IMPACT Coronary Heart Disease Policy Model and Prevention Policies
Submitting InstitutionUniversity of Liverpool
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Cardiorespiratory Medicine and Haematology, Public Health and Health Services
Summary of the impact
Capewell's MRC/EU/NIHR funded IMPACT programme has been developed at the
Liverpool (UoL) since 1999. It examines why cardiovascular disease (CVD)
death rates have
recently halved in the UK, USA and Europe (mainly risk factor improvements
treatments), and why CVD rates are increasing in China and most developing
risk factor trends reflecting a Westernised diet). Results have informed
CVD prevention strategies
in the UK and beyond, notably NICE Guidance on CVD prevention in whole
strong NICE recommendations on diet and tobacco were recently endorsed in
Commissioning Guidance and European and American guidance.
Cardiovascular disease (CVD) mainly comprises coronary heart disease and
generates a huge and unequal burden of premature mortality globally. In
the UK, annually causing
over 100,000 deaths and costing over £30 billion in the UK. However, CVD
Capewell has been Professor of Clinical Epidemiology in the University of
Liverpool (UoL) from 1999.
Research funding has come from the MRC, EU, BHF, NHS, NIH, NIHR and a
variety of foreign
sources. His team has included UoL Senior Lecturers Martin O'Flaherty and
(since 2006), plus many other UK and international colleagues.
Capewell's policy model, IMPACT, has been progressively developed and
refined at the UoL since
2000. The IMPACT model is comprehensive, synthesising data on all standard
treatments in all
patient groups, plus changes in all the major risk factors. It has been
tested, refined and validated,
particularly since 2008. IMPACT is the most widely used comprehensive CVD
policy model in the
world. It can now estimate deaths prevented or postponed,
life-years-gained, the cost-effectiveness of
different interventions, and the future deaths prevented by different
prevention policies (such as
increases in specific treatments or decreases in particular risk factors
IMPACT results have now been used to help to explain Coronary Heart
Disease (CHD) mortality
trends in over twenty very different populations, including England and
Wales, Scotland, Northern
Ireland, Ireland, Finland, Sweden, Iceland, Poland, the Czech Republic,
Italy, Spain, Syria,
Palestine, Tunisia, Turkey, China, New Zealand, Canada and the USA
The consistent findings from the IMPACT studies are that the largest
component of the widespread
declines in cardiovascular mortality rates reflects population-wide
improvements in major risk factors — notably
smoking, blood pressure and cholesterol (mainly reflecting diet).
contributions then coming from specific medical treatments for acute cases
and thereafter for patients
with chronic cardiovascular disease [1-6].
Worryingly, the recent rises in obesity and diabetes prevalence have
generated additional deaths in the
UK and far beyond . Westernisation of diet has been particularly
powerful and damaging in low and
middle income countries (such as China, Syria & Tunisia) which are now
suffering dramatic and costly
increases in non-communicable disease burdens (notably cardiovascular
disease and diabetes) .
Since 2006, this MRC-funded research programme has been exploring the
between evidence, policy makers and decision making . Collaborations
with UCL since 2010 have
produced IMPACTsec. This is the first comprehensive CHD policy model able
to quantify trends in
specific socio-economic groups. These studies confirmed the more powerful
effects of major risk
factors in deprived groups. Happily, they also demonstrated remarkably
equitable treatments across
all socioeconomic groups . From 2010 onwards, Capewell's group has also
refined food policy models. Results suggest that reducing dietary intake
of salt, transfats and saturated
fats and increasing fruit and vegetable consumption could massively reduce
death rates .
References to the research
These references report Capewell's coronary heart disease modelling to
explain past mortality
trends and to inform CVD prevention policies in the UK and beyond.
1. Ford ES, Ajani US, Croft JB, Critchley JA, Labarthe DR, Kottke DE,
Giles WH, Capewell S.
Explaining the Decrease in U.S. deaths from Coronary Disease, 1980-2000.
Journal of Medicine 2007; 356: 2388-2398. PMID: 17554120 Citations: 961
2. Huffman MD, Ning H, Shay CM, Ford ES, Lloyd-Jones BM, Guzman M, O'Flaherty
Capewell S. Quantifying Options For Reducing Coronary Heart Disease
Mortality By 2020.
