Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use

The rise of chronic non-communicable diseases in southeast Asia: time for action

Southeast Asia faces an epidemic of chronic non-communicable diseases, now responsible for 60% of deaths in the region. The problem stems from environmental factors that promote tobacco use, unhealthy diet, and inadequate physical activity. Disadvantaged populations are the hardest hit, with death rates inversely proportional to a country's gross national income. Families shoulder the financial burden, but entire economies suffer as well. Although attempts to control non-communicable diseases are increasing, more needs to be done. Health-care systems need to be redesigned to deliver chronic care that is founded on existing primary health-care facilities, but supported by good referral systems. Surveillance of key modifiable risk factors is needed to monitor the magnitude of the problem and to study the effects of interventions. All branches of government and all sectors of society have to get involved in establishing environments that are conducive to healthy living. The Association of Southeast Asian Nations is in a unique position to make a united stand against chronic non-communicable diseases in the region. Inaction will affect millions of lives-often, the lives of those who have the least.

Potential impact of single-risk-factor versus total risk management for the prevention of cardiovascular events in Seychelles

OBJECTIVE

To assess the prevalence of cardiovascular (CV) risk factors in Seychelles, a middle-income African country, and compare the cost-effectiveness of single-risk-factor management (treating individuals with arterial blood pressure ≥ 140/90 mmHg and/or total serum cholesterol ≥ 6.2 mmol/l) with that of management based on total CV risk (treating individuals with a total CV risk ≥ 10% or ≥ 20%).

METHODS

CV risk factor prevalence and a CV risk prediction chart for Africa were used to estimate the 10-year risk of suffering a fatal or non-fatal CV event among individuals aged 40-64 years. These figures were used to compare single-risk-factor management with total risk management in terms of the number of people requiring treatment to avert one CV event and the number of events potentially averted over 10 years. Treatment for patients with high total CV risk (≥ 20%) was assumed to consist of a fixed-dose combination of several drugs (polypill). Cost analyses were limited to medication.

FINDINGS

A total CV risk of ≥ 10% and ≥ 20% was found among 10.8% and 5.1% of individuals, respectively. With single-risk-factor management, 60% of adults would need to be treated and 157 cardiovascular events per 100000 population would be averted per year, as opposed to 5% of adults and 92 events with total CV risk management. Management based on high total CV risk optimizes the balance between the number requiring treatment and the number of CV events averted.

CONCLUSION

Total CV risk management is much more cost-effective than single-risk-factor management. These findings are relevant for all countries, but especially for those economically and demographically similar to Seychelles.

Effectiveness and cost-effectiveness of blood pressure screening in adolescents in the United States

OBJECTIVE

To compare the long-term effectiveness and cost-effectiveness of 3 approaches to managing elevated blood pressure (BP) in adolescents in the United States: no intervention, "screen-and-treat," and population-wide strategies to lower the entire BP distribution.

STUDY DESIGN

We used a simulation model to combine several data sources to project the lifetime costs and cardiovascular outcomes for a cohort of 15-year-old U.S. adolescents under different BP approaches and conducted cost-effectiveness analysis. We obtained BP distributions from the National Health and Nutrition Examination Survey 1999-2004 and used childhood-to-adult longitudinal correlation analyses to simulate the tracking of BP. We then used the coronary heart disease policy model to estimate lifetime coronary heart disease events, costs, and quality-adjusted life years (QALY).

RESULTS

Among screen-and-treat strategies, finding and treating the adolescents at highest risk (eg, left ventricular hypertrophy) was most cost-effective ($18000/QALY [boys] and $47000/QALY [girls]). However, all screen-and-treat strategies were dominated by population-wide strategies such as salt reduction (cost-saving [boys] and $650/QALY [girls]) and increasing physical education ($11000/QALY [boys] and $35000/QALY [girls]).

CONCLUSIONS

Routine adolescents BP screening is moderately effective, but population-based BP interventions with broader reach could potentially be less costly and more effective for early cardiovascular disease prevention and should be implemented in parallel.

Chronic diseases and injuries in India

Chronic diseases (eg, cardiovascular diseases, mental health disorders, diabetes, and cancer) and injuries are the leading causes of death and disability in India, and we project pronounced increases in their contribution to the burden of disease during the next 25 years. Most chronic diseases are equally prevalent in poor and rural populations and often occur together. Although a wide range of cost-effective primary and secondary prevention strategies are available, their coverage is generally low, especially in poor and rural populations. Much of the care for chronic diseases and injuries is provided in the private sector and can be very expensive. Sufficient evidence exists to warrant immediate action to scale up interventions for chronic diseases and injuries through private and public sectors; improved public health and primary health-care systems are essential for the implementation of cost-effective interventions. We strongly advocate the need to strengthen social and policy frameworks to enable the implementation of interventions such as taxation on bidis (small hand-rolled cigarettes), smokeless tobacco, and locally brewed alcohols. We also advocate the integration of national programmes for various chronic diseases and injuries with one another and with national health agendas. India has already passed the early stages of a chronic disease and injury epidemic; in view of the implications for future disease burden and the demographic transition that is in progress in India, the rate at which effective prevention and control is implemented should be substantially increased. The emerging agenda of chronic diseases and injuries should be a political priority and central to national consciousness, if universal health care is to be achieved.

Multiple risk factor interventions for primary prevention of coronary heart disease

BACKGROUND

Multiple risk factor interventions using counselling and educational methods assumed to be efficacious and cost-effective in reducing coronary heart disease (CHD) mortality and morbidity and that they should be expanded. Trials examining risk factor changes have cast doubt on the effectiveness of these interventions.

OBJECTIVES

To assess the effects of multiple risk factor interventions for reducing total mortality, fatal and non-fatal events from CHD and cardiovascular risk factors among adults assumed to be without prior clinical evidence CHD..

SEARCH STRATEGY

We updated the original search BY SEARCHING CENTRAL (2006, Issue 2), MEDLINE (2000 to June 2006) and EMBASE (1998 to June 2006), and checking bibliographies.

SELECTION CRITERIA

Randomised controlled trials of more than six months duration using counselling or education to modify more than one cardiovascular risk factor in adults from general populations, occupational groups or specific risk factors (i.e. diabetes, hypertension, hyperlipidaemia, obesity).

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. We expressed categorical variables as odds ratios (OR) with 95% confidence intervals (CI). Where studies published subsequent follow-up data on mortality and event rates, we updated these data.

MAIN RESULTS

We found 55 trials (163,471 participants) with a median duration of 12 month follow up. Fourteen trials (139,256 participants) with reported clinical event endpoints, the pooled ORs for total and CHD mortality were 1.00 (95% CI 0.96 to 1.05) and 0.99 (95% CI 0.92 to 1.07), respectively. Total mortality and combined fatal and non-fatal cardiovascular events showed benefits from intervention when confined to trials involving people with hypertension (16 trials) and diabetes (5 trials): OR 0.78 (95% CI 0.68 to 0.89) and OR 0.71 (95% CI 0.61 to 0.83), respectively. Net changes (weighted mean differences) in systolic and diastolic blood pressure (53 trials) and blood cholesterol (50 trials) were -2.71 mmHg (95% CI -3.49 to -1.93), -2.13 mmHg (95% CI -2.67 to -1.58 ) and -0.24 mmol/l (95% CI -0.32 to -0.16), respectively. The OR for reduction in smoking prevalence (20 trials) was 0.87 (95% CI 0.75 to 1.00). Marked heterogeneity (I(2) > 85%) for all risk factor analyses was not explained by co-morbidities, allocation concealment, use of antihypertensive or cholesterol-lowering drugs, or by age of trial.

