Marilyn Hunn

Principles for National and Regional Guidelines on Cardiovascular Disease Prevention A Scientific Statement From the World Heart and Stroke Forum

In the global effort to reduce suffering and death from CVD, the World Heart and Stroke Forum (WHSF) Guidelines Task Force of the World Heart Federation (WHF) recommends that every country develop a policy on CVD prevention. National policy should grow out of systematic and ongoing dialogue among governmental, public health, and professional clinical groups. National policy should set priorities for public health and clinical interventions appropriate to the country. It should also be the foundation for the development of national guidelines on CVD prevention, which are the focus of the present document. Cardiovascular disease (CVD) is a leading cause of global mortality, accounting for almost 17 million deaths annually. Nearly 80% of this global mortality and disease burden occurs in developing countries. In 2001, CVD was the leading cause of mortality in 5 of the 6 World Health Organization (WHO) worldwide regions. Of concern in developing countries is the projected increase in both proportional and absolute CVD mortality. This can be related to an increase in life expectancy due to public health advances, which reduce perinatal infections and nutritional deficiencies in infancy, childhood, and adolescence, and in some countries to improved economic conditions. This increasing longevity provides longer periods of exposure to CVD risk factors and thus a greater probability of clinically manifest CVD. The concomitant decline of infections and nutritional disorders (competing causes of death) also increases the proportional burden due to CVD. Adverse lifestyle changes accompanying industrialization, urbanization, and increased discretionary income increase the degree of exposure to CVD risk factors. Altered diet with increased fat and total caloric consumption and increased tobacco use are prevalent lifestyle trends. Demographic changes coupled with adverse lifestyle changes will accelerate the number of deaths due to CVD worldwide, many of which will be premature in the developing countries. Although continuation of this adverse trend is not inevitable, the CVD disease patterns now present in the economically developed countries are, in fact, becoming established in developing countries, as noted in the World Health Report 2002 1 (Data Supplement Figure I). Whereas the causes of CVD are common to all parts of the world, the approaches to its prevention at a societal or individual level will differ between countries for cultural, social, medical, and economic reasons. Although national guidelines will embrace the principles of CVD prevention recommended in this report, they may differ in terms of the organization of preventive cardiology, risk factor treatment thresholds and goals, and the use of medical therapies. The recommendations in this report focus on clinical management of patients with established CVD and those at high risk; however, it is essential that each country include a societal approach to CVD prevention. As stated in the WHO publication Integrated Management of Cardiovascular Risk, 2 “Epidemiological theory indicates that, compared with intensive individual treatment of high-risk patients, small improvements in the overall distribution of risk in a population will yield larger gains in disease reduction, when the underlying conditions that confer risk are widespread in the population.” Each country should seek to implement national clinical guidelines directed toward high-risk individuals and give equal importance to developing low-risk population strategies.

Low Priority of Cardiovascular and Chronic Diseases on the Global Health Agenda A Cause for Concern

At the beginning of the 20th century, cardiovascular disease (CVD) was responsible for ≈10% of all deaths worldwide; today, that figure has risen to ≈30%, with 80% occurring in developing countries. Current efforts toward CVD control are insufficient, particularly in low- and middle-income countries.1 In 2001, CVD was already the No. 1 cause of death worldwide,2 yet little global attention has been paid to the challenge of reducing this burden in developing countries, where it is on the rise. In addition to CVD, other chronic diseases such as diabetes mellitus, chronic respiratory disease, and cancer are being ignored by policy makers, development aid agencies, and leading foundations.3 One reason that CVD and other chronic diseases remain underrecognized and underfunded is the United Nation’s Millennium Development Goals (MDGs) process. Representatives of the chronic disease specialties were not appreciably involved.4 The United Nation’s MDGs are designed to reduce poverty in developing countries by the year 2015. Of the 8 goals (Table 1), 3 are specifically targeted at health issues: to reduce child mortality, to reduce maternal mortality, and to prevent the spread of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), malaria, and other diseases.5 Whereas the linkage between health and economic development is clearly established, the health goals are too narrowly defined and do not include the diseases affecting the majority of the world’s population. We believe that to truly begin to reduce poverty, both infectious and chronic diseases must be addressed. The correct approach is “and,” not “or.” View this table: Table 1. The United Nation’s MDGs Four compelling arguments can be made for including CVD in the MDG process and as such on the Global Health Agenda (Table 2). First, the most recent data on global burden of disease clearly reveal the predominance of CVD and other chronic diseases. …

Promotion of Cardiovascular Health in Preschool Children: 36-Month Cohort Follow-up

BACKGROUND Educational interventions in preschool children could improve dietary behavior and physical activity, and prevent unhealthy body weights in low- and middle-income countries. Previously, we have reported the beneficial impact of an educational intervention in preschoolers in a 6-month trial. We now report extended results after 36 months. METHODS Evaluating the cohort of previously intervened children, baseline measurements were made in May 2009 in 14 preschool facilities in Usaquén (Bogotá, Colombia). Follow-up measurements were performed at 18 and 36 months. The primary outcome was the mean change in childrens knowledge and attitudes scores regarding healthy eating and living an active lifestyle, including habits scores related to physical activity. Secondary outcomes were the change over time of childrens nutritional status and the mean change in parents knowledge, attitudes, and habits. RESULTS We included 1216 children, 3-5 years of age, and 928 parents. After adjusting by sex and age of children, socioeconomic status, age of parents, and age and education level of teachers, we found a significant increase in mean knowledge, attitudes, and habits scores at 36 months, compared with baseline: 87.94 vs 76.15 (P <.001); 86.39 vs 57.03 (P <.001); and 66.29 vs 48.72 (P <.001), respectively. We observed a similar increase in knowledge and attitude scores in parents: 73.45 vs 70.01 (P <.001); and 78.08 vs 74.65 (P <.001). The proportion of eutrophic children increased from 62.1% at baseline to 75.0% at 36 months (P <.0001). CONCLUSIONS After 36 months, the educational intervention maintained a beneficial trend toward a healthy lifestyle in children and their parents.