to ensure fair and equitable organ allocation (Figure). In 1986, OPTN contracted with the United Network for Organ Sharing (UNOS), a private nonprofit organization. Since its inception in 1988, the heart transplant (HT) allocation system of OPTN/UNOS has focused on listing patients based on severity of illness and time spent on a national waitlist. Initially, listing for HT was 2-tiered. With the introduction of left ventricular assist devices (LVADs), the allocation system was expanded to a 3-tiered system in 1998 (1A [high priority], 1B [intermediate priority], and 2 [low priority]) in an attempt to reduce waitlist time and mortality. In 2005, broader sharing rules were implemented to facilitate sharing over larger geographic areas, again in an attempt to reduce waitlist time for the most critically ill patients.1 With these changes, waitlist mortality initially declined.2 However, over the past decade, the HT waitlist has grown and at present lists over 4000 patients annually with ≈3000 HTs being performed nationally.3 By 2012, the number of patients listed as 1A and 1B had tripled, leading to a 3× higher waitlist mortality due to the longer waiting time for the most critically ill patients listed as 1A compared to those listed as 1B.4 In light of these emerging data and concerns that the existing system was suboptimal, the OPTN/UNOS heart subcommittee initiated the process of refining the heart allocation criteria, leading to a newly revised allocation policy in December 2016 that was finally implemented in October 2018.5 In this policy brief, we review major deficiencies in the old allocation system, summarize new changes, and discuss their potential impact on the landscape of transplant medicine. POLICY BRIEF
TL;DR: In this paper, the authors characterized the dose offered in supervised Cardiac Rehabilitation (CR) prognosis in clinical practice guidelines, but the dose prescribed varies highly by country. But, they did not evaluate the effectiveness of the recommended CR prognosis.
Abstract: Background: Cardiac rehabilitation (CR) is recommended in clinical practice guidelines, but dose prescribed varies highly by country. This study characterized the dose offered in supervised CR prog...
TL;DR: To learn how a digital health platform could be customized to better serve lowincome patients and the supports necessary to facilitate mHealth adoption with sustained engagement, a novel mHealth application was evaluated.
Abstract: Applications accessible on digital platforms are increasingly popular in healthcare settings and have the potential to help patients engage with their health through monitoring of health behaviors (eg, physical activity, dietary habits) and physiological parameters (eg, heart rate, blood pressure, blood glucose). Some mobile health (mHealth) applications provide patients access to their medical data through patient portals and the ability to participate in real-world, pragmatic research using their smart devices.1 For low-income populations, however, unique barriers to mHealth utilization exist, amplifying the impact of social determinants of health. These barriers include fluency with mobile applications, limited health literacy, lack of empowerment, and historical mistrust of healthcare systems.2 As mHealth platforms play a larger role in healthcare delivery, the digital divide could serve to worsen health disparities.3,4 mHealth applications that are sensitive to the user needs of vulnerable populations have the potential to gain uptake in more diverse communities. Consideration to the visual and linguistic design of mHealth applications, along with how mHealth applications are introduced to patients, may increase adoption and acceptability. One promising intervention is the use of community health workers (CHWs), whose role is to support patients in their health-related needs and address social determinants of health, to promote greater usage and understanding of health applications, although this has not been studied. Accordingly, to better understand the real-world challenges and potential catalysts, including the use of CHWs, in increasing mHealth technology uptake in vulnerable populations, we evaluated the onboarding, perspectives, and experiences of underserved patients using a novel mHealth application. We aimed to learn how a digital health platform could be customized to better serve lowincome patients and the supports necessary to facilitate mHealth adoption with sustained engagement.
TL;DR: Women exhibited substantially more variation in unique symptom phenotypes than men, regardless of whether the symptoms were derived from structured interviews or abstracted from the medical record, and may have important implications for teaching and improving clinicians’ ability to recognize the diagnosis of AMI in women.
Abstract: Background: The diagnosis of acute myocardial infarction (AMI) is missed more frequently in young women than men, which may be related to the cognitive psychology of the diagnostic process. Physici...