AUTHORS' CONCLUSIONS

Interventions using counselling and education aimed at behaviour change do not reduce total or CHD mortality or clinical events in general populations but may be effective in reducing mortality in high-risk hypertensive and diabetic populations. Risk factor declines were modest but owing to marked unexplained heterogeneity between trials, the pooled estimates are of dubious validity. Evidence suggests that health promotion interventions have limited use in general populations.

Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years

BACKGROUND

The burden of non-communicable chronic diseases, such as hypertension and diabetes, increases in sub-Saharan Africa. However, the majority of the rural population does still not have access to adequate care. The objective of this study is to examine the effectiveness of integrating care for hypertension and type 2 diabetes by task shifting to non-physician clinician (NPC) facilities in eight rural health districts in Cameroon.

METHODS

Of the 75 NPC facilities in the area, 69 (87%) received basic equipment and training in hypertension and diabetes care. Effectiveness was assessed after two years on status of equipment, knowledge among trained NPCs, number of newly detected patients, retention of patients under care, treatment cost to patients and changes in blood pressure (BP) and fasting plasma glucose (FPG) among treated patients.

RESULTS

Two years into the programme, of 54 facilities (78%) available for re-assessment, all possessed a functional sphygmomanometer and stethoscope (65% at baseline); 96% stocked antihypertensive drugs (27% at baseline); 70% possessed a functional glucose meter and 72% stocked oral anti-diabetics (15% and 12% at baseline). NPCs' performance on multiple-choice questions of the knowledge-test was significantly improved. During a period of two years, trained NPCs initiated treatment for 796 patients with hypertension and/or diabetes. The retention of treated patients at one year was 18.1%. Hypertensive and diabetic patients paid a median monthly amount of 1.4 and 0.7 Euro respectively for their medication. Among hypertensive patients with ≥ 2 documented visits (n = 493), systolic BP decreased by 22.8 mmHg (95% CI: -20.6 to -24.9; p < 0.0001) and diastolic BP by 12.4 mmHg (-10.9 to -13.9; p < 0.0001). Among diabetic patients (n = 79) FPG decreased by 3.4 mmol/l (-2.3 to -4.5; p < 0.001).

CONCLUSIONS

The integration of hypertension and diabetes into primary health care of NPC facilities in rural Cameroon was feasible in terms of equipment and training, accessible in terms of treatment cost and showed promising BP- and FPG-trends. However, low case-detection rates per NPC and a very high attrition among patients enrolled into care, limited the effectiveness of the programme.

Economic evaluations on cardiovascular preventive interventions in Argentina

Cardiovascular diseases are the main cause of death in Argentina. This article analyzes economic evaluations on cardiovascular prevention for this country. A literature search was conducted in five electronic databases during December 2009. Inclusion criteria were complete economic evaluations addressing at least one cardiovascular health outcome for the Argentinean population. Finally, nine studies were included evaluating 14 comparisons. Interventions oriented to primary or secondary prevention in patients that had undergone coronary angioplasty, with a previous cardiovascular event or equivalents, with a hospitalization for heart failure or general population were evaluated. Bread salt reduction, antihypertensive treatment, mass educational campaigns and polypill strategies could be considered cost effective. The available economic evidence to guide resource allocation in cardiovascular disease in Argentina seems to be scarce and limited.

Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness

The obesity epidemic is spreading to low-income and middle-income countries as a result of new dietary habits and sedentary ways of life, fuelling chronic diseases and premature mortality. In this report we present an assessment of public health strategies designed to tackle behavioural risk factors for chronic diseases that are closely linked with obesity, including aspects of diet and physical inactivity, in Brazil, China, India, Mexico, Russia, and South Africa. England was included for comparative purposes. Several population-based prevention policies can be expected to generate substantial health gains while entirely or largely paying for themselves through future reductions of health-care expenditures. These strategies include health information and communication strategies that improve population awareness about the benefits of healthy eating and physical activity; fiscal measures that increase the price of unhealthy food content or reduce the cost of healthy foods rich in fibre; and regulatory measures that improve nutritional information or restrict the marketing of unhealthy foods to children. A package of measures for the prevention of chronic diseases would deliver substantial health gains, with a very favourable cost-effectiveness profile.

Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries

National health systems need strengthening if they are to meet the growing challenge of chronic diseases in low-income and middle-income countries. By application of an accepted health-systems framework to the evidence, we report that the factors that limit countries' capacity to implement proven strategies for chronic diseases relate to the way in which health systems are designed and function. Substantial constraints are apparent across each of the six key health-systems components of health financing, governance, health workforce, health information, medical products and technologies, and health-service delivery. These constraints have become more evident as development partners have accelerated efforts to respond to HIV, tuberculosis, malaria, and vaccine-preventable diseases. A new global agenda for health-systems strengthening is arising from the urgent need to scale up and sustain these priority interventions. Most chronic diseases are neglected in this dialogue about health systems, despite the fact that non-communicable diseases (most of which are chronic) will account for 69% of all global deaths by 2030 with 80% of these deaths in low-income and middle-income countries. At the same time, advocates for action against chronic diseases are not paying enough attention to health systems as part of an effective response. Efforts to scale up interventions for management of common chronic diseases in these countries tend to focus on one disease and its causes, and are often fragmented and vertical. Evidence is emerging that chronic disease interventions could contribute to strengthening the capacity of health systems to deliver a comprehensive range of services-provided that such investments are planned to include these broad objectives. Because effective chronic disease programmes are highly dependent on well-functioning national health systems, chronic diseases should be a litmus test for health-systems strengthening.

Raising the priority of preventing chronic diseases: a political process

Chronic diseases, especially cardiovascular diseases, diabetes, cancer, and chronic obstructive respiratory diseases,are neglected globally despite growing awareness of the serious burden that they cause. Global and national policies have failed to stop, and in many cases have contributed to, the chronic disease pandemic. Low-cost and highly effective solutions for the prevention of chronic diseases are readily available; the failure to respond is now a political, rather than a technical issue. We seek to understand this failure and to position chronic disease centrally on the global health and development agendas. To identify strategies for generation of increased political priority for chronic diseases and to further the involvement of development agencies, we use an adapted political process model. This model has previously been used to assess the success and failure of social movements. On the basis of this analysis,we recommend three strategies: reframe the debate to emphasise the societal determinants of disease and the interrelation between chronic disease, poverty, and development; mobilise resources through a cooperative and inclusive approach to development and by equitably distributing resources on the basis of avoidable mortality; and build one merging strategic and political opportunities, such as the World Health Assembly 2008–13 Action Plan and the high level meeting of the UN General Assembly in 2011 on chronic disease. Until the full set of threats—which include chronic disease—that trap poor households in cycles of debt and illness are addressed, progress towards equitable human development will remain inadequate.

Noncommunicable chronic disease in Bangladesh: overview of existing programs and priorities going forward

OBJECTIVE

This paper reviews existing NCD programs in Bangladesh and identifies key priorities for the country to help address the NCD burden.