Circulation. 2013 127 2477. Citations: 0 Impact Factor: 15.202
3. Taylor-Robinson DC et al. Policy-makers' attitudes to decision
support models for
coronary disease: a qualitative study. BMC Public Health. 2008, 8:415
Impact Factors: 2.076
4. Bajekal M, Scholes S, Love H, Hawkins N, O'Flaherty M, Raine
R, Capewell S. Analysing
recent socioeconomic trends in coronary heart disease mortality in
England, 2000-2007: a
population modelling study. PLoS Medicine 2012; 9(6): e1001237.
doi:10.1371/journal.pmed.1001237 Citations: 9 Impact Factor: 15.253
5. Saidi O, Ben Mansour N, O'Flaherty M, Capewell S,
Critchley J, Ben Romdhan H.
Analyzing recent coronary heart disease mortality trends in Tunisia
between 1997 and
2009. PLoS ONE 2013 8(5): e63202. doi:10.1371/journal.pone.0063202
Impact Factor: 3.730
6. O'Flaherty M, Flores-Mateo G, Nnoaham K, Lloyd-Williams F, Capewell
cardiovascular mortality reductions with different food policy options in
Bulletin of WHO 2012, 90: 522-531. PMID: 22807598 Citations 8 Impact
Key grant awards relating to this work
2006-2008. Medical Research Council MRC. (£405,000). Extending the
coronary heart disease model to different health policy contexts
[G0500920], PI S Capewell
2008-2012. Liverpool Primary Care Trust, MerseyBEAT, £2m,
S Capewell (PI and
Programme Director), M Gabbay, J Wilding, M Pearson, M
Whitehead, J Neilson, T
Walley, K Wilson; Liverpool Institute for Health
Inequalities Research (LivHIR).
2009-2012. Medical Research Council. (NPRI3).
(£500,700) Prevention IMPACT:
developing and evaluating economic models for planning optimal
strategies, £500k, PI S Capewell
2008-2012. European Commission PHEA. 2008 -2012. (2,800,000 Euros).
"MedCHAMPS — MEDiterranean studies of Cardiovascular
disease and Hyperglycaemia:
Analytical Modelling of Population Socio-economic
transitions. €2.8m. N Unwin, JA
Critchley, S Capewell, K Bennett, B Ahmad, P Phillimore, B Unal, Y
Demiral, B Kilic; W
Maziak; A Mataria, A Husseini, N Abu-Rmeileh, R Khatib, H Rhomdane & H
2012-2016. NIHR School for Public Health Research Liverpool &
(£2.5m) M Whitehead , J Popay, S Capewell, P Diggle and C
(including: Modelling preventive interventions to address inequalities in
PI S Capewell).
2012-2017 British Heart Foundation Programme Grant (£1,507,000)
Vascular risk and
functional decline in old age. E Brunner (PI), M Kivimaki, A
Singh-Manoux, M Marmot, & S
Details of the impact
The process through which the research led to the impact
Since 2000, this University of Liverpool programme led by Capewell has
provided innovative and
robust analyses consistently showing that upward or downward trends in
death rates from heart
disease and stroke mainly reflect changes in powerful cardiovascular risk
smoking and diet. The contributions from specific medical treatments have
also been consistently
quantified. This and subsequent work enabled Capewell and Liverpool
colleagues to widely
disseminate evidence-base key messages on strategies for the prevention of
disease and non-communicable diseases. Notably, that population-wide
can be powerful, rapid, equitable and cost saving.
This cutting edge IMPACT CHD Policy research has influenced public policy
debate in the UK and
internationally. It has provided scientific evidence endorsing UK policies
on tobacco control and
healthy diet. It has informed the evaluation of the subsequent
interventions in Europe and beyond.
Furthermore, Professor Capewell has shared his findings with policy makers
in numerous countries
developing CVD prevention strategies, including Sweden, Tunisia, China and
The principal beneficiaries have been policy makers and the general
public through improved
public health polices and information that reduces CVD and improves
health. Capewell's seminal
work has been widely cited. He has also received invitations to talk to
politicians and policy
makers in London, the European Parliament in Brussels and the World Health
(details below), plus presentations to lecture in prestigious academic
settings in the UK, Europe,
the USA (Harvard, Yale etc), and Australia (Sydney & Melbourne
Proof of contribution
Capewell's research has been seen as a key contributor to CVD prevention
policy for well over a
decade. Capewell and colleagues have extensively disseminated their
including to policy makers and politicians. This led in 2008 to an
invitation to Capewell from NICE
(The National Institute of Health and Clinical Excellence) to write a
specification for a full guidance
review on Cardiovascular disease prevention at the population level.
