Public Health Module
Venue
Date
Unit: Public Health Aspects of
Coronary Heart Disease
© 2010
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Introduction to public health
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What is health?
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WHO Definition
‘a state of complete
physical, mental and social
well-being and not merely
the absence of disease
or infirmity’
Antonovosky:
Salutogenic model
‘sense of coherence’
Seedhouse and Duncan:
Achievement of potential
Empirical
Lack of health
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What is public health?
‘the science and art of preventing disease, prolonging life
and promoting health through the organized efforts of
society’
C.E.A. Winslow, 1920
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The Wider Determinants of Health
Source: Dahlgreen and Whitehead, G
and Whitehead M (1991)
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The Challenge for Public Health
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Statistical description of nation’s health
Census data
Health Inequalities data
Infant Mortality Rates
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Part 1: Introduction to CHD
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• Coronary heart disease (CHD) is a
condition in which there is inadequate
supply of blood and oxygen to a
portion of the myocardium
• common cause is atherosclerotic
disease of a coronary artery (or
arteries) due to build-up of plaque in
the inner lining of an artery
• CHD manifests as sudden
cardiac collapse
• Acute coronary syndromes (acute
myocardial infarction (MI) and
unstable angina)
• Exertional angina
• Heart failure
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Global CHD
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Global CHD: Cause of death
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Global trends in CHD
Q 1. How would you explain a higher CHD death rate and
CHD burden in low and middle income countries?
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Global trends in CHD
•
•
•
•
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CHD is the most common single cause of death in UK (both men and
women)
UK has one of the highest death rates from CHD in the world
A decline in CHD mortality since the 1970s
•
45% of this reduction from improvement in treatment
•
55% from reduction in risk factors (stopping smoking and control
of hypertension)
Large regional, socio-economic and ethnic differences in CHD morbidity
and mortality
•
Low socio-economic groups, South Asian population and Northern
regions of the UK have been shown to have greater risk of CHD
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Q2: What effect will adverse trends in risk
behaviours have on CHD mortality rates?
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Impact of CHD
•
•
•
•
•
•
Individual
Premature death (death before 75 years)
Disability
Loss of independence
Loss of earnings
Health related quality of life
• Summary measure
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Impact of CHD
•
•
•
•
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Society
Informal care costs
Loss in economy
Costs to
healthcare system
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Health care costs of
CHD, 2006, UK
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CHD and Public Health
Q3. Why is CHD a major public health concern
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Part 2: Risk factors for CHD
Fixed factors:
•
Increasing age
•
Male sex
•
Familial (including
race, genetics)
Modifiable risk factors
•
Tobacco smoke
•
High blood cholesterol
•
Obesity
•
High blood pressure
•
Diabetes mellitus
•
Psychosocial wellbeing
•
Physical inactivity and
•
•
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overweight
Alcohol
Daily consumption of
fruit and vegetables
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Data sources for risk factors
• Population based surveys
Health survey for England
Welsh Health Survey
Scottish Health Survey
• Representative
• Rely upon individuals correctly recalling and reporting
information about their lifestyles
Q4. What are the strengths and limitations of
using health surveys?