METHODS

To identify existing chronic disease programs in Bangladesh, country experts were interviewed and literature searches were conducted in PubMed and Ovid Medline (January 1970 to June 2009) for potentially relevant studies focused on tobacco-related illnesses, diabetes or cardiovascular disease. Programs not being implemented at the time of the study were excluded. Programs underway at the time of the study were included.

RESULTS

Bangladesh has a total of 11 NCD programs at varying levels of development. Roughly half of the programs involved diabetes; three addressed the reduction of primary risk factors and about half provided infrastructure (e.g., hospitals or clinics) for NCD services or health professional training. The programs were roughly divided between the government and nongovernment organizations (NGOs).

CONCLUSIONS

The Bangladeshi government and non-government organizations have taken several steps to implement appropriate NCD programs, but there are many areas where efforts could be enhanced or strengthened. Key among them is improved monitoring and evaluation of NCD programs and the development of nationally representative NCD surveillance data which includes prevalence and associated risk factors.

Estimation of the burden of cardiovascular disease attributable to modifiable risk factors and cost-effectiveness analysis of preventative interventions to reduce this burden in Argentina

BACKGROUND

Cardiovascular disease (CVD) is the primary cause of mortality and morbidity in Argentina representing 34.2% of deaths and 12.6% of potential years of life lost (PYLL). The aim of the study was to estimate the burden of acute coronary heart disease (CHD) and stroke and the cost-effectiveness of preventative population-based and clinical interventions.

METHODS

An epidemiological model was built incorporating prevalence and distribution of high blood pressure, high cholesterol, hyperglycemia, overweight and obesity, smoking, and physical inactivity, obtained from the Argentine Survey of Risk Factors dataset. Population Attributable Fraction (PAF) of each risk factor was estimated using relative risks from international sources. Total fatal and non-fatal events, PYLL and Disability Adjusted Life Years (DALY) were estimated. Costs of event were calculated from local utilization databases and expressed in international dollars (I$). Incremental cost-effectiveness ratios (ICER) were estimated for six interventions: reducing salt in bread, mass media campaign to promote tobacco cessation, pharmacological therapy of high blood pressure, pharmacological therapy of high cholesterol, tobacco cessation therapy with bupropion, and a multidrug strategy for people with an estimated absolute risk > 20% in 10 years.

RESULTS

An estimated total of 611,635 DALY was lost due to acute CHD and stroke for 2005. Modifiable risk factors explained 71.1% of DALY and more than 80% of events. Two interventions were cost-saving: lowering salt intake in the population through reducing salt in bread and multidrug therapy targeted to persons with an absolute risk above 20% in 10 years; three interventions had very acceptable ICERs: drug therapy for high blood pressure in hypertensive patients not yet undergoing treatment (I$ 2,908 per DALY saved), mass media campaign to promote tobacco cessation amongst smokers (I$ 3,186 per DALY saved), and lowering cholesterol with statin drug therapy (I$ 14,432 per DALY saved); and one intervention was not found to be cost-effective: tobacco cessation with bupropion (I$ 59,433 per DALY saved)

CONCLUSIONS

Most of the interventions selected were cost-saving or very cost-effective. This study aims to inform policy makers on resource-allocation decisions to reduce the burden of CVD in Argentina.

Cost-effectiveness analysis of interventions to prevent cardiovascular disease in Vietnam

BACKGROUND

Vietnam is in the process of an epidemiological transition, with cardiovascular disease (CVD) now ranked as the leading cause of death. The burden of CVD will continue to rise unless effective interventions for addressing its underlying risk factors are put in place.

OBJECTIVES

To assess the costs, health effects and cost-effectiveness of a set of personal and non-personal prevention strategies to reduce CVD in Vietnam, including mass media campaigns for reducing consumption of salt and tobacco, drugs for lowering blood pressure or cholesterol, and combined pharmacotherapy for people at varying levels of absolute risk of a cardiovascular event.

METHODS

WHO-CHOICE methods and analytical models were employed, using local data to estimate the costs, effects and cost-effectiveness of 12 population and individual interventions implemented singly or in combination. Costs were measured in Vietnamese Dong for the year 2007 (discounted at a rate of 3% per year), while health effects were expressed in age-weighted and discounted disability-adjusted life years (DALYs) averted.

RESULTS

A health education programme to reduce salt intake (VND 1 945 002 or US$118 per DALY averted) and individual treatment of systolic blood pressure above 160 mmHg (VND 1 281 596 or US$78 per DALY averted) were found to be the most cost-effective measures for population- and individual-based approaches, respectively. Where budget is very limited, a mass media education programme on salt intake and a combination mass media programme addressing salt intake, cholesterol and tobacco should be selected first. If more resources become available, greatest population health gains can be achieved via individual treatment of systolic blood pressure and the absolute risk approach to CVD prevention.

CONCLUSIONS

Contextualization of WHO-CHOICE using local data provides health decision-makers with more sound economic evidence for policy debates on prioritizing health interventions to reduce cardiovascular diseases in Vietnam. When used, cost-effectiveness analysis could increase efficiency in allocating scare resources.

Urinary sodium excretion, dietary sources of sodium intake and knowledge and practices around salt use in a group of healthy Australian women

OBJECTIVE

Strategies that aim to facilitate reduction of the salt content of foods in Australia are hampered by sparse and outdated data on habitual salt intakes. This study assessed habitual sodium intake through urinary excretion analyses, and identified food sources of dietary sodium, as well as knowledge and practices related to salt use in healthy women.

METHODS

Cross-sectional, convenient sample of 76 women aged 20 to 55 years, Wollongong, NSW. Data included a 24 hour urine sample, three-day food diary and a self-administered questionnaire.

RESULTS

Mean Na excretion equated to a NaCl (salt) intake of 6.41 (SD=2.61) g/day; 43% had values <6 g/day. Food groups contributing to dietary sodium were: bread and cereals (27%); dressings/sauces (20%); meat/egg-based dishes (18%); snacks/desserts/extras (11%); and milk and dairy products (11%). Approximately half the sample reported using salt in cooking or at the table. Dietary practices reflected a high awareness of salt-related health issues and a good knowledge of food sources of sodium.

CONCLUSION

These findings from a sample of healthy women in the Illawarra indicate that dietary sodium intakes are lower in this group than previously reported in Australia. However, personal food choices and high levels of awareness of the salt reduction messages are not enough to achieve more stringent dietary targets of <4 g salt per day.

IMPLICATIONS

Urinary Na excretion data are required from a larger nationally representative sample to confirm habitual salt intakes. The bread and cereals food group are an obvious target for sodium reduction strategies in manufactured foods.

WASH-world action on salt and health

There is overwhelming evidence that our current high-salt intake is the major factor increasing blood pressure (BP) and, thereby, a major cause of cardiovascular disease and kidney disease worldwide. A reduction in salt intake to the recommended level of <5-6 g/day is very beneficial, and could prevent millions of deaths each year and make major savings for healthcare services. Several countries, e.g., Finland and the UK, have already reduced the amount of salt being consumed by a combined policy of getting the food industry to decrease the amount of salt added to foods, clear labelling on food products, and increasing public awareness of the harmful effects of salt on health. Many other developed countries, e.g., Australia, Canada, and the US, are also stepping up their activities. The major challenge now is to spread this out worldwide, particularly to developing countries where ≈80% of global BP-related disease burden occurs. In many developing countries, most of the salt consumed comes from salt added during cooking or from sauces; therefore, public health campaigns are needed to encourage consumers to use less salt. A modest reduction in salt intake across the whole population will result in major improvements in public health and have huge economic benefits in all countries around the world. World Action on Salt and Health (WASH) is a coalition of health professionals from different countries who know very well the harm of high BP and has a major role in implementing changes in their own countries. We welcome nephrologists to join (http://www.worldactiononsalt.com).

