Presenter: Dr. Reshma Sougaijam Moderator: Dr. Abhishek Raut Framework: What are the cardiovascular disorders Burden of disease -Globally -South East Asia -India Descriptive Epidemiology of CVD -Maharashtra Analytical Epidemiology 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 cardiovascular diseases 9 31 33 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 cardiovascular diseases Injuries 2.1 Other NCDs 11 25 10 7.8 9.6 35 Estimated percentage of deaths by cause: South-East Asia Region, 2008 communicable diseases,maternal, perinatal &nutritional defeciencies chronic respiratory disorder cancer diabetes other NCDs India CVD Injuries 10 24 Cancer 37 6 11 10 respiratory disorder diabetes 2 Communicable, maternal, perinatal, nutritional condition other NCD Source: WHO country profile 2011 Descriptive Epidemiology Major causes of death in India: Male vs Female 25 20 15 10 5 20.3 16.9 CVDs cause 1.7-2.0 million deaths annually in India 9.3 8 6.7 9.9 7.1 6.4 6.2 5.4 7.1 4.7 5.4 5.2 6 4.5 0 male female Million death study 2009 Major Causes of Death in India: Rural vs Urban India 35 Rural Urban 30 25 20 28.6 16.8 15 10 5 0 9 8.8 7.5 4.8 6.8 6.7 3 6.1 3 5.2 5.3 Million death study 2009 7.9 5 4.4 India Transition to NCD Disease burden estimates1990 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 Unhealthy diet Tobacco use Physical inactivity Harmful use of alcohol Metabolic RF Globalization Urbanization Ageing Poverty Illiteracy Behavioural RF Social Determinats Chain from determinants to health outcome High BP Obesity Diabetes Raised Blood Lipids CVD Other factors: Family history/ Hereditary Fetal programming 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/m2. 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 or10 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 firstdegree 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 9% Raised Blood Glucose 6% Physical inactivity 6% Over weight and Obesity 5% WHO Global health risk 2009 Burden of Risk factor in India Behavioural risk factor Male Female Total Current daily tobacco smoking 25.1 2 13.9 Physical inactivity 10.8 17.3 14 Raised BP 33.2 31.7 32.5 Raised blood glucose 10 10 10 overweight 9.9 12.2 11 Obesity 1.3 2.4 1.9 Raised cholesterol 25.8 28.3 27.1 Metabolic risk factors 2008 estimated prevalence 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 Primordial Prevention Metabolic RF • Obesity • Raised BP(HTN) • Raised Blood glucose (DM) • Hyperlipidaemia Primary Prevention • Cardiovascular diseases outcome 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 Interventions: health programme to prevent CVD by policy & environmental intervention in an effective, community focused manner 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 Main risk factors in North Karelia between 1972 and 2007 among Men and Women aged 30 to 59 years Women Men Year Smoking Serum BP (%) cholesterol Smoking (%) Serum cholesterol BP 1972 52 6.9 149/92 10 6.9 153/92 1977 44 6.5 143/89 10 6.4 141/86 1982 36 6.3 145/87 15 6.1 141/85 1987 36 6.3 144/88 16 6 139/83 1992 32 5.9 142/85 17 5.6 135/80 1997 31 5.7 140/84 16 5.6 133/80 2002 33 5.7 137/83 22 5.5 132/78 2007 31 5.4 138/83 18 5.2 134/78 Table : Mortality changes in North Karelia (per 100 000) among men aged 35 to 64 years 1969-1971 2006 Change All cardiovascular 855 182 -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 Men Women HT prevalence 15% to 12.1% 12.4% to 10.9% Cigarette smoking 58% to 47.2% 6.9 %to 3.7% Heavy alcohol consumption 38.2% to 14.4% 2.6% to 0.6% Moderate exercise 16.9% to 22.1% 1.3% to 2.7% Mean population serum cholesterol 5.5 mmol/l to 4.7mmol/l 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 Intervention Tobacco use Harmful use of alcohol Raised taxes on alcohol Restrict access to retailed alcohol Enforce bans on alcohol advertising Unhealthy diet and physical inactivity 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. Raised taxes on tobacco Protect people from tobacco smoke Warn about dangers of tobacco Enforce bans on tobacco advertising 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 noncommunicable disease intervention programme in Mauritius. BMJ 1995; 311 12. Premanath M et al. Mysore childhood obesity study. Indian Pediatrics 2010;47:171–3.