Abstract: November 2020 821 © 2020 American Heart Association, Inc. The highly interdependent relationship between the heart and kidneys was described as early as in 1836 by Sir Richard Bright, who identified cardiac structural abnormalities in a series of patients with advanced chronic kidney disease.1 Around the same time in 1835, French chemists isolated phlorizin, a natural, nonselective inhibitor of SGLT1 (sodium glucose co-transporter 1) and SGLT2, as part of early attempts to create an animal model for diabetes. Since then, despite major developments in cardiorenal and metabolic medicine, there has been a relative chasm between availability of new approaches to optimize cardiovascular and kidney outcomes and their implementation in clinical practice. With the advent of the sodium glucose cotransporter 2 inhibitors (SGLT2is) and the glucagon-like receptor-1 agonists and other new cardiorenal protective therapies, the spheres of cardio-nephrology and metabolic medicine have converged in unprecedented ways with the potential for population-level improvements in multidomain health. However, despite high-quality evidence for cardiovascular and kidney protection afforded by these agents, these therapies seem mismatched with population risk such that they are not reaching the highest risk patients with established cardiovascular and/or kidney disease.2,3 For instance, in one study, younger, healthier, and non-Black patients were most likely to start SGLT2i, although patients with cardiovascular or kidney disease were less likely to use SGLT2i from 2013 to 2018.3 This perspective piece explores potential explanations for the underutilization and appropriate deployment of risk-reduction strategies in patients with type 2 diabetes mellitus, kidney disease, and/or cardiovascular disease, and offers the concept of a multidisciplinary cardio-renal-metabolic care model that may help overcome some of these barriers.
TL;DR: The Learning Collaborative developed a framework for a HF value-based payment model with a longitudinal focus on disease management and prevention and an optional track to prevent high-risk stage B pre-HF from progressing to stage C.
Abstract: Heart failure (HF) is a leading cause of hospitalizations and readmissions in the United States. Particularly among the elderly, its prevalence and costs continue to rise, making it a significant population health issue. Despite tremendous progress in improving HF care and examples of innovation in care redesign, the quality of HF care varies greatly across the country. One major challenge underpinning these issues is the current payment system, which is largely based on fee-for-service reimbursement, leads to uncoordinated, fragmented, and low-quality HF care. While the payment landscape is changing, with an increasing proportion of all healthcare dollars flowing through value-based payment models, no longitudinal models currently focus on chronic HF care. Episode-based payment models for HF hospitalization have yielded limited success and have little ability to prevent early chronic disease from progressing to later stages. The available literature suggests that primary care-based longitudinal payment models have indirectly improved HF care quality and cardiovascular care costs, but these models are not focused on addressing patients' longitudinal chronic disease needs. This article describes the efforts and vision of the multi-stakeholder Value-Based Models Learning Collaborative of The Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. The Learning Collaborative developed a framework for a HF value-based payment model with a longitudinal focus on disease management (to reduce adverse clinical outcomes and disease progression among patients with stage C HF) and prevention (an optional track to prevent high-risk stage B pre-HF from progressing to stage C). The model is designed to be compatible with prevalent payment models and reforms being implemented today. Barriers to success and strategies for implementation to aid payers, regulators, clinicians, and others in developing a pilot are discussed.
TL;DR: A greater number of SDVs significantly increased risk of incident HF hospitalization among adults <65 years, which persisted after adjustment for cardiovascular risk factors.
Abstract: Background: Socially determined vulnerabilities (SDVs) to health disparities often cluster within the same individual. SDVs are separately associated with increased risk of heart failure (HF). The ...
TL;DR: A paradoxical relationship was observed between clinical outcomes and costs among racial and ethnic minorities and the SDOH risk model alone performed with equal or superior accuracy to the model based on clinical comorbidities.
Abstract: Background: Risk models in the private insurance setting may systematically underpredict in the socially disadvantaged. In this study, we sought to determine whether US minority Medicare beneficiar...
TL;DR: A decision model suggests that FAV provides a modest, medium-term survival benefit over expectant fetal management and Appropriate patient selection and low risk of fetal demise with FAV are critical factors for obtaining a survival benefit.
Abstract: Background: Fetal aortic valvuloplasty (FAV) may prevent progression of midgestation aortic stenosis to hypoplastic left heart syndrome. However, FAV has well-established risks, and its survival be...
TL;DR: Biykem Bozkurt, MD, FACC, FAHA, Chair as mentioned in this paper, Chair-Elect Hani Jneid and Srinath Adusumalli.
Abstract: Biykem Bozkurt, MD, FACC, FAHA, Chair
Hani Jneid, MD, FACC, FAHA, Chair-Elect
Srinath Adusumalli, MD, MSc, FACC
Sana Al-Khatib, MD, MHS, FACC, FAHA[‖][1]
H. Vernon Anderson, MD, FACC, FAHA[‖][1]
Deepak L. Bhatt, MD, MPH, FACC, FAHA
Bruce E. Bray, MD, FACC
Grant Nigel Graham, MD, FACC
TL;DR: Physician outpatient practices that serve the most socioeconomically disadvantaged patients with CAD perform worse on some clinical outcomes, despite providing similar guideline-recommended care as other practices, and consequently could fare poorly under value-based payment programs.