The 10 keys to healthy aging: findings from an innovative prevention program in the community

OBJECTIVE

To develop and evaluate a novel, comprehensive prevention program for older adults designed to assess and improve adherence to preventive health care goals.

METHOD

In McKeesport, Pennsylvania, 389 men and women aged 65 and older were enrolled. We assessed adherence to 10 preventive health goals, provided education and counseling, and reevaluated after 12 months.

RESULTS

At baseline, adherence varied. After 12 months, proportions of participants meeting goals were improved for several areas. Overall, improvements were seen for the proportion of participants meeting goals for low-density lipoprotein (LDL) cholesterol (+43%), blood pressure control in hypertensives (+17%), blood glucose control in diabetics (+50%), and colon cancer screening (+13%). Among those without prior vaccination, influenza vaccine increased by 25% and pneumonia vaccine by 20%.

DISCUSSION

This comprehensive prevention program had short-term benefits for improving adherence to established prevention guidelines in older adults. This low-cost effective program could be disseminated nationwide.

Adverse events associated with nicotine replacement therapy (NRT) for smoking cessation. A systematic review and meta-analysis of one hundred and twenty studies involving 177,390 individuals

Background

Nicotine replacement therapy (NRT) is the most common form of smoking cessation pharmacotherapy and has proven efficacy for the treatment of tobacco dependence. Although expectations of mild adverse effects have been observed to be independent predictors of reduced motivation to use NRT, adverse effects associated with NRT have not been precisely quantified.

Objective

A systematic review and meta-analysis aimed to identify all randomized clinical trials (RCTs) of NRT versus inert controls and all observational studies to determine the magnitude of reported adverse effects with NRT.

Methods

Searches of 10 electronic databases from inception to November 2009 were conducted. Study selection and data extraction were carried out independently in duplicate. RCTs were pooled using a random effects method with Odds Ratio [OR] as the effect measure, while proportions were pooled from observational studies. A meta-regression analysis was applied to examine whether the nicotine patch is associated with different adverse effects from those common to orally administered NRT.

Results

Ninety-two RCTs involving 32,185 participants and 28 observational studies involving 145, 205 participants were identified. Pooled RCT evidence of varying NRT formulations found an increased risk of heart palpitations and chest pains (OR 2.06, 95% Confidence Interval [CI] 1.51-2.82, P < 0.001); nausea and vomiting (OR 1.67, 95% CI 1.37-2.04, P < 0.001); gastrointestinal complaints (OR 1.54, 95% CI, 1.25-1.89, P < 0.001); and insomnia (OR 1.42, 95% CI, 1.21-1.66, P < 0.001). Pooled evidence specific to the NRT patch found an increase in skin irritations (OR 2.80, 95% CO, 2.28-3.24, P < 0.001). Orally administered NRT was associated with mouth and throat soreness (OR 1.87, 95% CI, 1.36-2.57, P < 0.001); mouth ulcers (OR 1.49, 95% CI, 1.05-2.20, P < 0.001); hiccoughs (OR 7.68, 95% CI, 4.59-12.85, P < 0.001) and coughing (OR 2.89, 95% CI, 1.92-4.33, P < 0.001). There was no statistically significant increase in anxiety or depressive symptoms associated with NRT use. Non-comparative observational studies demonstrated the prevalence of these events in a broad population.

Conclusion

The use of NRT is associated with a variety of side effects. In addition to counseling and medical monitoring, clinicians should inform patients of potential side effects which are associated with the use of NRT for the treatment of tobacco dependence.

2010 Canadian Hypertension Education Program (CHEP) recommendations: the scientific summary - an update of the 2010 theme and the science behind new CHEP recommendations

The present article is a summary of the theme, the key recommendations for management of hypertension and the supporting clinical evidence of the 2010 Canadian Hypertension Education Program (CHEP). In 2010, CHEP emphasizes the need for health care professionals to stay informed about hypertension through automated updates at www.htnupdate.ca. A new interactive Internet-based lecture series will be available in 2010 and a program to train community hypertension leaders will be expanded. Patients can also sign up to receive regular updates in a pilot program at www.myBPsite.ca. In 2010, the new recommendations include consideration for using automated office blood pressure monitors, new targets for dietary sodium for the prevention and treatment of hypertension that are aligned with the national adequate intake values, and recommendations for considering treatment of selected hypertensive patients at high risk with calcium channel blocker/angiotensin-converting enzyme inhibitor combinations and the use of angiotensin receptor blockers.

Prevalence and correlates of tobacco smoking in Sri Lanka

OBJECTIVES

This study aimed to determine the prevalence and underlying sociodemographic correlates of smoking among Sri Lankans.

METHODS

A cross-sectional sample (N = 5000, age >18 years) was selected using a multistage random cluster sampling. Data were collected using an interviewer-administered questionnaire.

RESULTS

Response rate was 91% (n = 4532); males 40%; mean age 46.1 years (±15.1). Overall, urban and rural prevalence of current smoking (smoking) was 18.3%, 17.2%, and 18.5%, respectively (P = nonsignificant, urban vs rural). Smoking was much higher in males than in females (38.0% vs 0.1%, P < .0001). Ex-smokers comprised 10.0% (males 20.7%, females 0.1%, P < .0001). Among the smokers 87.0% smoked <10 cigarettes per day. The male age groups < 20 and 20 to 29 years had the lowest (15.6%) and the highest (44.6%) prevalence of smoking, respectively. In males, smoking was highest in the least educated (odds ratio = 1.96, P = .001).

CONCLUSIONS

Smoking is common among Sri Lankan males and is associated with lower education, income, and middle age.

Tackling Africa's chronic disease burden: from the local to the global

Africa faces a double burden of infectious and chronic diseases. While infectious diseases still account for at least 69% of deaths on the continent, age specific mortality rates from chronic diseases as a whole are actually higher in sub Saharan Africa than in virtually all other regions of the world, in both men and women. Over the next ten years the continent is projected to experience the largest increase in death rates from cardiovascular disease, cancer, respiratory disease and diabetes. African health systems are weak and national investments in healthcare training and service delivery continue to prioritise infectious and parasitic diseases. There is a strong consensus that Africa faces significant challenges in chronic disease research, practice and policy. This editorial reviews eight original papers submitted to a Globalization and Health special issue themed: "Africa's chronic disease burden: local and global perspectives". The papers offer new empirical evidence and comprehensive reviews on diabetes in Tanzania, sickle cell disease in Nigeria, chronic mental illness in rural Ghana, HIV/AIDS care-giving among children in Kenya and chronic disease interventions in Ghana and Cameroon. Regional and international reviews are offered on cardiovascular risk in Africa, comorbidity between infectious and chronic diseases and cardiovascular disease, diabetes and established risk factors among populations of sub-Saharan African descent in Europe. We discuss insights from these papers within the contexts of medical, psychological, community and policy dimensions of chronic disease. There is an urgent need for primary and secondary interventions and for African health policymakers and governments to prioritise the development and implementation of chronic disease policies. Two gaps need critical attention. The first gap concerns the need for multidisciplinary models of research to properly inform the design of interventions. The second gap concerns understanding the processes and political economies of policy making in sub Saharan Africa. The economic impact of chronic diseases for families, health systems and governments and the relationships between national policy making and international economic and political pressures have a huge impact on the risk of chronic diseases and the ability of countries to respond to them.

