Presenter: Dr. Reshma Sougaijam
Moderator: Dr. Abhishek Raut
Framework:
What are the cardiovascular disorders
 Burden of disease
-Globally
-South East Asia
-India
Descriptive Epidemiology of CVD
-Maharashtra
Analytical Epidemiology
 Risk factors of cardiovascular disorders
 Burden of Risk factors in India
 Application of Epidemiology for prevention and control
 Prevention and control
 Evidence for prevention of cardiovascular disorders
 National programme

What are cardiovascular diseases
Cardiovascular diseases (CVDs) are
a 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
Major cause of death Globally
cardiovascular diseases
9
31
33
communicable
diseases,maternal,perinatal
&nutritional condition
other NCDs
27
injuries
CVD leading cause of death in the world
Source: WHO 2011 Global Atlas on CVD
Prevention & Control
Distribution of CVD deaths due to heart attacks,
strokes and other types of cardiovascular diseases
50
45
40
35
30
25
20
15
10
5
0
46
38
34
37
11
14
6 7
2 2
1 1
Male
Female
Source: WHO 2011 Global Atlas on CVD Prevention & Control
South East Asia
cardiovascular diseases
Injuries
2.1 Other
NCDs
11
25
10
7.8
9.6
35
Estimated percentage of deaths by cause:
South-East Asia Region, 2008
communicable
diseases,maternal,
perinatal &nutritional
defeciencies
chronic respiratory
disorder
cancer
diabetes
other NCDs
India
CVD
Injuries
10
24
Cancer
37
6
11
10
respiratory disorder
diabetes
2
Communicable, maternal, perinatal, nutritional
condition
other NCD
Source: WHO country profile 2011
Descriptive Epidemiology
Major causes of death in India: Male vs Female
25
20
15
10
5
20.3
16.9
CVDs cause 1.7-2.0 million deaths annually in India
9.3
8
6.7
9.9
7.1
6.4
6.2
5.4 7.1
4.7
5.4
5.2
6
4.5
0
male
female
Million death study 2009
Major Causes of Death in India:
Rural vs Urban India
35
Rural
Urban
30
25
20
28.6
16.8
15
10
5
0
9
8.8
7.5
4.8
6.8
6.7
3
6.1
3
5.2
5.3
Million death study 2009
7.9
5
4.4
India Transition to NCD
Disease burden estimates1990
Disease burden estimate-2020
Source: Nutrition transition in India,1947-2007,Ministry
of women and child welfare
Maharashtra


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)
Analytical Epidemiology
Risk factors for Cardiovascular disorders
Unhealthy
diet
Tobacco use
Physical
inactivity
Harmful use
of alcohol
Metabolic RF
Globalization
Urbanization
Ageing
Poverty
Illiteracy
Behavioural RF
Social Determinats
Chain from determinants to health outcome
High BP
Obesity
Diabetes
Raised Blood
Lipids
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.
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 firstdegree 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 factors
Risk 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 India
Behavioural risk
factor
Male
Female
Total
Current daily tobacco
smoking
25.1
2
13.9
Physical inactivity
10.8
17.3
14
Raised BP
33.2
31.7
32.5
Raised blood glucose
10
10
10
overweight
9.9
12.2
11
Obesity
1.3
2.4
1.9
Raised cholesterol
25.8
28.3
27.1
Metabolic risk factors
2008 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
Primordial Prevention
Metabolic RF
• Obesity
• Raised BP(HTN)
• Raised Blood
glucose (DM)
• Hyperlipidaemia
Primary Prevention
• Cardiovascular
diseases
outcome
Secondary Prevention
Application of Epidemiology for
prevention and control
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 recurrence and progression 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 strategies
complimentary and synergetic
Source: Integrated management of CVD, WHO 2002
Evidence on Prevention of cardiovascular
diseases (Population Strategy)

North Karelia Project (Finland): A comprehensive public

Interventions:
health programme to prevent CVD by policy & environmental
intervention in an effective, community focused manner


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 years
Women
Men
Year
Smoking Serum
BP
(%)
cholesterol
Smoking
(%)
Serum
cholesterol
BP
1972
52
6.9
149/92
10
6.9
153/92
1977
44
6.5
143/89
10
6.4
141/86
1982
36
6.3
145/87
15
6.1
141/85
1987
36
6.3
144/88
16
6
139/83
1992
32
5.9
142/85
17
5.6
135/80
1997
31
5.7
140/84
16
5.6
133/80
2002
33
5.7
137/83
22
5.5
132/78
2007
31
5.4
138/83
18
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%
Evidence based population approach:


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”
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




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.
Raised taxes on tobacco
Protect people from tobacco smoke
Warn about dangers of tobacco
Enforce bans on tobacco advertising
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
NPCDCS
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).
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
References
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. 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, 9:8
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.
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–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 noncommunicable disease intervention programme in Mauritius.
BMJ 1995; 311
12. Premanath M et al. Mysore childhood obesity study. Indian
Pediatrics 2010;47:171–3.