(WP)NCD/ICPINCD/040-E
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Report Series No.: RS/97/GE/02(MAA)
REPORT
))IORKING GROUP ON INTEGRA TED PREVENTION AND CONTROL OF CARDIOVASCULAR DISEASES AND DIABETES
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Kuala Lumpur, Malaysia 17-21 November 1997
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NOTE
The views expressed in this report are those of the partIcIpants in the Working Group on Integrated Prevention and Control of Cardiovascular Diseases and Diabetes and do not necessarily reflect the policies of the World Health Organization.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for the participants in the Working Group on Integrated Prevention and Control of Cardiovascular Diseases and Diabetes, held in Kuala Lumpur, Malaysia, from 17 to 21 November 1997.
CONTENTS
SUMMARy .................................................................................................................................... i 1. INTRODUCTION ................................................................................................................. 1 1.1 Objectives ...................................................................................................................... 1 1.2 Opening of the meeting ................................................................................................. 2 1.3 Participants and resource persons ................................................................................. 2 1.4 Organization .................................................................................................................. 2 2. PROCEEDINGS .................................................................................................................... 2 2.1 2.2 3. The global context ofCVD and diabetes ...................................................................... 2 Regional CVD and diabetes situation ........................................................................... 3
IMPLEMENTATION OF CVD AND DIABETES PREVENTION PROGRAMMES ....... 5 3.1 3.2 3.3 3.4 The community-based intervention programmes ......................................................... 5 The promotion of protective factors ............................................................................. 6 The control of individual risk factors ........................................................................... 7 Diabetes prevention and control ................................................................................... 8
4.
THE DEVELOPMENT OF NATIONAL PREVENTION AND CONTROL POLICIES AND PROGRAMMES .......................................................................................................... 9 DEVELOPMENT OF INTEGRATED APPROACHES AND A PLAN FOR THE INTEGRATED PREVENTION AND CONTROL OF CVD AND DIABETES ............... 10 5.1 Definition of integrated prevention ............................................................................. 10 5.2 Justification ................................................................................................................. 10 5.3 Barriers ........................................................................................................................ 10 5.4 Counter arguments ...................................................................................................... 10 5.5 Principles of action ..................................................................................................... 11 5.6 Strategies ..................................................................................................................... II 5.7 Implementation ........................................................................................................... 11 5.8 Development of networks ........................................................................................... 12 5.9 Regional plan for integrated prevention and control ofCVD and diabetes ................ 12
5.
6. 7.
RESEARCH AGENDA ....................................................................................................... 12 CONCLUSIONS AND RECOMMENDATIONS .............................................................. 12 7.1 7.2 Conclusions ................................................................................................................. 12 Recommendations ....................................................................................................... 13
ANNEXES: ANNEX 1 ANNEX 2 ANNEX 3 ANNEX 4 OPENING REMARKS BY THE REGIONAL DIRECTOR .................... 15 LIST OF TEMPORARY ADVISERS, CONSULTANTS, SECRETARIAT AND OBSERVERS ....................................................... 17 PROVISIONAL AGENDA ....................................................................... 23 DRAFT REGIONAL PLAN FOR INTEGRA TED PREVENTION AND CONTROL OF CVD AND DIABETES .......................................... 25
Key words Cardiovascular diseases - prevention & control/Diabetes mellitus - prevention & control/Malaysia
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SUMMARY
The Working Group on Integrated Prevention and Control of Cardiovascular Diseases (CVD) and Diabetes was convened by the WHO Regional Office for the Western Pacific and held at the Institute for Medical Research, Kuala Lumpur, Malaysia, from 17 to 21 November 1997. The working group was composed of 14 members from 10 countries in the Region. Two consultants, three observers and a WHO Secretariat from the Regional Office and Headquarters also attended. Objectives of the meeting were: (1) To review the epidemiological situation, assess the implementation of the programmes on prevention and control of CVD and diabetes, and further strengthen community-based programmes; . to identify approaches which further develop national programmes and enhance capacity for development of health policies; to review the draft regional dietary guidelines being developed for prevention of noncommunicable diseases; and to recommend appropriate strategies and a plan for integrated prevention and control of CVD and diabetes within the context of primary health care.