Reducing population salt intake worldwide: from evidence to implementation

Raised blood pressure is a major cause of cardiovascular disease, responsible for 62% of stroke and 49% of coronary heart disease. There is overwhelming evidence that dietary salt is the major cause of raised blood pressure and that a reduction in salt intake lowers blood pressure, thereby, reducing blood pressure-related diseases. Several lines of evidence including ecological, population, and prospective cohort studies, as well as outcome trials, demonstrate that a reduction in salt intake is related to a lower risk of cardiovascular disease. Increasing evidence also suggests that a high salt intake may directly increase the risk of stroke, left ventricular hypertrophy, and renal disease; is associated with obesity through soft drink consumption; is related to renal stones and osteoporosis; is linked to the severity of asthma; and is probably a major cause of stomach cancer. In most developed countries, a reduction in salt intake can be achieved by a gradual and sustained reduction in the amount of salt added to foods by the food industry. In other countries where most of the salt consumed comes from salt added during cooking or from sauces, a public health campaign is needed to encourage consumers to use less salt. Several countries have already reduced salt intake. The challenge now is to spread this out to all other countries. A modest reduction in population salt intake worldwide will result in a major improvement in public health.

The promise of prevention: the effects of four preventable risk factors on national life expectancy and life expectancy disparities by race and county in the United States

BACKGROUND

There has been substantial research on psychosocial and health care determinants of health disparities in the United States (US) but less on the role of modifiable risk factors. We estimated the effects of smoking, high blood pressure, elevated blood glucose, and adiposity on national life expectancy and on disparities in life expectancy and disease-specific mortality among eight subgroups of the US population (the "Eight Americas") defined on the basis of race and the location and socioeconomic characteristics of county of residence, in 2005.

METHODS AND FINDINGS

We combined data from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System to estimate unbiased risk factor levels for the Eight Americas. We used data from the National Center for Health Statistics to estimate age-sex-disease-specific number of deaths in 2005. We used systematic reviews and meta-analyses of epidemiologic studies to obtain risk factor effect sizes for disease-specific mortality. We used epidemiologic methods for multiple risk factors to estimate the effects of current exposure to these risk factors on death rates, and life table methods to estimate effects on life expectancy. Asians had the lowest mean body mass index, fasting plasma glucose, and smoking; whites had the lowest systolic blood pressure (SBP). SBP was highest in blacks, especially in the rural South--5-7 mmHg higher than whites. The other three risk factors were highest in Western Native Americans, Southern low-income rural blacks, and/or low-income whites in Appalachia and the Mississippi Valley. Nationally, these four risk factors reduced life expectancy at birth in 2005 by an estimated 4.9 y in men and 4.1 y in women. Life expectancy effects were smallest in Asians (M, 4.1 y; F, 3.6 y) and largest in Southern rural blacks (M, 6.7 y; F, 5.7 y). Standard deviation of life expectancies in the Eight Americas would decline by 0.50 y (18%) in men and 0.45 y (21%) in women if these risks had been reduced to optimal levels. Disparities in the probabilities of dying from cardiovascular diseases and diabetes at different ages would decline by 69%-80%; the corresponding reduction for probabilities of dying from cancers would be 29%-50%. Individually, smoking and high blood pressure had the largest effect on life expectancy disparities.

CONCLUSIONS

Disparities in smoking, blood pressure, blood glucose, and adiposity explain a significant proportion of disparities in mortality from cardiovascular diseases and cancers, and some of the life expectancy disparities in the US. Please see later in the article for the Editors' Summary.

Hypertension in seven Latin American cities: the Cardiovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study

BACKGROUND

Little information is available regarding hypertension, treatment, and control in urban population of Latin America.

OBJECTIVE

We aimed to compare blood pressure (BP) distribution, hypertension prevalence, treatment, and control in seven Latin American cities following standard methodology.

METHODS

The Cardiovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study was a cross-sectional, epidemiologic study assessing cardiovascular risk factors using stratified multistage sampling of adult populations (aged 25-64 years) in seven cities: Barquisimeto (Venezuela; n = 1848); Bogotá (n = 1553); Buenos Aires (n = 1482); Lima (n = 1652); Mexico City (n = 1720); Quito (n = 1638); and Santiago (n = 1655). The prevalence of hypertension and high normal BP were determined based on 2007 European Society of Hypertension and European Society of Cardiology definitions.

RESULTS

BP increased with age in men and women; pulse pressure increased mainly in the upper age group. The hypertension prevalence ranged from 9% in Quito to 29% in Buenos Aires. One-quarter to one-half of the hypertension cases were previously undiagnosed (24% in Mexico City to 47% in Lima); uncontrolled hypertension ranged from 12% (Lima) to 41% (Mexico City). High normal BP was also evident in a substantial number of each city participants (approximately 5-15%). Majority of population has other cardiovascular risk factors despite hypertension; only 9.19% of participants have no risk factors apart from hypertension.

CONCLUSION

From 13.4 to 44.2% of the populations of seven major Latin American cities were hypertensive or had high normal BP values. Most hypertensive patients have additional risk factors. Public health programs need to target prevention, detection, treatment, and control of total cardiovascular risk in Latin America.

The effect of an educational intervention on patients' knowledge about hypertension, beliefs about medicines, and adherence

BACKGROUND

The burden of chronic noncommunicable diseases continues to rise in South Africa, leading to high rates of morbidity and mortality. The control of hypertension is far from optimal because of factors such as inadequate patient understanding of the condition and its therapy, as well as poor adherence to prescribed regimens.

OBJECTIVE

This study investigated the effect of an educational intervention on selected hypertensive participants' levels of knowledge about hypertension, their beliefs about medicines, and adherence to antihypertensive therapy.

METHOD

Participants took part in an educational intervention that provided them with information about hypertension and its therapy through presentations, monthly meetings, and a summary information leaflet. The participants' levels of knowledge about hypertension and its therapy as well as their beliefs about medicines were measured using interviews and/or self-administered questionnaires. Levels of adherence were assessed using pill counts, self-reports, and punctuality in collecting medication refills. Paired t tests for dependent samples were performed to compare the participants' levels of knowledge about hypertension and its therapy, beliefs about medicines, and levels of adherence to antihypertensive therapy before and after the educational intervention.

RESULTS

There were significant increases in the participants' levels of knowledge about hypertension and its therapy (P<.0001). Most of the parameters used to indicate beliefs about medicines were significantly modified in a positive manner (P<.01 for concerns about medicines, P<.01 for beliefs about the harmful nature of medicines, and P<.01 for the necessity-concerns differential).

CONCLUSION

Results of this study show that the educational intervention led to an increase in the participants' levels of knowledge about hypertension and a positive influence on their beliefs about medicines. Despite these positive changes, adequate time is required before anticipated behavioral changes, such as increased adherence, can be observed.

Projected effect of dietary salt reductions on future cardiovascular disease

BACKGROUND

The U.S. diet is high in salt, with the majority coming from processed foods. Reducing dietary salt is a potentially important target for the improvement of public health.

