Presenter: Dr. Reshma Sougaijam Moderator: Dr. Abhishek Raut

Framework:

  Burden of disease -Globally -South East Asia -India Descriptive Epidemiology of CVD -Maharashtra Analytical Epidemiology  What are the cardiovascular disorders Risk factors of cardiovascular disorders      Burden of Risk factors in India Application of Epidemiology for prevention and control Prevention and control Evidence for prevention of cardiovascular disorders National programme

What are cardiovascular diseases

Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels & they include:

 Coronary heart disease   Cerebrovascular disease Peripheral arterial disease   Rheumatic heart disease Congenital heart disease

Burden of disease

Major cause of death Globally

9 cardiovascular diseases 33 31 communicable diseases,maternal,perinatal &nutritional condition other NCDs 27 injuries CVD leading cause of death in the world Source: WHO 2011 Global Atlas on CVD Prevention & Control

Distribution of CVD deaths due to heart attacks, strokes and other types of cardiovascular diseases

50 45 40 35 30 25 20 15 10 5 0 46 38 34 37 11 14 6 7 2 2 1 1 Male Female Source: WHO 2011 Global Atlas on CVD Prevention & Control

South East Asia

2,1 Other NCDs 10 7,8 9,6 Injuries 11 35 25

Estimated percentage of deaths by cause: South-East Asia Region, 2008

cardiovascular diseases communicable diseases,maternal, perinatal &nutritional defeciencies chronic respiratory disorder cancer diabetes other NCDs

India

Injuries

10 24 37 6 11 10 2 Communicable, maternal, perinatal, nutritional condition CVD Cancer respiratory disorder diabetes other NCD Source: WHO country profile 2011

Descriptive Epidemiology

Major causes of death in India: Male vs Female

25 20 20,3 15 16,9 CVDs cause 1.7-2.0 million deaths annually in India 10 9,3 8 6,7 9,9 7,1 5 6,4 6,2 5,4 7,1 4,7 5,4 6 0 5,2 4,5 Million death study 2009 male female

Major Causes of Death in India: Rural vs Urban India

35 30 10 5 0 25 20 15 28,6 16,8 9 7,5 8,8 4,8 6,8 3 6,7 3 Rural Urban 6,1 5,3 5,2 7,9 5 4,4 Million death study 2009

India Transition to NCD

Disease burden estimates 1990

Disease burden estimate-2020 Source: Nutrition transition in India,1947-2007,Ministry of women and child welfare

Maharashtra

 Maharashtra Sevagram: Prevalence of CHD in 1988 is

4.36%

 Wardha: Out of 7,42,736 population (>30 yr old & pregnant mothers) screened, the suspected cases of HT is 23,047 (3.1%) & of Diabetes is 19,779 (2.66%).

(NPCDCS)

Analytical Epidemiology

Risk factors for Cardiovascular disorders

Chain from determinants to health outcome Globalization Urbanization Ageing Poverty Illiteracy Unhealthy diet Tobacco use Physical inactivity Harmful use of alcohol High BP Obesity Diabetes Raised Blood Lipids Other factors: Family history/ Hereditary Fetal programming

CVD

Source: WHO (2013). A global brief on high blood pressure (hypertension): preventing heart disease, strokes and kidney failure. Geneva.

Social determinants

    Globalization: Increases the availability of processed foods & diets high in total energy, fats, salts and sugar Urbanization: Urban lifestyles increases the risk of NCDs.

The ICMR and WHO multi-centric study in India among men and women aged 15–64 years shows that behavioural, anthropometric and biochemical risk factors of NCDs are more prevalent in urban than in rural areas.

Ageing: Independent risk factor for CVD ; risk of stroke doubles every decade after age 55

Social determinants cont.

Poverty:

   In developed world, CVDs and RF originally more common in upper socioeconomic groups but have gradually become more common in lower socioeconomic group SEAR: Risk factors are equally or more prevalent in the lower socioeconomic strata of society.

For example, in Indonesia, hypertension was as common (33%) in the top income quintile as (31%) in the bottom quintile

Social determinants cont.

 Illiteracy: Studies have revealed that both smoking and smokeless tobacco use are more prevalent among the less educated in Bangladesh, India, Indonesia, Sri Lanka and Thailand

Behavioural Risk Factors

  Tobacco: Smoking is estimated to cause nearly 10% of CVD A 50-year follow-up of British doctors demonstrated that, among ex-smokers, the age of quitting has a major impact on survival prospects: those who quit between 35 and 44 years of age had same survival rates as those who had never smoked.

Behavioural Risk Factors

  Physical inactivity: Insufficient physical activity can be defined as less than 5 times 30 minutes of moderate activity per week, or less than 3 times 20 minutes of vigorous activity per week, or equivalent.

Increases risk of heart disease and stroke by 50%.

 150 minutes of moderate physical activity each week reduce the risk of IHD by approximately 30% and risk of DM by 27%.