(2)
(3) (4)
Review of the epidemiology situation in the Region indicates an increasing burden of CVD and diabetes associated with demographic, social, economic and cultural changes with considerable diversity among countries. The Working Group viewed with alarm this increasing burden and concluded that the treatment and long term management of these diseases will impose unsustainable costs on health services, individuals and families in all countries. The only sustainable approach to these epidemics in the medium and long term is through primary prevention. Fortunately, current knowledge is sufficient to justify integrated prevention and control programmes appropriate to local situations with the aim of lowering the CVD and diabetes risk levels in entire populations. Integrated prevention and control programmes should aim to increase population physical activity levels, reduce overweight and obesity, promote appropriate diet, and promote non-smoking. Country specific targets are required. The achievement of these aims requires a wide range of interventions across a variety of sectors; positive political leadership is critical for initiating and sustaining effective prevention programmes. The Working Group made several recommendations of which the following is a summary: (I) The integrated prevention and control of CVD and diabetes should be given a higher priority at both country and regional levels. A draft Regional Plan for Integrated Prevention and Control ofCVD and Diabetes has been developed and should be finalized. National technical expertise at all levels of the health system should be strengthened through training in CVD and diabetes epidemiology, prevention and control and, more generally, in public health and health promotion.
(2)
(3)
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(4)
National food based dietary guidelines based on the Food Based Dietary Guidelines (FBDGs) for the Western Pacific: Nutrition in Transition-Application to Emergent Chronic Noncommunicable Diseases, which was endorsed by the Working Group, should be developed and implemented. International collaboration should be strengthened and institutional support should be sought, for the development of a state-of-the-art information technology network to facilitate integrated prevention and control ofNCDs. Baseline disease and risk factor data on suitable population samples are essential. The development of simplified and appropriate monitoring systems for disease trends and food patterns and other risk factors in countries with lim ited resources should be supported. The CYD and diabetes epidemiological situation, including food and risk factor patterns, and prevention and control programmes should be regularly monitored and evaluated at country and regional level approximately every five years. Tobacco control, national eating habits and the maintenance of regular physical activity should be given high priority in all countries. A full range of policies based on the Regional Plan for Tobacco or Health for 1995-1999 and the FBDGs for Western Pacific: Nutrition in Transition should be implemented. Guidelines which incorporate the concept of absolute risk and take into account the availability of resources should be considered for the control of specific risk factors. CYD and diabetes prevention and control activities should be integrated into all levels of the health system and, particularly, into primary health care. The role of primary health care workers should be a priority for action to reflect recent advances in knowledge on prevention and control strategies and methods. All Member States should establish national integrated CYD and diabetes prevention and control programmes as an integral part of national health planning. Establishment of a national coordinating committee headed by a member of the health sector and formed by representatives of related sectors, and setting of achievable goals over the short, medium and long term should be major components.
(5)
(6)
(7)
(8)
(9)
(10)
(II)
(12)
Because of the major cultural variations in the Region and the emerging problems of obesity, assessment of obesity should be an important part of the assessment of major risk factors of CYD and diabetes and development of preventive programmes. Although many of the underlying causes of CYD and diabetes are known and are qualitatively similar in all countries of the Region, there is scope for further research.
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I.