. This was subsequently
supported by the NICE Topic Review Group, and then approved by ministers.
This then led to the
formation of the NICE Programme Development Group (PDG) in 2009. Capewell
as PDG Vice Chair. He also served as a topic expert, authoring three NICE
evidence papers which
were subsequently cited as evidence in the final NICE publication in 2010
The NICE Guidance was published in June 2010 . Fully implemented, the
could prevent up to 40,000 premature cardiovascular deaths each year. The
received extensive positive media coverage including the Telegraph (front
page), The Times, BBC,
ITV etc. Altogether totaling over 150 separate news items, plus invited
editorials for Capewell in
the New Scientist, JAMA, European Heart J and Heart (all 2010), thus
influencing the wider clinical
The 2010 NICE guidance has now been endorsed and extended in the 2012
Guide on CVD prevention . This has informed Primary Health Care Trusts
Commissioning Groups and Wellbeing Boards. Thus, directly influencing NHS
and local authority CVD
budgets which exceed £10 billion per year.
The NICE Report has also been endorsed by the European Society of
We also reinforced the nutrition messages in a BMJ editorial , which
then fed into recent
American Heart Association Guidelines on CVD prevention .
These publications also increased the weight of scientific evidence and
political pressure acting on
the policy makers and officials planning the UN High Level Meeting on
Prevention and Control in Sept 2011. That specifically recommended
reductions in dietary salt and
tobacco which were subsequently actioned by the World Health Organisation
Capewell's research has also translated into UK Faculty of Public
Health Position papers.
These are used as authoritative guidance by public health practitioners
across the UK. Capewell
has been notably active in co-authoring and advocating improvements in
food policy, specifically
around European subsidies from the Common Agricultural Policy, and front
of pack Traffic Light
Labelling to better inform consumers [13, 14].
Capewell was also invited as the sole public health expert on the Academy
of Medical Royal
Colleges Obesity Review . He was thus able to advise on the most
effective and cost-effective
interventions. As well as dissemination to the AoMRC membership of over
200,000 doctors, the
report, Measuring Up: the medical profession's prescription for the
nation's obesity crisis received
extensive positive media coverage, raising public awareness, and
influencing policy makers and
politicians. The recommendations highlighted the crucial need for
effective policy interventions to
prevent obesity (and subsequent chronic diseases), notably protecting
children from the
aggressive marketing of junk food and sugary drinks, putting a duty on
sugary drinks, and ensuring
that healthy food was routinely provided in ALL UK schools .
Sources to corroborate the impact
Each source listed below provides evidence for the corresponding numbered
claim made in section
4 (details of the impact).
- Capewell S, Blamey A, Lincoln P, Mwatsama M, Lloyd
Williams F; Critchley JA,
Ireland R, Birt C, Platt S, Summerton N, Miller C, Field
J. Cardiovascular disease
prevention at the population level. NICE Potential Public Health
Programme Guidance, 2179.
2008. NICE, London.
- NICE Public Health Guidance: Prevention of cardiovascular disease at
2010 (PH25). http://guidance.nice.org.uk/PH25
- NICE CMG45: Integrated commissioning for the prevention of
cardiovascular disease. (2012).
- Jørgensen T et al. Population level changes to promote
cardiovascular health. European
Journal of Preventive Cardiology (2013); 20 (3): 409-21
- Mozaffarian D. United Nations dietary policies to prevent
cardiovascular disease. Modest
diet changes could halve the global burden. BMJ 2011; 343: d5747 PMIB:
- Mozaffarian D et al. American Heart Association Council on
Epidemiology and Prevention,
Council on Nutrition, Physical Activity and Metabolism, Council on
Council on Cardiovascular Disease in the Young.
Population approaches to improve diet, physical activity, and smoking
habits: a scientific
statement from the American Heart Association. Circulation.
- Birt C, Maryon-Davis A, Stewart L, Parkin C, Mwatswama M, Capewell
A CAP on Health. UK Faculty of Public Health. 2008. ISBN: 1-900273-25-X
- UK Faculty of Public Health. Position statement: Traffic-light food
labelling. August 2008.
- Stephenson T, Bhui K, Capewell S et al. Measuring Up:
the medical profession's
prescription for the nation's obesity crisis. Academy of Medical
Royal Colleges, London.