Behavioural risk factors

 Unhealthy diet: Low fruit and vegetable intake is estimated to cause about 31% of CHD and 11% of stroke worldwide.

 WHO recommends a population salt intake of less than 5 grams/person/day to help the prevention of CVD  Harmful use of alcohol: 60 or more grams of pure alcohol per day is associated with the risk of CVD.

Metabolic risk factors

  Obesity: Risks of coronary heart disease, ischaemic stroke and type 2 diabetes mellitus increase steadily with an increasing BMI. Data from Demographic and Health Surveys1996-2006, prevalence of obesity increase from 11% to 15% in India  BMI to be maintained in the range 18.5–24.9 kg/m 2 .

 Raised blood sugar (Diabetes): CVD accounts for about 60% of all mortality in people with diabetes.  Risk of cardiovascular events is 2 - 3 times higher in people with diabetes .

Metabolic risk factor

 Raised blood pressure (Hypertension): For every 20 mmHg systolic or 10 mmHg diastolic increase in BP, there is doubling of mortality from both IHD and stroke.

 Longitudinal data from Framingham Heart Study indicated that BP values between130–139/85–89 mmHg are associated with more than two fold increase in relative risk from CVD as compared with those with BP levels below 120/80 mmHg.

Metabolic Risk Factors

 Raised blood cholesterol: Raised blood cholesterol increases the risk of heart disease and stroke.  10% reduction in serum cholesterol in 40-year old men has been reported to result in 50% reduction in heart disease within five years

Other factors

 Fetal programming: Low birth weight is associated with an increased risk of adult diabetes and CVD.  Hereditary or family history: Increased risk if a first degree blood relative has had CHD or stroke before the age of 55 years (for a male relative) or 65 years (for a female relative).

Attributable deaths due to Cardio Vascular risk factors

Risk Factor Attributable death

Raised BP 13% Tobacco use Raised Blood Glucose Physical inactivity Over weight and Obesity 9% 6% 6% 5% WHO Global health risk 2009

Burden of Risk factor in India

Behavioural risk factor

Current daily tobacco smoking Physical inactivity Metabolic risk factors Raised BP Raised blood glucose overweight Obesity Raised cholesterol 2008 estimated prevalence

Male

25.1

10.8

33.2

10 9.9

1.3

25.8

Female

2 17.3

Total

13.9

14 31.7

10 12.2

2.4

32.5

10 11 1.9

28.3

27.1

Source: WHO NCD Country profile 2011

Conceptual framework of risk factors and level of prevention and management of Cardiovascular Diseases:

• Tobacco • Alcohol • Physical Inactivity • Unhealthy diet Behavioural RF Metabolic RF • Obesity • Raised BP(HTN) • Raised Blood glucose (DM) • Hyperlipidaemia • Cardiovascular diseases outcome Primordial Prevention Primary Prevention Secondary Prevention

Application of Epidemiology for prevention and control

Prevention and control

   Primordial prevention: Focused on decreasing risk factor load in the population by increasing awareness and access through education and health promotion Primary prevention: Primary prevention is directed towards control of CVD risk factors E.g. 5 mmHg reduction of SBP in the population would result -14 percent overall reduction in mortality due to stroke, - 9 percent reduction in mortality due to CHD, - 7 percent decrease all-cause mortality.

Prevention and control

 Secondary prevention: Aim of secondary prevention is to prevent the recurrence and progression of disease.

 Lifestyle changes, risk factor control and pharmacological strategies in patients with established CVD

Strategies

   Population approach: Addresses life style modification of modifiable risk factors such as diet, smoking & tobacco use, sedentary lifestyle and availability of screening & diagnostic services.

e.g. removing saturated fats from food or lowering salt from processed food would have an influence on BP of whole population.

High risk approach: Assess risk factors to determine individual risk. Medical interventions are often required.

Population-wide and high-risk strategies complimentary and synergetic

Source: Integrated management of CVD, WHO 2002

Evidence on Prevention of cardiovascular diseases (Population Strategy)

  

North Karelia Project (Finland):

A comprehensive public health programme to prevent CVD by policy & environmental intervention in an effective, community focused manner

Interventions:

Raised awareness among -Local consumers -Schools -Social & Health services  Policy modification -Banned tobacco advertisements -Low fat and vegetable products -Change in farmer’s payment scheme -Incentives for communities achieving low cholesterol level

Year

Main risk factors in North Karelia between 1972 and 2007 among Men and Women aged 30 to 59 years Men

Smoking (%) Serum cholesterol BP Smoking (%)

Women

Serum cholesterol BP

1972 1977 1982 1987 1992 1997 2002 2007 52 44 36 36 32 31 33 31 6.9

6.5

6.3

6.3

5.9

5.7

5.7

5.4

149/92 143/89 145/87 144/88 142/85 140/84 137/83 138/83 10 10 15 16 17 16 22 18 6.9

6.4

6.1

6 5.6

5.6

5.5

5.2

153/92 141/86 141/85 139/83 135/80 133/80 132/78 134/78

Table : Mortality changes in North Karelia (per 100 000) among men aged 35 to 64 years