Abstract: Background: Medicare patients with coronary artery disease (CAD) have been a significant focus of value-based payment programs for outpatient practices. Physicians and policymakers, however, have v...
TL;DR: This work sought to measure the impact of the COVID-19 pandemic on emergency transfers for STEMI, stroke, and acute aortic emergencies within the regional health system.
Abstract: The COVID-19 pandemic has dramatically impacted healthcare delivery worldwide. In hotspot areas such as Wuhan, Lombardy, and New York City, the disease has forced hospitals to focus on COVID-19 patients. Anecdotal reports have suggested that the pandemic has led to a decrease in patients presenting to these hospitals with serious cardiovascular and neurologic diseases such as ST-elevation myocardial infarction (STEMI) and stroke. We sought to measure the impact of the COVID-19 pandemic on emergency transfers for STEMI, stroke, and acute aortic emergencies within our regional health system.
TL;DR: In this article, patients with atrial fibrillation and severely decreased kidney function were excluded from the pivotal non-vitamin K antagonist oral anticoagulants (NOAC) trials.
Abstract: Background: Patients with atrial fibrillation and severely decreased kidney function were excluded from the pivotal non–vitamin K antagonist oral anticoagulants (NOAC) trials, thereby raising quest...
TL;DR: Investigation of incidence, trends, causes, and risk factors for SCD in the young in people aged 1 to 35 years in Australia found that incidence has declined in recent years and proportion of SCD related to sudden arrhythmic death syndrome increased over the study period.
Abstract: Background: Sudden cardiac death (SCD) in the young is devastating. Contemporary incidence remains unclear with few recent nationwide studies and limited data addressing risk factors for causes. We...
Northwestern University1, Duke University2, Durham University3, Temple University4, Roy J. and Lucille A. Carver College of Medicine5, Veterans Health Administration6, Wilmington University7, University of California, San Francisco8, Vanderbilt University Medical Center9, University of Kansas10, Cornell University11
TL;DR: The ADAPTABLE computable phenotype served as an efficient method to recruit patients in a multisite pragmaticclinical trial testing the optimal dose of aspirin for secondary prevention of atherosclerotic cardiovascular disease events.
Abstract: Background: Many large-scale cardiovascular clinical trials are plagued with escalating costs and low enrollment. Implementing a computable phenotype, which is a set of executable algorithms, to id...
TL;DR: Although reimagining prior authorization requires collective action by all stakeholders, it may significantly reduce administrative burden for clinicians and payers while improving outcomes for patients.
Abstract: Utilization management strategies, including prior authorization, are commonly used to facilitate safe and guideline-adherent provision of new, individualized, and potentially costly cardiovascular therapies. However, as currently deployed, these approaches encumber multiple stakeholders. Patients are discouraged by barriers to appropriate access; clinicians are frustrated by the time, money, and resources required for prior authorizations, the frequent rejections, and the perception of being excluded from the decision-making process; and payers are weary of the intensive effort to design and administer increasingly complex prior authorization systems to balance value and appropriate use of these treatments. These issues highlight an opportunity to collectively reimagine utilization management as a transparent and collaborative system. This would benefit the entire healthcare ecosystem, especially in light of the shift to value-based payment. This article describes the efforts and vision of the multistakeholder Prior Authorization Learning Collaborative of the Value in Healthcare Initiative, a partnership between the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. We outline how healthcare organizations can take greater utilization management responsibility under value-based contracting, especially under different state policies and local contexts. Even with reduced payer-mandated prior authorization in these arrangements, payers and healthcare organizations will have a continued shared need for utilization management. We present options for streamlining these programs, such as gold carding and electronic and automated prior authorization processes. Throughout the article, we weave in examples from cardiovascular care when possible. Although reimagining prior authorization requires collective action by all stakeholders, it may significantly reduce administrative burden for clinicians and payers while improving outcomes for patients.
TL;DR: There are meaningful sociodemographic disparities in access and outcomes for LVAD implantation, and Medicaid expansion was not associated with an increase in LVAD rates.
Abstract: Background: Left ventricular assist device (LVAD) therapy is an increasingly viable alternative for patients who are not candidates for heart transplantation or who are waiting for a suitable donor...
TL;DR: A national model suggests that the full implementation of the US calorie menu labeling law will generate significant health gains and healthcare and societal cost-savings.
Abstract: Background: Excess caloric intake is linked to weight gain, obesity, and related diseases, including type 2 diabetes mellitus and cardiovascular disease (CVD). Obesity incidence is rising, with nea...