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Smoking
• British Doctors Study – mortality
60% higher in smokers, 80%
higher in heavy smokers than
non-smokers
• INTERHEART study –Risk of MI
in smokers and ex-smokers is 2x
more compared to non smokers
• In 2006, 23% of men and 21% of
women in Great Britain smoked
(Source General Household Survey)
• Decline in smoking rates over last
30yrs (increase for teenage girls
since 1990s)
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Prevalence of cigarette smoking by sex, 1972 to 2006, Great Britain
Smoking
• Smoking rates vary by age
Cigarette smoking by sex and socio-economic classifi cation, adults aged 16 and over 2006, Great
Britain
• Smoking rates higher in
Scotland compared to rest
of UK
• More prevalent among
manual social groups
• Smoking rates vary between
ethnic groups in the UK
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High Cholesterol
• Low levels of High-density
lipoprotein cholesterol (HDL-C)
are associated with increased
risk of CHD. Guidelines on HDLC recommend treatment for
those with concentrations below
1.0mmol/l
• Framingham heart study - The
lower the high-density lipoprotein
cholesterol (HDL-C) and higher
low-density lipoprotein
cholesterol (LDL-C) levels , the
greater is the likelihood of
developing CHD
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Prospective Studies Collaboration –
1 mmol/L lower total cholesterol was
associated with about a half , a third
and a sixth lower IHD mortality in both
sexes at ages 40-49, 50-69 & 70-89,
respectively
Prospective Studies Collaboration
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High Cholesterol
• Total blood cholesterol levels in the UK are around average for Europe but
high by international standards, particularly in women
• In England the prevalence of raised total cholesterol is decreasing for men
and women
• Rates of low HDL-cholesterol are much higher in men than women – over
five times higher overall
• The Whitehall II study- low HDL- cholesterol levels vary with income; those
with higher incomes are less likely to have levels of HDL-cholesterol
below 1.0mmol/l
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Overweight and Obesity
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The WHO Report 2002
• ~ over 7% of all disease burden in developed countries caused by raised
body mass index (BMI)
• ~a third of CHD and ischaemic stroke and almost 60% of hypertensive
disease in developed countries was due to overweight
INTERHEART
• ~63% of heart attacks in Western Europe due to abdominal obesity
• abdominal obesity doubles the risk of a heart attack compared to
those without
In England in 2006 (joint health surveys):
• 43% of men and 32% of women were overweight (a BMI of 25-30 kg/m2)
• 24% of men and 24% of women were obese (a BMI of more than
30 kg/m2)
• 32% of men and 41% of women had central obesity
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Overweight/Obesity
Prevalence of obesity by sex, adults aged 16 and over,
1994 to 2006, England
Overweight and obesity are
increasing rapidly
Rates of obesity among women
are rising faster in the North than
the South of England.
Foresight project -predict 60% of
the UK adult population could be
obese by 2050
Source: data:Joint Health Surveys Unit (2008) Health Survey for England 2006. Cardiovascular disease and risk factors.
The Information Centre: Leeds. Chart: BHF www.heartstat.org
•
•
•
WHO SuRF Report 2 - prevalence of overweight and obesity in the UK is
among the highest in Europe
Overweight and obesity including central obesity- increases with age
Prevalence is high in low income & in Black Afro-Caribbean groups
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Q5a: Is there a UK policy to reduce smoking?
Q5b: Is there a UK policy to improve cholesterol?
Q5c: Is there a UK policy to reduce obesity?
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Hypertension
Evidence:
• Risk of CHD is directly related to both systolic
and diastolic blood pressure levels.
• Definition: Systolic blood pressure greater
than or equal to 140mmHg, and / or
diastolic blood pressure greater than or equal
to 90mmHg
• Recommendations for BP no greater than
130mmHg / 80mmHg for diabetes or chronic
renal failure
• Threshold for drug treatment : Sustained
levels of systolic blood pressure greater than
or equal to 160mmHg, and / or diastolic blood
pressure greater than or equal to 100mmHg
• Prevalence of hypertension increases with age
• In UK more prevalent amongst BlackCaribbean group
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PSC:
• Each 20mmHg increase in usual systolic
blood pressure, or 10mmHg increase in
usual diastolic blood pressure, doubles the
risk of death from CHD
The World Health Report 2002:
• ~11% of all disease burden in developed
countries is caused by raised
blood pressure
• over 50% of CHD is due to systolic blood
pressure levels in excess of the theoretical
minimum (115mmHg)
INTERHEART study:
• Around 22% of heart attacks in Western
Europe and 25% of heart attacks in Central
and Eastern Europe were due to a history of
high blood pressure
Diabetes
• Type I (insulin-dependent) and
Type 2 (non-insulin-dependent)associated with increased risk
of CHD
• Other types : gestational diabetes
(marker of greater risk of
developing Type 2 diabetes in
later life)
• Diabetes mellitus is diagnosed by:
• Fasting plasma glucose greater
than or equal to 7.0 mmol/L
or
• 2-hour plasma glucose (following
a 75 g glucose load) greater than
or equal to 11.1 mmol/L
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Any patient with insulin resistance has
numerous reasons to be at very high
risk for atherosclerosis
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Diabetes - evidence
MRFIT • Presence of diabetes equivalent to the
presence of 2–3 risk factors
• Magnifies the effect of other risk factors
for CHD
Other studies:
• Framingham Study - Men with Type 2
diabetes have a 2-4 fold greater annual
risk of CHD / 3-5 fold higher risk in women
•
INTERHEART study - 15% of heart
attacks in Western Europe due to
diagnosed diabetes
people with diagnosed diabetes are at
3 times the risk of a heart attack
compared to those without
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Diabetes
•
Diabetes - common noncommunicable disease globally
•
Developed countries currently
have higher rates than
developing countries UK is
average for developed countries
.