INTRODUCTION
The countries and areas of the Western Pacific Region of the World Health Organization have great diversity in geographic and population size, climate, ethnic composition and social, economic and cultural characteristics. However, all countries of the Region share a common concern about cardiovascular diseases (CVD) and non-insulin dependent diabetes. In parallel with a rapid health transition occurring in the Region, the burden of noncommunicable diseases (NCO) is increasing in all countries, especially the burden from CVD and diabetes. This burden is experienced in terms of premature mortality, morbidity and disability and poses major, but unquantafiable, social, personal and economic costs on all societies in the Region. No country in the Region can afford the existing and the projected increased burden ofCVD and diabetes. The extent of the existing CVD and diabetes problem in the Region is reasonably clear although patterns vary and more standardized data would be helpful. Already CVD is one ofthe leading causes of death in 32 of the 37 countries and areas of the Region. Prevalence of diabetes is increasing rapidly and places a tremendous burden on health care systems in many countries of the Region. There are approximately 3 million CVD deaths in the Region each year and approximately 30 million prevalent cases of diabetes. The pattern ofCVD and diabetes has some unique features in the Region. However, the main causes of the CVD and diabetes epidemics in the Region are known and are similar to those in other, mostly western, countries which have a longer history of epidemiological investigations. The standard risk factors for CVD and diabetes are also causally implicated in the development of other NCO and this forms a major justification for the integrated approach to the prevention of NCO. The totality of epidemiological evidence, combined with clinical, laboratory and experimental data, provides convincing evidence that the prevention of the CVD and diabetes epidemics is achievable. In some countries of the Region considerable progress has been made in prevention and control, especially of CVD, with a consequent increase in the life expectancy of middle-aged and older men and women. However, there is still much scope for extending the benefits of existing knowledge to all sections of society in all countries in the Region. With this background the Working Group met to review the regional situation with regard to CVD (primarily, coronary heart disease (CHD), stroke, rheumatic heart disease and hypertension) and non-insulin dependent diabetes, to assess progress and constraints in the implementation of the current strategies and approaches, and to make recommendations for further development ofthe strategies in the Region. 1.1 Objectives The objectives of the meeting were: (I) To review the epidemiological situation, assess the implementation of the programmes on prevention and control ofCVD and diabetes, and further strengthen community-based programmes; (2) to identify approaches which further develop national programmes and enhance capacity for development of health policies; (3) to review the draft regional dietary guidelines being developed for prevention of noncommunicable diseases; and
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(4) to recommend appropriate strategies and a plan for integrated prevention and control ofCVD and diabetes within the context of primary health care. 1.2 Opening of the meeting
Dato' Dr M. Jegathesan, Deputy Director General of Health, the Ministry of Health welcomed the participants and stressed the importance of the outcome of the workshop to Malaysia. Dr S.T. Han, Regional Director for the Western Pacific welcomed the participants and pointed out the increasing trends of noncommunicable diseases in the Region. He emphasized the importance of the integrated prevention and control of noncommunicable diseases and requested systematic actions to be taken in strengthening prevention and control of noncommunicable diseases in the context of New Horizons for Health (Annex I). 1.3 Participants and resource persons
The working group was composed of 14 members from 10 countries in the Region. Two consultants and a WHO Secretariat from the Regional Office and Headquarters and three observers also attended the meeting (Annex 2). Dr Zainal Ariffin Omar from Malaysia and Professor Clive Cockram from Hong Kong, China were elected Chair and Vice Chair respectively and Dr Margaret Cornelius from Fiji was designated as Rapporteur. 1.4 Organization
The agenda for the meeting is in Annex 3. Prior to the meeting review papers were prepared by members who spoke to their papers during the meeting. The current situation in the Region in relation to the organization of the meeting was systematically reviewed, and recommendations were drafted progressively for review and finalization during the last day of the meeting.
2.
