Epidemiology of cardiovascular disorders

1. Epidemiology ofcardiovascular disorders

2. 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

3. Cardiovascular 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

4. CVD leading cause of death in the world Source: WHO 2011 Global Atlas on CVD Prevention & Control

5. Source: WHO 2011 Global Atlas on CVD Prevention & Control

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

7. Communicable, maternal, perinatal, nutritional condition Source: WHO country profile 2011

8. CVDs cause 1.7-2.0 million deaths annually in India Million death study 2009

9. Million death study 2009

10. 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

11. Maharashtra Sevagram: Prevalence of CHD in 1988 is 4.36% • Wardha:Out of 7,42,736 population(>30 yrold & pregnant mothers) screened,the suspected cases of HT is 23,047 (3.1%) & of Diabetes is 19,779 (2.66%).(NPCDCS)

12. Chain from determinants to health outcome 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.

13. 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

14. 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

15. 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

16. 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.

17. 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%.

18. 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.

19. 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 .

20. 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.

21. 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

22. 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).

23. WHO Global health risk 2009

24. Source: WHO NCD Country profile 2011 2008 estimated prevalence

25. Primordial Prevention Primary Prevention Secondary Prevention

26. 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.

27. 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

28. 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.

29. Source: Integrated management of CVD, WHO 2002

30. 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

31. Men Women

33. 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”

35. 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.

37. 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

39. 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

40. 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).

41. 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

42. 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

43. 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. NoncommunicableDiseases 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.

44. 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. PremanathM et al. Mysore childhood obesity study. Indian Pediatrics 2010;47:171–3.

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