Anselm Hennis

Regional contributions of six preventable risk factors to achieving the 25 × 25 non-communicable disease mortality reduction target: a modelling study

BACKGROUND Countries have agreed to reduce premature mortality from the four main non-communicable diseases (NCDs) by 25% from 2010 levels by 2025 (referred to as the 25 × 25 target). Countries also agreed on a set of global voluntary targets for selected NCD risk factors. Previous analyses have shown that achieving the risk factor targets can contribute substantially towards meeting the 25 × 25 mortality target at the global level. We estimated the contribution of achieving six of the globally agreed risk factor targets towards meeting the 25 × 25 mortality target by region. METHODS We estimated the effect of achieving the targets for six risk factors (tobacco and alcohol use, salt intake, obesity, and raised blood pressure and glucose) on NCD mortality between 2010 and 2025. Our methods accounted for multicausality of NCDs and for the fact that, when risk factor exposure increases or decreases, the harmful or beneficial effects on NCDs accumulate gradually. We used data for risk factor and mortality trends from systematic analyses of available country data. Relative risks for the effects of individual and multiple risks, and for change in risk after decreases or increases in exposure, were from reanalyses and meta-analyses of epidemiological studies. FINDINGS The probability of dying between the ages 30 years and 70 years from the four main NCDs in 2010 ranged from 19% in the region of the Americas to 29% in southeast Asia for men, and from 13% in Europe to 21% in southeast Asia for women. If current trends continue, the probability of dying prematurely from the four main NCDs is projected to increase in the African region but decrease in the other five regions. If the risk factor targets are achieved, the 25 × 25 target will be surpassed in Europe in both men and women, and will be achieved in women (and almost achieved in men) in the western Pacific; the regions of the Americas, the eastern Mediterranean, and southeast Asia will approach the target; and the rising trend in Africa will be reversed. In most regions, a more ambitious approach to tobacco control (50% reduction relative to 2010 instead of the agreed 30%) will contribute the most to reducing premature NCD mortality among men, followed by addressing raised blood pressure and the agreed tobacco target. For women, the highest contributing risk factor towards the premature NCD mortality target will be raised blood pressure in every region except Europe and the Americas, where the ambitious (but not agreed) tobacco reduction would have the largest benefit. INTERPRETATION No WHO region will meet the 25 × 25 premature mortality target if current mortality trends continue. Achieving the agreed targets for the six risk factors will allow some regions to meet the 25 × 25 target and others to approach it. Meeting the 25 × 25 target in Africa needs other interventions, including those addressing infection-related cancers and cardiovascular disease. FUNDING UK Medical Research Council.

Accuracy and Usefulness of Select Methods for Assessing Complete Collection of 24-Hour Urine: A Systematic Review

Twenty‐four–hour urine collection is the recommended method for estimating sodium intake. To investigate the strengths and limitations of methods used to assess completion of 24‐hour urine collection, the authors systematically reviewed the literature on the accuracy and usefulness of methods vs para‐aminobenzoic acid (PABA) recovery (referent). The percentage of incomplete collections, based on PABA, was 6% to 47% (n=8 studies). The sensitivity and specificity for identifying incomplete collection using creatinine criteria (n=4 studies) was 6% to 63% and 57% to 99.7%, respectively. The most sensitive method for removing incomplete collections was a creatinine index <0.7. In pooled analysis (≥2 studies), mean urine creatinine excretion and volume were higher among participants with complete collection (P<.05); whereas, self‐reported collection time did not differ by completion status. Compared with participants with incomplete collection, mean 24‐hour sodium excretion was 19.6 mmol higher (n=1781 specimens, 5 studies) in patients with complete collection. Sodium excretion may be underestimated by inclusion of incomplete 24‐hour urine collections. None of the current approaches reliably assess completion of 24‐hour urine collection.

Improved Blood Pressure Control to Reduce Cardiovascular Disease Morbidity and Mortality: The Standardized Hypertension Treatment and Prevention Project

Hypertension is the leading remediable risk factor for cardiovascular disease, affecting more than 1 billion people worldwide, and is responsible for more than 10 million preventable deaths globally each year. While hypertension can be successfully diagnosed and treated, only one in seven persons with hypertension have controlled blood pressure. To meet the challenge of improving the control of hypertension, particularly in low‐ and middle‐income countries, the authors developed the Standardized Hypertension Treatment and Prevention Project, which involves a health systems–strengthening approach that advocates for standardized hypertension management using evidence‐based interventions. These interventions include the use of standardized treatment protocols, a core set of medications along with improved procurement mechanisms to increase the availability and affordability of these medications, registries for cohort monitoring and evaluation, patient empowerment, team‐based care (task shifting), and community engagement. With political will and strong partnerships, this approach provides the groundwork to reduce high blood pressure and cardiovascular disease‐related morbidity and mortality.

Premature Mortality from Cardiovascular Disease in the Americas - Will the Goal of a Decline of "25% by 2025" be Met?