All cardiovascular

1969-1971

855

2006

182

Change

-79% Coronary heart disease 672 103 -85%

Evidence based population approach:

 

Mauritius national NCD intervention Programme1987:

Baseline was done at 1987 and follow up done after 5 years 1992

Intervention:

 Health education at community, school and work place    Legislative measures Mass media Policy: Substitution of palm oil with soyabean oil, as subsidized “ration oil”

Results of NCD intervention in Mauritius

Results

HT prevalence

Men

15% to 12.1% Cigarette smoking 58% to 47.2% Heavy alcohol consumption 38.2% to 14.4% Moderate exercise Mean population serum cholesterol

Women

12.4% to 10.9% 6.9 %to 3.7% 2.6% to 0.6% 16.9% to 22.1% 5.5 mmol/l to 4.7mmol/l 1.3% to 2.7%

Evidence of secondary prevention

    Japan- long-term hypertension detection and

control program for stroke prevention.

The hypertension detection and control program was initiated in 1963.

Comparative cost-effectiveness and budget-impact analyses for the period 1964-1987 of the costs of public health services and treatment of patients with hypertension and stroke, was minus 28,358 yen per capita over 24 years.

Government's policy to support this program may have contributed to substantial decline in stroke incidence and mortality, which was largely responsible for increase in Japanese life expectancy.

Best buys for prevention and control of CVDs

Risk factor/disease

Tobacco use Harmful use of alcohol Unhealthy diet and physical inactivity    

Intervention

Raised taxes on tobacco Protect people from tobacco smoke Warn about dangers of tobacco Enforce bans on tobacco advertising    Raised taxes on alcohol Restrict access to retailed alcohol Enforce bans on alcohol advertising    Reduce salt intake in food Reduce trans-fat with polyunsaturated fat Promote public awareness about diet and physical activity CVD and diabetes  Provide counseling and multidrug therapy for people with medium-high risk of developing heart attack and stroke.

National programme

 Integrated Disease Surveillance Project (IDSP) :  Initiated with assistance of World Bank in the year 2004.

 Community based surveys of population aged 15-64 to provide data on the risk factors of non communicable diseases

National program for Prevention and control of Cancer, Diabetes, Cardiovascular diseases and Stroke

(NPCDCS):  Launched during Eleventh five year plan (2007-2012).  NPCDCS is implemented in a phased manner with a pilot being done in Preparatory Phase 2006-2007  The programme is being implemented in 20000 subcentres & 700 community health centres in 100 districts spread over 21 States during 2010-2012

NPCDCS Services offered under NPCDCS

 A Cardiac care unit at each of the 100 district hospitals.

   NCD clinic at 100 district hospitals and 700 CHC for diagnosis & M/M Availability of life saving drugs.

Screening for diabetes and high BP (Age>30yrs).

Achievements so far

 Funds for implementation of NPCDCS in 27 districts across 19 states were released in March 2011.

 Efforts are being taken to increase awareness for promotion of healthy lifestyle through Mass media.

 Pilot Project on School based Diabetes Screening Programme initiated in 6 districts

NPCDCS in Wardha District

 Programme started on Aug 2011 in Wardha District.

 More (only) emphasis on screening of patients.

 Each RH has NPCDCS unit of 6 people.

 Challenges -Validity of data.

-Not enough trained man power.

-Final diagnosis at CHC.

-Treatment

References

1. Global Atlas on cardiovascular disease prevention and control. Published by the World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization; WHO 2011.

2. Noncommunicable Diseases in the South-East Asia Region: 2011 Situation and Response; WHO, Regional Office for South-East Asia.

3. Gupta R, Guptha S, Joshi R, Xavier D. Translating evidence into policy for cardiovascular disease control in India. Health Research Policy and Systems 2011, 9:8 4. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS).

Operational guideline . Directorate General of Health Services Ministry of Health & Family welfare Government Of India5. Puska P.

5. The North Karelia Project: 30 years successfully preventing chronic diseases. Diabetes voice. 2008;53: 26-9.

References cont.

6. IDSP Non-Communicable Disease Risk Factors Survey, Phase-I States of India, 2007-08. New Delhi, India 2009.

7. Milicevic Z et al. Natural History of Cardiovascular Disease in Patients With Diabetes. Diabetes Care 2008;31 (Suppl. 2):S155–S160 8. Pandve TH, Chawla PS, Fernandez K. journal of family medicine and primary care.2012;1(1): 79-80.

9. World Health Organization. Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva, WHO, 2009.

10. WHO. Integrated Management of Cardiovascular Risk. Geneva, WHO 2002 11. Dr G K Dowse. Changes in population cholesterol concentrations and other cardiovascular risk factor levels after five years of the non communicable disease intervention programme in Mauritius.

BMJ 1995; 311 12. Premanath M et al. Mysore childhood obesity study. Indian Pediatrics 2010;47:171–3.