METHODS

We used the Coronary Heart Disease (CHD) Policy Model to quantify the benefits of potentially achievable, population-wide reductions in dietary salt of up to 3 g per day (1200 mg of sodium per day). We estimated the rates and costs of cardiovascular disease in subgroups defined by age, sex, and race; compared the effects of salt reduction with those of other interventions intended to reduce the risk of cardiovascular disease; and determined the cost-effectiveness of salt reduction as compared with the treatment of hypertension with medications.

RESULTS

Reducing dietary salt by 3 g per day is projected to reduce the annual number of new cases of CHD by 60,000 to 120,000, stroke by 32,000 to 66,000, and myocardial infarction by 54,000 to 99,000 and to reduce the annual number of deaths from any cause by 44,000 to 92,000. All segments of the population would benefit, with blacks benefiting proportionately more, women benefiting particularly from stroke reduction, older adults from reductions in CHD events, and younger adults from lower mortality rates. The cardiovascular benefits of reduced salt intake are on par with the benefits of population-wide reductions in tobacco use, obesity, and cholesterol levels. A regulatory intervention designed to achieve a reduction in salt intake of 3 g per day would save 194,000 to 392,000 quality-adjusted life-years and $10 billion to $24 billion in health care costs annually. Such an intervention would be cost-saving even if only a modest reduction of 1 g per day were achieved gradually between 2010 and 2019 and would be more cost-effective than using medications to lower blood pressure in all persons with hypertension.

CONCLUSIONS

Modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs and should be a public health target.

A systematic survey of the sodium contents of processed foods

BACKGROUND

Processed foods are major contributors to population dietary salt intake. Parts of the Australian food industry have started to decrease salt in a number of products. A definitive baseline assessment of current sodium concentrations in foods is key to targeting reformulation strategies and monitoring progress.

OBJECTIVES

Our objectives were to systematically collate data on the sodium content of Australian processed food products and compare sodium values against maximum target levels established by the UK Food Standards Agency (UK FSA).

DESIGN

Categories of processed foods that contribute the majority of salt to Australian diets were identified. Food-composition data were sought for all products in these categories, and the sodium content in mg/100 g (or mg/100 mL for liquids) was recorded for each. Mean sodium values were calculated for each grouping and compared with the UK FSA benchmarks.

RESULTS

Sodium data were collected for 7221 products in 10 food groups, 33 food categories, and 90 food subcategories. The food groups that were highest in sodium were sauces and spreads (1283 mg/100 g) and processed meats (846 mg/100 g). Cereal and cereal products (206 mg/100 g) and fruit and vegetables (211 mg/100 g) were the lowest in sodium. Sixty-three percent of food categories had mean sodium concentrations above the UK FSA targets, and most had wide ranges between the most and least salty product.

CONCLUSIONS

Many products, particularly breads, processed meats, and sauces, have salt amounts above reasonable benchmarks. The variation in salt concentrations between comparable products suggests that reformulation is highly feasible for many foods.

Financing of health systems to achieve the health Millennium Development Goals in low-income countries

Concern that underfunded and weak health systems are impeding the achievement of the health Millennium Development Goals in low-income countries led to the creation of a High Level Taskforce on Innovative International Financing for Health Systems in September, 2008. This report summarises the key challenges faced by the Taskforce and its Working Groups. Working Group 1 examined the constraints to scaling up and costs. Challenges included: difficulty in generalisation because of scarce and context-specific health-systems knowledge; no consensus for optimum service-delivery approaches, leading to wide cost differences; no consensus for health benefits; difficulty in quantification of likely efficiency gains; and challenges in quantification of the financing gap owing to uncertainties about financial commitments for health. Working Group 2 reviewed the different innovative mechanisms for raising and channelling funds. Challenges included: variable definitions of innovative finance; small evidence base for many innovative finance mechanisms; insufficient experience in harmonisation of global health initiatives; and inadequate experience in use of international investments to improve maternal, newborn, and child health. The various mechanisms reviewed and finally recommended all had different characteristics, some focusing on specific problems and some on raising resources generally. Contentious issues included the potential role of the private sector, the rights-based approach to health, and the move to results-based aid. The challenges and disagreements that arose during the work of the Taskforce draw attention to the many issues facing decision makers in low-income countries. International donors and recipient governments should work together to improve the evidence base for strengthening health systems, increase long-term commitments, and improve accountability through transparent and inclusive national approaches.

Analysis of salt content in meals in kindergarten facilities in Novi Sad

Introduction. Investigations have brought evidence that salt intake is positively related to systolic blood pressure and that children with higher blood pressure are more susceptible to hypertension in adulthood. In developed countries the main source of salt is processed food. Objective The aim of this paper was to determine total sodium chloride (NaCl) in average daily meal (breakfast, snack and dinner) and in each of three meals children receive in kindergarten. Methods. From kindergarten, in the meal time, 88 samples of daily meals ( breakfast, snacks and dinner) offered to children aged 4-6 years were taken. Standardized laboratory methods were applied to determine proteins, fats, ash and water in order to calculate energy value of meal. The titrimetric method with AgNO3, and K2CrO4 as indicator, was applied in order to determine chloride ion. Content of NaCl was calculated as %NaCl = mlAgNO3 ? 0.05844 ? 5 ? 100/g tested portion. NaCl content in total daily meal and each meal and in 100 kcal of each meal was calculated using descriptive statistical method. Student?s t-test was applied to determine statistical differences of NaCl amount among meals. Results. NaCl content in average daily meal was 5.2?1.7 g (CV 31.7%), in breakfast 1.5?0.6 g (CV 37.5%), in dinner 3.5?1.6 g (CV 46.1%) and in snack 0.3?0.4 g (CV 163.3%). NaCl content per 100 kcal of breakfast was 0.4?0.1 g (CV 29.5%), dinner 0.7?0.2 g (CV 27.8%) and snack 0.13?0.19 g (CV 145.8%). The difference of NaCl content among meals was statistically significant (p<0.01). Conclusion. Children in kindergarten, through three meals, received NaCl in a quantity that exceeded internationally established population nutrient goal for daily salt intake. The main source of NaCl was dinner, a meal that is cooked at place.

Economic aspects of chronic diseases in Vietnam

Introduction

There remains a lack of information on economic aspects of chronic diseases. This paper, by gathering available and relevant research findings, aims to report and discuss current evidence on economic aspects of chronic diseases in Vietnam.

Methods

Data used in this paper were obtained from various information sources: international and national journal articles and studies, government documents and publications, web-based statistics and fact sheets.

Results

In Vietnam, chronic diseases were shown to be leading causes of deaths, accounting for 66% of all deaths in 2002. The burdens caused by chronic disease morbidity and risk factors are also substantial. Poorer people in Vietnam are more vulnerable to chronic diseases and their risk factors, other than being overweight. The estimated economic loss caused by chronic diseases for Vietnam in 2005 was about US$20 million (0.033% of annual national GDP). Chronic diseases were also shown to cause economic losses for families and individuals in Vietnam. Both population-wide and high-risk individual interventions against chronic disease were shown to be cost-effective in Vietnam.

Conclusion

Given the evidence from this study, actions to prevent chronic diseases in Vietnam are clearly urgent. Further research findings are required to give greater insights into economic aspects of chronic diseases in Vietnam.