3.1% of men and 1.5% of
women aged 35 and over have
undiagnosed diabetes –
(HSE 2003)
•
•
•
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Prevalence of diagnosed diabetes in adults, 1991 to 2006, England
Source: Joint Health Surveys Unit (2008) Health Survey for England 2006.
Cardiovascular disease and risk factors. The Information Centre: Leeds.
Diabetes increases with age
High prevalence of diagnosed
diabetes: Black Caribbean and
South Asian
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Prevalence rates of diabetes is
increasing- since 1991 more
than doubled
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Psychosocial well-being
Four different types of psychosocial factor have been found to be
most consistently associated with an increased risk of CHD:
•
•
•
•
work stress
lack of social support
depression (including anxiety)
personality (particularly hostility)
Among South Asians, the distribution of psychosocial factors
found to be consistent with ethnic differences in coronary rates.
South Asians report high GHQ12 scores.
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Q7. How do you think psychosocial well-being can effect
CHD risk?
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Physical inactivity
• People who are physically active have a lower risk of CHD maximum benefit with regular and aerobic activity
• WHO 2002 Report > 20% of CHD in developed countries was
due to physical inactivity
• Evidence from observational studies:
• Regular physical activity reduces risk of CHD associated with overweight
or obesity
• Active obese individuals have lower morbidity and mortality than normal
weight individuals
• Physical activity levels are low in the UK & below the EU average.
• ~ one third of English adults are inactive (participate in less than one
occasion of 30 minutes activity a week)
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Q8. What factors are likely to influence levels of activities
from an individual and wider society perspective?
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Alcohol
• High levels of intake – particularly in ‘binges’ – the risk of CHD is increased
Moderate alcohol consumption reduces the risk of CVD
• WHO Report 2002 - 2% of CHD developed countries is due to alcohol
• From late 1950s alcohol consumption increasing steadily, more
than doubling
• Government advises between 2-3 units a day for women and 3-4 for men
• 40% of men and 33% of women consume more than recommended amount
in England 2006
• The prevalence of binge drinking was highest in the 16 to 24 years
age group
• Adults from each minority ethnic group were less likely to drink alcohol
than the general population - except for the Irish who drink beyond
recommended levels
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Early Life course
• Evidence is fairly consistent that childhood socioeconomic position (often
measured as parents’ occupation or education) is also inversely associated
with CHD
• Cumulative exposure to socioeconomic disadvantage across the life course
may be inversely associated with CHD; the mechanisms are not fully clear
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Exercise I:
What are the key patterns in CHD risk factors by
age, sex, ethnicity, deprivation and region?
Why is it important to understand differences in
risk factors between groups?
What do trends in the levels of alcohol, smoking
and obesity suggest for future levels of CHD?
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Part 3: Prevention
• CHD is a preventable disease. About half of the decline in CHD
mortality is due to lifestyle changes and half due to better
treatment and care
• Two approaches for the practical management of risk factors
(Rose, 1989)
• Population approach
• High risk approach
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Population and High Risk Strategy
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Q 12. What are the ethical considerations in a population
based approach?
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Efficacy and effectiveness
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•
Efficacy: The extent to which a specific intervention
produces a beneficial result under ideal conditions. Ideally,
the calculation of efficacy is based on the results of a
randomised controlled trial.
i.e. Whether a treatment can work under ideal (e.g. RCT)
circumstances (compared with effectiveness which is
examined in routine circumstances)
•
Effectiveness: A measure of the extent to which a specific
intervention when used in the field in routine
circumstances, does what it is intended to do for a specified
population. This is a measure of the extent to which a health
care intervention fulfils its objectives.
e.g. The degree to which a treatment or programme works in
an everyday service setting rather than a research
environment
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Q13. Why might the efficacy and effectiveness for an
intervention differ?
