epidemiology of cardiovascular disorders
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Epidemiology of cardiovascular disorders. What are the cardiovascular disorders Burden of disease -Globally -South East Asia - India - Wardha Risk factors of cardiovascular disorders Burden of Risk factors in India Prevention and control - PowerPoint PPT PresentationTRANSCRIPT
Epidemiology ofcardiovascular disorders
Presenter: Dr. Reshma Sougaijam
Moderator: Dr. Abhishek Raut
Framework: What are the cardiovascular disorders Burden of disease -Globally -South East Asia -India -Wardha Risk factors of cardiovascular disorders Burden of Risk factors in India Prevention and control Evidence for prevention of cardiovascular disorders National programme
What are cardiovascular diseasesCardiovascular diseases (CVDs) area 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
31
27
339
Major cause of death Globally
cardiovascular diseases
communicable dis-eases,maternal,perinatal&nutritional con-dition
other NCDs injuries
CVD leading cause of death in the world
Source: WHO 2011 Global Atlas on CVD Prevention & Control
0
10
20
30
40
5046
34
116
2 1
38 37
147
2 1
Male
Distribution of CVD deaths due to heart attacks, strokes and other types of cardiovascular diseases
Source: WHO 2011 Global Atlas on CVD Prevention & Control
South East Asia
25
359.6
7.8
2.1
10 11cardiovascular diseases
communicable dis-eases,maternal, perinatal &nutritional defeciencies
chronic respiratory disorder
cancer
diabetes other NCDsinjuries
Injuries
Other NCDs
Estimated percentage of deaths by cause: South-East Asia Region, 2008
24
6
11
2
10
37
10
CVD Cancerrespiratory disorder diabetesother NCD communicable,mater
nal,perinatal&nutritional condition
injuries
Injuries
Communicable, maternal, perinatal, nutritional condition
Source: WHO country profile 2011
India
Major causes of death in India: Male vs Female
CVDCOPD
Diarrho
ea
Perin
atal
Respira
tor... TB
cancer
s
injuri
es0
5
10
15
20
2520.3
9.36.7 6.4
5.47.1
5.4 5.2
16.9
89.9
6.27.1
4.7 64.5
male
CVDs cause 1.7-2.0 million deaths annually in India
Million death study 2009
Major Causes of Death in India:Rural vs Urban India
CVDCOPD
Diarrho
ea
Perin
atal
Respira
tor... TB
Cancer
Injuri
es0
5
10
15
20
25
30
35
16.8
9 8.86.8 6.7 6.1 5.2 5
28.6
7.54.8 3 3
5.3 7.9 4.4
RuralUrban
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 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)
Wardha
Risk factors for Cardiovascular disorders
Soci
al D
eter
min
ats Globalizati
onUrbanizationAgeingPovertyIlliteracy
Beha
viou
ral R
FUnhealthy dietTobacco usePhysical inactivityHarmful use of alcohol
Met
abol
ic R
FHigh BPObesityDiabetesRaised Blood Lipids
Other factors: Family history/ Hereditary Fetal programming
CVD
Chain from determinants to health outcome
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 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 factorsRisk 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 IndiaBehavioural risk factor
Male Female Total
Current daily tobacco smoking
25.1 2 13.9
Physical inactivity 10.8 17.3 14Metabolic risk factorsRaised BP 33.2 31.7 32.5Raised blood glucose
10 10 10
overweight 9.9 12.2 11Obesity 1.3 2.4 1.9Raised cholesterol 25.8 28.3 27.12008 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
• Obesity• Raised BP(HTN)• Raised Blood
glucose (DM)• Hyperlipidaemia
Metabolic RF • Cardiovascular
diseases
outcome
Primordial Prevention
Primary Prevention
Secondary Prevention
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 progression and recurrence 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 strategiescomplimentary 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
Main risk factors in North Karelia between 1972 and 2007 among Men
and Women aged 30 to 59 yearsMen
Women
Year Smoking (%)
Serum cholesterol
BP
1972 52 6.9 149/921977 44 6.5 143/891982 36 6.3 145/871987 36 6.3 144/881992 32 5.9 142/851997 31 5.7 140/842002 33 5.7 137/832007 31 5.4 138/83
Smoking(%)
Serum cholesterol
BP
10 6.9 153/9210 6.4 141/8615 6.1 141/8516 6 139/8317 5.6 135/8016 5.6 133/8022 5.5 132/7818 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%
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”
Evidence based population approach:
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 Raised taxes on tobacco
Protect people from tobacco smoke Warn about dangers of tobacco Enforce bans on tobacco advertising
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.
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
NPCDCSServices 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
References1. 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, 9:84. 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–S1608. 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 200211. 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; 31112. Premanath M et al. Mysore childhood obesity study. Indian Pediatrics 2010;47:171–3.
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