Contribution of chronic diseases to disability in elderly people in countries with low and middle incomes: a 10/66 Dementia Research Group population-based survey

BACKGROUND

Disability in elderly people in countries with low and middle incomes is little studied; according to Global Burden of Disease estimates, visual impairment is the leading contributor to years lived with disability in this population. We aimed to assess the contribution of physical, mental, and cognitive chronic diseases to disability, and the extent to which sociodemographic and health characteristics account for geographical variation in disability.

METHODS

We undertook cross-sectional surveys of residents aged older than 65 years (n=15 022) in 11 sites in seven countries with low and middle incomes (China, India, Cuba, Dominican Republic, Venezuela, Mexico, and Peru). Disability was assessed with the 12-item WHO disability assessment schedule 2.0. Dementia, depression, hypertension, and chronic obstructive pulmonary disease were ascertained by clinical assessment; diabetes, stroke, and heart disease by self-reported diagnosis; and sensory, gastrointestinal, skin, limb, and arthritic disorders by self-reported impairment. Independent contributions to disability scores were assessed by zero-inflated negative binomial regression and Poisson regression to generate population-attributable prevalence fractions (PAPF).

FINDINGS

In regions other than rural India and Venezuela, dementia made the largest contribution to disability (median PAPF 25.1% [IQR 19.2-43.6]). Other substantial contributors were stroke (11.4% [1.8-21.4]), limb impairment (10.5% [5.7-33.8]), arthritis (9.9% [3.2-34.8]), depression (8.3% [0.5-23.0]), eyesight problems (6.8% [1.7-17.6]), and gastrointestinal impairments (6.5% [0.3-23.1]). Associations with chronic diseases accounted for around two-thirds of prevalent disability. When zero inflation was taken into account, between-site differences in disability scores were largely attributable to compositional differences in health and sociodemographic characteristics.

INTERPRETATION

On the basis of empirical research, dementia, not blindness, is overwhelmingly the most important independent contributor to disability for elderly people in countries with low and middle incomes. Chronic diseases of the brain and mind deserve increased prioritisation. Besides disability, they lead to dependency and present stressful, complex, long-term challenges to carers. Societal costs are enormous.

FUNDING

Wellcome Trust; WHO; US Alzheimer's Association; Fondo Nacional de Ciencia Y Tecnologia, Consejo de Desarrollo Cientifico Y Humanistico, Universidad Central de Venezuela.

Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies

OBJECTIVE

To assess the relation between the level of habitual salt intake and stroke or total cardiovascular disease outcome.

DESIGN

Systematic review and meta-analysis of prospective studies published 1966-2008.

DATA SOURCES

Medline (1966-2008), Embase (from 1988), AMED (from 1985), CINAHL (from 1982), Psychinfo (from 1985), and the Cochrane Library. Review methods For each study, relative risks and 95% confidence intervals were extracted and pooled with a random effect model, weighting for the inverse of the variance. Heterogeneity, publication bias, subgroup, and meta-regression analyses were performed. Criteria for inclusion were prospective adult population study, assessment of salt intake as baseline exposure, assessment of either stroke or total cardiovascular disease as outcome, follow-up of at least three years, indication of number of participants exposed and number of events across different salt intake categories.

RESULTS

There were 19 independent cohort samples from 13 studies, with 177 025 participants (follow-up 3.5-19 years) and over 11 000 vascular events. Higher salt intake was associated with greater risk of stroke (pooled relative risk 1.23, 95% confidence interval 1.06 to 1.43; P=0.007) and cardiovascular disease (1.14, 0.99 to 1.32; P=0.07), with no significant evidence of publication bias. For cardiovascular disease, sensitivity analysis showed that the exclusion of a single study led to a pooled estimate of 1.17 (1.02 to 1.34; P=0.02). The associations observed were greater the larger the difference in sodium intake and the longer the follow-up.

CONCLUSIONS

High salt intake is associated with significantly increased risk of stroke and total cardiovascular disease. Because of imprecision in measurement of salt intake, these effect sizes are likely to be underestimated. These results support the role of a substantial population reduction in salt intake for the prevention of cardiovascular disease.

Middle-aged women's awareness of cholesterol as a risk factor: results from a national survey of Korean Middle-aged Women's Health Awareness (KomWHA) study

BACKGROUND

Dyslipidemia, a risk factor for cardiovascular disease (CVD), is more prevalent in middle-aged women than in men of the same age in Korea. This study, the first national survey that focused on cholesterol in Korean women, aimed to: (1) assess their awareness and knowledge of cholesterol, (2) evaluate their risk reduction behavior, and (3) examine differences in these variables among geographical regions in Korea.

METHODS

A questionnaire survey study was conducted in a randomly selected national sample of 1304 Korean women, aged 40-64 years in 3 geographic regions.

RESULTS

High cholesterol was identified as a cause of CVD by 54.4% of respondents, however, 95.4% did not know their own values. Only 4.1% of respondents were aware of desirable level of total cholesterol. Eight percent of respondents perceived correctly the meaning of high-density lipoprotein cholesterol (HDL-C) as good cholesterol. And 32.9% had cholesterol check at least once a year. No significant regional differences were found in women's awareness and knowledge on cholesterol. No smoking (93.6%), low salt diet (52.5%) and weight management (50.6%) were the most prevalent risk reduction behaviors. Women in the rural area performed less risk reduction behaviors than those in urban area.

CONCLUSIONS

Given the low level of awareness and knowledge about cholesterol in these women, nurses need to increase their education about cholesterol and risk reduction behaviors of CVD for middle-aged Korean women, particularly those in rural area. To resolve identified disparities in women's risk reduction behaviors between the rural and urban area, a national-level health policy can result in a successful effort to promote women's awareness of cholesterol and risk reduction behaviors for the cardiovascular health of the public.

Public health requirements for rapid progress in global health

Effective public health interventions can save hundreds of millions of lives in developing countries, as well as create broad social and economic benefits. Unfortunately, public health approaches and solutions applied in developed countries are often assumed to be inappropriate or unattainable in developing countries. This has sometimes forestalled effective interventions in parts of the world where they are most needed, despite conditions that now facilitate lasting solutions to both long-standing and emerging global public health problems. Core public health functions are similar regardless of a country's income level. Although some resource-intensive approaches from industrialised nations are inappropriate in less developed countries, many basic public health measures achieved decades ago in developed countries are urgently needed, highly appropriate, extremely cost-effective and eminently attainable in developing countries today. About half of the disease burden in low and middle-income countries is now from non-communicable diseases, but non-communicable disease epidemics that will otherwise increase rapidly in the developing world can be avoided or reversed. Progress of public health in developing countries is possible, but will require sufficient funding and human resources; improved physical plant and information systems; effective programme implementation and regulatory capacity; and, most importantly, political will at the highest levels of government.

Clustering of chronic non-communicable disease risk factors among selected Asian populations: levels and determinants

BACKGROUND

The major chronic non-communicable diseases (NCDs) operate through a cluster of common risk factors, whose presence or absence determines not only the occurrence and severity of the disease, but also informs treatment approaches. Primary prevention based on mitigation of these common risk factors through population-based programmes is the most cost-effective approach to contain the emerging epidemic of chronic NCDs.

OBJECTIVES

This study was conducted to explore the extent of risk factors clustering for the major chronic NCDs and its determinants in nine INDEPTH Health and Demographic Surveillance System (HDSS) sites of five Asian countries.