Background Cardiovascular diseases (CVD) are the underlying cause 1.6 million deaths per year in the Americas, accounting for 30% of total mortality and 38% of by non-communicable deaths diseases (NCDs). A 25% reduction in premature mortality due four main NCDs was targeted by the 2011 High-level Meeting of the General Assembly on the Prevention and Control of NCDs. While overall CVD mortality fell in the Americas during the past decade, trends in premature CVD mortality during the same period have not been described, particularly in the countries of Latin America and the Caribbean. Methods This is a population-based trend-series study based on a total of 6,133,666 deaths to describe the trends and characteristics of premature mortality due to CVD and to estimates of the average annual percentage of change during the period 2000–2010 in the Americas. Findings Premature mortality due to CVD in the Americas fell by 21% in the period 2000–2010 with a -2.5% average annual rate of change in the last 5 year—a statistically significant reduction of mortality—. Mortality from ischemic diseases, declined by 25% - 24% among men and 26% among women. Cerebrovascular diseases declined by 27% -26% among men and 28% among women. Guyana, Trinidad and Tobago, the Dominican Republic, Bahamas, and Brazil had CVD premature mortality rates over 200 per 100,000 population, while the average for the Region was 132.7. US and Canada will meet the 25% reduction target before 2025. Mexico, Costa Rica, Venezuela, Dominican Republic, Panama, Guyana, and El Salvador did not significantly reduce premature mortality among men and Guyana, the Dominican Republic, and Panama did not achieve the required annual reduction in women. Conclusions Trends in premature mortality due to CVD observed in last decade in the Americas would indicate that if these trends continue, the Region as a whole and a majority of its countries will be able to reach the goal of a 25% relative reduction in premature mortality even before 2025.

A public health approach to hypertension

1 Angell SY, De Cock KM, Frieden TR. A public health approach to global management of hypertension. Lancet 2015; 385: 825–27. 2 PAHO. Plan of action for the prevention and control of noncommunicable diseases (NCDs) in the Americas 2013–2019. Washington: Pan American Health Organization, 2014. 3 Ordunez P, Martinez R, Niebylski ML, Campbell NR. Hypertension Prevention and Control in Latin America and the Caribbean. J Clin Hypertens (Greenwich) 2015; published online Feb 28. DOI:10.1111/jch.12518. 4 PAHO. PAHO strategic fund. Washington: Pan American Health Organization, 2014. http:// www.paho.org/hq/index.php?option=com_co ntentv 15: 249. 6 PAHO. Antiretroviral treatment in the spotlight: a public health analysis in Latin America and the Caribbean 2013. Washington: Pan American Health Organization, 2013. 7 WHO. A global brief on hypertension: silent killer, global public health crisis. Geneva: World Health Organization, 2013. Created in 2000, and based on PAHO’s experiences managing the Revolving Fund for vaccines, the PAHO Strategic Fund is an effective mechanism to procure drugs and medical technology at reduced prices to treat people with communicable and non-communicable diseases. As an example of its relevance in the Americas, between 2004, and 2012, the monetary value of antiretrovirals procured for HIV/AIDS through the PAHO Strategic Fund increased by more than 1500 times. Participating countries also receive technical cooperation to strengthen their capacity for planning and management of essential medical supplies. The PAHO Strategic Fund has evolved to better respond to the needs of countries and improve access to quality drugs for non-communicable diseases. As a result of an international bidding process and time-bound agreements, PAHO member states are able to procure antihypertensive drugs recommended by the GSHT Project at a unique price for each country. This mechanism also applies to drugs for cancer and diabetes. However, the success of the PAHO Strategic Fund depends on a high level of participation by member states, which allows PAHO to negotiate lower prices, thus increasing availability of drugs and providing benefi ts to larger numbers of people aff ected. Guaranteeing long-term daily treatment for a billion people with hypertension worldwide is extremely complex. Prioritisation of the availability and aff ordability of a core set of quality-assured drugs to treat hypertension, one of the pillars of the GSHT Project, is highly strategic. As such, the PAHO Strategic Fund represents a model that ensures access to a set of core drugs at competitive prices. Management and sustaining of such a fund is not without challenges— among them, the powerful competing economic interests of manufacturers. Innovative strategies will need to be adopted for advances towards as did three RCTs in the systematic review. Good RCTs are invaluable, but poor RCTs produce bad evidence. Restating conclusions based on poor evidence makes it harder to gather good evidence and sets back the progress of evidence-based medicine.

A Rapid Assessment Study on the Implementation of a Core Set of Interventions to Improve Cardiovascular Health in Latin America and the Caribbean