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Levels of prevention
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• Primary prevention : Prevents the disease from occurring in
those at risk. An example of primary prevention of CHD would
be to provide smoking cessation advise to an individual with no
history of CHD
• Secondary prevention: Aims to identity high risk individuals in
a population and prevent disease progression i.e. from angina
to MI or death. An example would be the provision of lipid
lowering medications to those with a history of CHD
• Tertiary prevention: Aims to prevent the recurrence of a MI.
An example would be revascularisation after a MI for severe
cases of CHD
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Prevention and Management
Adapted from: George A. Mensah, William H. Dietz, Virginia B. Harris, Rosemarie Henson, Darwin R. Labarthe, Frank Vinicor, Howell Wechsler.
Prevention and Control of Coronary Heart Disease and Stroke—Nomenclature for Prevention Approaches in Public Health: A Statement for Public Health
Practice from the Centers for Disease Control and Prevention American Journal of Preventive Medicine, Volume 29, Issue 5, Supplement 1, December
2005, Pages 152-157
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Population wide approach
A population wide approach may include
•
•
•
•
Integrated national policies
health promotion campaigns (e.g. Change4 life see
http://www.nhs.uk/Change4life) or
disease prevention interventions (e.g. legislation to reduce the level of salt in
processed food)
Health promotion can be defined as the process of enabling people to
increase control over their health and its determinants, and thereby improve
their health (WHO 2005)
The overall objective should be to make it easy for the population to make
healthy choices related to diet, physical activity and avoidance of tobacco.
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Q14. Discuss the rationale for preventative interventions
targeted at:
a) high risk groups
b) the whole population
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Effective Health Promotion Policies
Promote healthy eating:
Agricultural subsidies for fruits and vegetables
Food pricing and availability
Labelling of food
School health education
Promote physical activity
Public transport
Pedestrian- and cyclist friendly road planning
Reduce smoking
Tobacco control measures (prohibition of advertising /ban in public spaces)
Smoking cessation services
Prevention of sudden death by CHD
Availability of automatic external defibrilliators in public places –
stations, shopping centres, airport
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Primary Prevention
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•
Primary prevention involves high risk approach
•
No national policy for cardiovascular screening of the healthy
population in primary care
•
High risk patients are being detected through new patient checks
and opportunistic screening
•
Essential that the high-risk approach is complemented by
population-wide public health strategies
•
Public health approaches can effectively slow down the
development of atherosclerosis and reduce incidence of CVD
•
Population-wide strategies will also support lifestyle modification
in those at high risk
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Risk Prediction tools
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Joint British Societies charts assess the ten-year risk of CVD in three age
categories and recommend that CVD prevention in clinical practice should
focus equally on:
• people with established atherosclerotic CVD
• people with diabetes
• apparently healthy individuals at high risk (CVD risk of > =20% over 10
years) of developing symptomatic atherosclerotic disease
Inappropriate in certain patients such as:
• smoking status which should reflect lifetime risk and not just current use
• premature menopause
Risk estimates have not been validated in ethnic minorities.
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Intensity of Intervention should be
proportional to risk
Source: Cardiovascular disease prevention. Translating evidence into action. Geneva, World Health Organization, 2005.
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NHS Health Checks
See http://www.nhs.uk/Planners/NHSHealthCheck/Pages/NHSHealthCheck.aspx
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Effective policies – Primary Prevention
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Promote physical activity
Encouraged to take at least 30 minutes of moderate physical activity (e.g.