DESIGN

Data originated from a multi-site chronic NCD risk factor prevalence survey conducted in 2005. This cross-sectional survey used a standardised questionnaire developed by the WHO to collect core data on common risk factors such as tobacco use, intake of fruits and vegetables, physical inactivity, blood pressure levels, and body mass index. Respondents included randomly selected sample of adults (25-64 years) living in nine rural HDSS sites in Bangladesh, India, Indonesia, Thailand, and Vietnam.

RESULTS

Findings revealed a substantial proportion (>70%) of these largely rural populations having three or more risk factors for chronic NCDs. Chronic NCD risk factors clustering was associated with increasing age, being male, and higher educational achievements. Differences were noted among the different sites, both between and within country.

CONCLUSIONS

Since there is an extensive clustering of risk factors for the chronic NCDs in the populations studied, the interventions also need to be based on a comprehensive approach rather than on a single factor to forestall its cumulative effects which occur over time. This can work best if it is integrated within the primary health care system and the HDSS can be an invaluable epidemiological resource in this endeavor.

Using the INDEPTH HDSS to build capacity for chronic non-communicable disease risk factor surveillance in low and middle-income countries

Background

Chronic non-communicable diseases (NCDs) are the leading cause of morbidity, mortality, and disability worldwide. More than 80% of chronic disease deaths occur in low-income and middle-income countries. Epidemiological data on the burden of chronic NCD and the risk factors which predict them are lacking in most low-income countries. The INDEPTH Network (http://www.indepth-network.org) which includes the Health and Demographic Surveillance System (HDSS) with many surveillance sites in low-middle income countries provided an opportunity to establish surveillance of the major chronic NCD risk factors in 2005 using a standardised approach.

Objective

This paper presents the conceptual framework and research design of the chronic NCD risk factor surveillance within nine rural INDEPTH HDSS settings in Asia.

Methods

This multi-site study was designed as a baseline cross-sectional survey with sufficient sample size to measure trends over time. In each of nine HDSS sites in five Asian countries, a sample of 2,000 men and women aged 25–64 years, using the WHO STEPwise approach to Surveillance (http://who.int/chp/steps), was selected using stratified random sampling (in each 10-year interval) from the HDSS sampling frame.

Results

A total of 18,494 men and women from the nine sites were interviewed with an overall response rate of 98%. The major NCDs risk factors included self-reported information on tobacco and alcohol consumption, fruit and vegetable intake, physical activity patterns, and measured body weight, height, waist circumference, and blood pressure. A series of training sessions were conducted for research scientists, supervisors, and surveyors in each site. Data quality was ensured through spot check, re-check, and data validation procedures, including accuracy and completeness of data obtained. Standardised data entry programme, created using the EPIDATA software, was used to ensure uniform database structure across sites. The data merging and analysis were done using STATA Version 10.

Conclusion

This multi-site study confirmed the feasibility of conducting chronic NCD risk factor surveillance in the low and middle-income settings by integrating the chronic NCDs risk factor surveillance into an existing HDSS data collection and management setting. This collaborative work has provided reliable epidemiological data as a basis for developing chronic NCD prevention and control activities.

Would achieving healthy people 2010's targets reduce both population levels and social disparities in heart disease?

BACKGROUND

The US Healthy People 2010 (HP2010) agenda set targets for major risk factors for coronary heart disease (CHD). However, the potential impact of achieving those risk factor reductions on both population levels and social disparities in CHD has not been quantified.

METHODS AND RESULTS

Data on 10-year risk of CHD (from the First National Health and Nutrition Examination Epidemiological Follow-Up study 1971 to 1982), prevalence of major CHD risk factors (from the National Health and Nutrition Examination Survey 2003 to 2004), and HP2010 targets for CHD risk factors (reduction of smoking rate to 12%, hypertension to 14%, high cholesterol levels to 17%, diabetes to 2.5%, and obesity to 15%) were used to estimate effects of different scenarios on population levels and social disparities in CHD. Over a 10-year period, the largest relative reductions in population levels of CHD (20.0% in men; 23.9% in women) would be achieved if all social groups met the HP2010 targets. CHD disparities would be most reduced if the less educated (absolute disparities reduced by 66.1% in men; 56.3% in women) and the low income group (absolute disparities reduced by 93.7% in men; 94.3% in women) achieved the targets before the most advantaged. These reductions are larger than those expected if targets were achieved overall for the population but relative social group differences in risk factors remained, or under leveling-up approaches in which the least advantaged achieved the current levels of risk factors of the most advantaged.

CONCLUSIONS

Interventions to reduce CHD risk factors to HP2010 targets that focus on all social groups would produce the best overall scenario for both population levels and disparities in CHD.

Divergent fifteen-year trends in traditional and cardiometabolic risk factors of cardiovascular diseases in the Seychelles

Objective

Few studies have assessed secular changes in the levels of cardiovascular risk factors (CV-RF) in populations of low or middle income countries. The systematic collection of a broad set of both traditional and metabolic CV-RF in 1989 and 2004 in the population of the Seychelles islands provides a unique opportunity to examine trends at a fairly early stage of the "diabesity" era in a country in the African region.

Methods

Two examination surveys were conducted in independent random samples of the population aged 25–64 years in 1989 and 2004, attended by respectively 1081 and 1255 participants (participation rates >80%). All results are age-standardized to the WHO standard population.

Results

In 2004 vs. 1989, the levels of the main traditional CV-RF have either decreased, e.g. smoking (17% vs. 30%, p < 0.001), mean blood pressure (127.8/84.8 vs. 130.0/83.4 mmHg, p < 0.05), or only moderately increased, e.g. median LDL-cholesterol (3.58 vs. 3.36 mmol/l, p < 0. 01). In contrast, marked detrimental trends were found for obesity (37% vs. 21%, p < 0.001) and several cardiometabolic CVD-RF, e.g. mean HDL-cholesterol (1.36 vs. 1.40 mmol/l, p < 0.05), median triglycerides (0.80 vs. 0.78 mmol/l, p < 0.01), mean blood glucose (5.89 vs. 5.22 mmol/l, p < 0.001), median insulin (11.6 vs. 8.3 μmol/l, p < 0.001), median HOMA-IR (2.9 vs. 1.8, p < 0.001) and diabetes (9.4% vs. 6.2%, p < 0.001). At age 40–64, the prevalence of elevated total cardiovascular risk tended to decrease (e.g. WHO-ISH risk score ≥10; 11% vs. 13%, ns), whereas the prevalence of the metabolic syndrome (which integrates several cardiometabolic CVD-RF) nearly doubled (36% vs. 20%, p < 0.001). Data on physical activity and on intake of alcohol, fruit and vegetables are also provided. Awareness and treatment rates improved substantially for hypertension and diabetes, but control rates improved for the former only. Median levels of the cardiometabolic CVD-RF increased between 1989 and 2004 within all BMI strata, suggesting that the worsening levels of cardiometabolic CVD-RF in the population were not only related to increasing BMI levels in the interval.

Conclusion

The levels of several traditional CVD-RF improved over time, while marked detrimental trends were observed for obesity, diabetes and several cardiometabolic factors. Thus, in this population, the rapid health transition was characterized by substantial changes in the patterns of CVD-RF. More generally, this analysis suggests the importance of surveillance systems to identify risk factor trends and the need for preventive strategies to promote healthy lifestyles and nutrition.