Cardiovascular diseases (CVD) are the leading cause ofdeathintheAmericaswith1.6milliondeathsperyear,halfamillion of which occur before age 70 years. CVD (Interna-tional Classification of DiseaseseTenth Revision, I00eI99)represent 38% of all causes of death in the region [1].Although mortality due to CVD in the region declined at arate of 1.9% per year from 2000 to 2010, low- income andmedium-income countries, compared with high-incomecountries, had an excess of CVD mortality of 56.7% and20.6%, respectively [2].The 2013 World Health Assembly, in response to the2011 U.N. political declaration on noncommunicable dis-eases (NCD), established a goal of 25% reduction in pre-mature mortality due to 4 major NCD by 2025 (25 25goal). These NCD are CVD, cancer, diabetes, and chronicrespiratory diseases. Achieving a reduction of this magni-tude will depend primarily on successes in the preventionand control of CVD.The2010regionalconsultationoncardiovascularhealth(CVHregionalconsultation)ledbythePanAmericanHealthOrganization (PAHO) established a list of priority in-terventions to improve CVH in the Americas. The list, pre-pared before the U.N.’s 2011 high-level meeting on NCD,serves as a road map for the region beyond that importantevent. A regional expert group, including PAHO technicaladvisors, representatives of health ministries, professionalsocieties, academic institutions, and several nongovern-mentalorganizations,definedasetofinterventionsaround4main areas: 1) public policy and advocacy; 2) health pro-motion; 3) surveillance; and 4) disease management andintegrated control for risk factors [3].Much progress has been made by PAHO’s memberstates since the CVH regional consultation [4]. Although4 years is a relatively short time to fully implement acomprehensive package of interventions, it may be anappropriate interval to assess progress and make neces-sary course corrections. It is unlikely that progress willoccur at the same rate among all countries. Our aim is toinvestigate the state of implementation of the core set ofinterventions recommended by the 2010 CVH regionalconsultation.

Educational Health Disparities in Cardiovascular Disease Risk Factors: Findings from Jamaica Health and Lifestyle Survey 2007–2008

Objectives Socioeconomic disparities in health have emerged as an important area in public health, but studies from Afro-Caribbean populations are uncommon. In this study, we report on educational health disparities in cardiovascular disease (CVD) risk factors (hypertension, diabetes mellitus, hypercholesterolemia, and obesity), among Jamaican adults. Methods We analyzed data from the Jamaica Health and Lifestyle Survey 2007–2008. Trained research staff administered questionnaires and obtained measurements of blood pressure, anthropometrics, glucose and cholesterol. CVD risk factors were defined by internationally accepted cut-points. Educational level was classified as primary or lower, junior secondary, full secondary, and post-secondary. Educational disparities were assessed using age-adjusted or age-specific prevalence ratios and prevalence differences obtained from Poisson regression models. Post-secondary education was used as the reference category for all comparisons. Analyses were weighted for complex survey design to yield nationally representative estimates. Results The sample included 678 men and 1,553 women with mean age of 39.4 years. The effect of education on CVD risk factors differed between men and women and by age group among women. Age-adjusted prevalence of diabetes mellitus was higher among men with less education, with prevalence differences ranging from 6.9 to 7.4 percentage points (p < 0.05 for each group). Prevalence ratios for diabetes among men ranged from 3.3 to 3.5 but were not statistically significant. Age-specific prevalence of hypertension was generally higher among the less educated women, with statistically significant prevalence differences ranging from 6.0 to 45.6 percentage points and prevalence ratios ranging from 2.5 to 4.3. Similarly, estimates for obesity and hypercholesterolemia suggested that prevalence was higher among the less educated younger women (25–39 years) and among more educated older women (40–59 and 60–74 years). There were no statistically significant associations for diabetes among women, or for hypertension, high cholesterol, or obesity among men. Conclusion Educational health disparities were demonstrated for diabetes mellitus among men, and for obesity, hypertension, and hypercholesterolemia among women in Jamaica. Prevalence of diabetes was higher among less educated men, while among younger women the prevalence of hypertension, hypercholesterolemia, and obesity was higher among those with less education.

Chronic Disease Challenges in the Caribbean

Highlights The Caribbean sub-region has the highest premature mortality from NCD in the Americas. Sustained political leadership and multisectoral action to prevent and control NCD is required. Scale-up of technical and financial support to SIDS by the international community is needed.

Implementation Research to Address the United States Health Disadvantage: Report of a National Heart, Lung, and Blood Institute Workshop.

Four decades ago, U.S. life expectancy was within the same range as other high-income peer countries. However, during the past decades, the United States has fared worse in many key health domains resulting in shorter life expectancy and poorer health-a health disadvantage. The National Heart, Lung, and Blood Institute convened a panel of national and international health experts and stakeholders for a Think Tank meeting to explore the U.S. health disadvantage and to seek specific recommendations for implementation research opportunities for heart, lung, blood, and sleep disorders. Recommendations for National Heart, Lung, and Blood Institute consideration were made in several areas including understanding the drivers of the disadvantage, identifying potential solutions, creating strategic partnerships with common goals, and finally enhancing and fostering a research workforce for implementation research. Key recommendations included exploring why the United States is doing better for health indicators in a few areas compared with peer countries; targeting populations across the entire socioeconomic spectrum with interventions at all levels in order to prevent missing a substantial proportion of the disadvantage; assuring partnership have high-level goals that can create systemic change through collective impact; and finally, increasing opportunities for implementation research training to meet the current needs. Connecting with the research community at large and building on ongoing research efforts will be an important strategy. Broad partnerships and collaboration across the social, political, economic, and private sectors and all civil society will be critical-not only for implementation research but also for implementing the findings to have the desired population impact. Developing the relevant knowledge to tackle the U.S. health disadvantage is the necessary first step to improve U.S. health outcomes.