brisk walking) a day
Smoking status
Nonsmokers should be encouraged not to start smoking
Smokers encouraged to quit smoking and other forms of tobacco be advised
to stop
Risk >20% nicotine replacement and /or nortriptyline or amfebutamone
(bupropion) to motivated smokers who fail to quit with counselling
Overweight and obesity
Encouraged to reduce total fat and saturated fat, salt intake
Increased range of fruits and vegetables as well as whole grains
and pulses
Increase physical activity
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Effective policies – Primary Prevention
• Alcohol - Reduce alcohol intake to recommended levels
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•
Hypertension - Threshold for treatment: 160/100 mm Hg, or less if
target organ damage and specific lifestyle advice
•
Serum cholesterol - All individuals with total cholesterol at
or above 8 mmol/l (320 mg/dl), should be advised to follow
a lipid lowering diet and given a statin to lower the risk of
cardiovascular disease
•
Diabetes/plasma glucose - Individuals with persistent
fasting blood glucose >6 mmol/l despite diet control should
be given metformin
•
Risk is 30% or more - Antiplatelet : low dose aspirin recommended
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Secondary prevention
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• Risk charts not necessary to make treatment decisions in
people with established cardiovascular disease - as these
patients are at very high risk of developing recurrent
cardiovascular events
• Intensive life style advice (as in primary prevention) should be
given simultaneously with drug treatment
• Following an MI drugs recommended to reduce further attacks
and mortality:
•
•
•
•
•
•
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Ace inhibitors (to lower high BP)
Beta blocker (to lower high BP)
Antiplatelets (reduce clotting)
statin (to reduce cholesterol)
antihypertensive (to lower high BP)
anti glycaemic (to manage high blood glucose)
Tertiary Prevention
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CABG
Should be considered as an adjunct to optimal medical
treatment including aspirin, lipid lowering treatment, ACE
inhibitors and beta-blockers) in those patients at moderate and
high risk who are considered likely to have left main stem or
triple vessel disease.
PTCA
Should be considered for relief of anginal symptoms in patients
with refractory angina who are already receiving optimal
medical treatment.
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Exercise 2:
Using the evidence provided in the workbook, work out a
10 point action plan to reduce the risk of CHD in your
local area
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Summary
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• Coronary Heart Disease is a major public health issue. It is
responsible for much of the global burden of disease and is the
UK’s biggest killer
• It has substantial impact of the health and well-being of patients
• Costs include the individual patient, family and other carers, NHS
and the wider economy
• Much of CHD mortality and morbidity is preventable
• All health professionals have opportunities to support and
promote effective preventive interventions
• Tackling the determinants and risk factors for CHD will also
impact on other major diseases, such as stroke and
type 2 diabetes
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Part 4: Statistics on CHD
Statistics on:
Morbidity – incidence, prevalence, trends
Mortality
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Morbidity
Morbidity is state of being diseased
Two key measures of morbidity:
Incidence is an estimate of risk of developing disease and useful for
looking at causes or determinants of disease
• e.g. the incidence of new cases of CHD in a population
Prevalence indicates amount of illness requiring care and is useful in
health service planning
• e.g. the proportion of the population with a history of CHD
Sources of morbidity data include:
• Hospitals
• Primary care
• Self reported surveys
• Health Survey for England and the General Household Survey suggest
morbidity, particularly in older age groups, appears to be rising
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Incidence (new cases)
Estimated incidence of CHD per year in UK by gender
Source:BHF statistics
estimates based on 2006 CHD mortality data (MI), 2006 UK population estimates - Scottish Continuous Morbidity Study data & (angina), TheHillingdon
Heart Failure Study
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Incidence (new cases)
Estimated incidence of CHD per
year in the UK by gender
Source:BHF statistics
estimates based on 2006 CHD mortality data (MI), 2006 UK population estimates - Scottish Continuous Morbidity Study data & (angina), TheHillingdon
Heart Failure Study
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Prevalence
Estimated prevalence of CHD per year in the UK by
gender
8.0
Men
Women
7.0
Prevalence (%)
6.0
5.0
4.0
3.0
2.0
1.0
0.0
1994
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1998
2003
2006
Q 17. What is the weakness of using self reported
diagnosis to determine prevalence?
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Prevalence (existing cases)
Estimated prevalence of myocardial infarction, angina and
heart failure by gender, 2006
Prevalence men
Total
Myocardial
infarction
(age 35yrs +)
970000
439000
1.4 million
Angina
(35yr +)
1132000
849000
1.98 million
CHD*
1.5 million
1 million
2.5 million
Source: BHF www.heartstats.org
Estimates are derived from applying age-specifi c rates to the UK population estimates for 2006,*from self reported doctor diagnosed CHD (angina or heart
attack)
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Prevalence (existing cases)
Estimated prevalence of CHD per year in the UK by age group among men.
35
35-44yrs
45-54yrs
55-64yrs
65-74yrs
75+yrs
30
Prevalence (%)
25
20
15
10
5
0
1994
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1998
2003
2006
Prevalence
Prevalence of disease 2006/07, England, Wales and Scotland.
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Trends in morbidity
Change in incidence of myocardial infarction, adults aged between 30 and 69, between 1966 and 1996,
UK studies compared
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Q18. Comment on the regional and gender
differences in incidence trends in the table above.
Q19. What drives trends in incidence?
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Trends in morbidity
Changes in prevalence rates in CHD, stroke and CHD or stroke by sex, 1994 to 2006, England
Source: Joint Health Surveys Unit (2008) Health Survey for England 2006. Cardiovascular disease and risk factors. The Information Centre: Leeds; and
previous editions.
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Q 20. By looking at the source of prevalence do you
think this may be a true reflection?
Q 21. What effect do you think upward trends in the
prevalence of obesity will have on the incidence and
prevalence of CHD?
Q22. What is the public health importance of increasing
prevalence?
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Morbidity - inequalities
• The WHO MONICA project - incidence rates in the two UK populations
included in the study, Belfast and Glasgow, were among the highest in the
world, particularly in women
• The incidence rate of CHD is higher in men and increases with age
• Incidence of MI in women increases significantly after menopause
• Prevalence of all CHD:
• Higher in the North of England and in Wales
• Higher in lower socio-economic groups
• High in South Asian men
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Mortality
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•
Mortality is the number of deaths in a population in a given period
•
Crude mortality which is expressed as the number of deaths per 1,000
population at risk of dying during a period
• easy to calculate
• difficult to compare across studies as differences may reflect the age
structure of the population
•
Specific mortality estimates calculate the number of deaths in a
population by subgroup (expressed as per 1,000 population) such as age
or sex specific mortality
• allows comparisons of subgroups and to identify those most at risk
•
Standardised mortality ratios
• This allows direct comparison of mortality experience between two
populations by taking into account the different age structures
•
Data source: Death certificates
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Mortality
Deaths by cause, men, 2006, United Kingdom
Source: data: England and Wales, Office for National Statistics (2008) Deaths registered by cause and area of residence, personal communication.
Scotland, General Register Office (2008) Deaths registered by cause and area of residence, personal communication.
Northern Ireland, Statistics and Research Agency (2008) Deaths registerted by cause and area of residence, personal communication
charts: BHF
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Deaths by cause, women, 2006, UK
Trends – Age specific mortality rates
Age specific death rates from CHD, men, 1968 to
2006 in UK plotted as a percentage of the rate in
1968
Age specific death rates from CHD, women, 1968 to
2006 in UK plotted as a percentage of the rate in
1968
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Trends - SES
Since the 1970s the premature death rate has fallen across all social groups
for both men and women.
Mortality rate has fallen faster in non-manual workers than in manual
workers, that is the difference in death rates increased between these groups.
Mortality rates from CHD by social class, men and women aged 35 to 64, 1978 to 1998, England and Wales
Source: Data from 1993/96 from Offi ce for National Statistics (2003) Trends in social class differences in mortality by cause, 1986 to 2000. The Stationery Offi ce: London.
Chart:BHF
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Q23. What could be possible explanations for the
positive relationship between deaths from circulatory
diseases and levels of deprivation?
Q24. How could these differences be addressed?
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Mortality trends
• Decline in CHD mortality in men and women since late 1970s
• But CHD mortality in the UK is still amongst the highest in
Western Europe
• In recent years slower decline in younger age groups
• May reflect attitudes to risk behaviour change among younger
populations – young people continuing to smoke, drink heavily
and higher prevalence of obesity
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Mortality - inequalities
Death rates are higher:
• Scotland than the South of England
• Manual workers than in non-manual workers
• Ethnic groups- South Asia
• During winter period- excess winter mortality
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Q25. Discuss possible reasons for inequality in CHD
mortality among South Asians
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Q 26. What could be possible explanations for different
rates of decline in CHD mortality in different developed
countries?
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