PROCEEDINGS
2.1
The global context of CVD and diabetes
CVD and diabetes are major causes of premature mortality, morbidity and disability in most countries, including those in the Western Pacific Region of WHO. It has been estimated that, of the total of IS million CVD deaths worldwide each year, approximately 10 million occur in developing countries. Globally there are more deaths each year from CHD, approximately 7 million, than from stroke (about 4.5 million each year), although the relative importance ofCHD and stroke varies between countries. In many countries in Asia and the Pacific, stroke especially haemorrhagic stroke, is much more common than CHD. It has been estimated that CHD and stroke will be the first and second leading causes of death globally and leading causes of the disability adjusted life years lost by the year 2020. Although there are many uncertainties in these estimates, they do indicate the approximat<.: order of magnitude of the likely future burden from CVD and diabetes. The prevalence of diabetes in adults worldwide in 1995 was estimated to be 4.0% and is expected to rise to 5.4% by 2025 on the basis of demographic changes alone. It is likely that these estimates may be conservative since they do not consider the impact of increasing
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urbanization and industrialization and the widespread trend towards increasing average population weight levels. This global context confirms the urgency for effective and efficient prevention and control programmes for CYD and diabetes. 2.2 Regional CYD and diabetes situation
A wealth of information is available on the CYD and diabetes situation in the Region, ranging from routinely available mortality data and hospital discharge statistics to CYD registers and risk factor survey data. Some studies in the Region have been part of international projects coordinated by WHO, such as the WHO Monica Project; other studies have been national or local initiatives. Regional estimates and projections on the NCD burden are also available from the recent WHO/World Bank Global Burden of Disease Study and from the WHO Ad Hoc Diabetes Reporting Group. Despite the available information, serious gaps remain. for example, only a minority of countries in the Region regularly reports national mortality statistics to WHO and in few countries are these routine data regularly validated. Regular surveys of CYD and diabetes riskfactor levels in samples of the population using standardized methods have been conducted in only a few areas. However, on the basis of the published information and the papers prepared by members of the working group, a reasonably clear picture can be gained of the CYD and diabetes situations in the Region. Currently, CYD is one of the leading causes of death in 32 of the Region's 37 countries and areas. No fewer than 3 million deaths per year are due to these diseases in the Region. Age-adjusted mortality from CYD is now higher in many developing countries in the Region than in the developed countries. The prevalence of hypertension exceeds 10% in 19 countries and areas. This significantly contributes to the rates of stroke, coronary heart disease, heart failure and renal failure. The morbidity and mortality due to coronary heart disease are now rising in many developing countries of the Region. Stroke remains common and is responsible for much death and disability. In China, it has been estimated that there are 1.5 million new cases of stroke each year, and about I million deaths. Diabetes is now one of the most daunting challenges to public health in the Region. This is both because its prevalence is increasing rapidly and because the complications associated with diabetes impose a heavy burden on the health care system and on the quality of life of individuals, with diabetes being a major cause of blindness, renal failure and lower limb amputations. Recent data show that the prevalence of diabetes exceeds 8% in 13 countries and areas of the Region. The prevalence of diabetes is increasing in countries where significant socioeconomic changes are occurring. There is particularly high prevalence in Pacific island countries. The current number of diabetics in the Region is estimated to be 30 million. It is estimated that there will be at least 55 million adults with diabetes in the Region by 2020, with about 38 million in China, with another 9 million in Japan. 2.2.1 CYD and diabetes mortality The pattern of recent mortality is to an extent what might have been expected based on previous international work. Coronary heart disease mortality is higher in Australia and New Zealand than in North Asian countries such as China and Japan, while the reverse is true for stroke mortality. Rheumatic heart disease mortality is highest in the less economically developed nations of the Region. Diabetes mortality is highest in the Pacific islands. What would not have been so readily predicted is the relative level of mortality from coronary heart disease in many of the countries geographically located between North Asia and
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Australia. The Pacific island nations have higher rates than Australia despite being at an earlier stage of economic development. CHD mortality in Fiji, for example, was 398.9 per 100000 for male and 103.8 per 100000 for female. This contrasts with Australia rates of 104.6 per 100000 for male and 29.4 per 100000 for female, respectively. The relative position of many of the developing countries on the total CVD mortality was also surprising. The highest rates were found in the Pacific island nations for which data was available. Their total CVD mortality was twice as high as in Australia. A number of other developing nations, including China (male: 183.7, female: 140.5) and the Republic of Korea (male: 188.0, female: I 03.2) occupied higher positions than Australia (male: 156.2,female:58.1), with the total mortality burden from these diseases being lowest for Japan (male; 113.8, female:47.5) and Hong Kong (male: 105.4, female:53.6). The excess of deaths in North Asian was particularly evident for females and. for both sexes, the major contribution to the high CVD mortality came from high stroke rates. The situation analysis had to rely on the mortality data provided and the information given by the contributing countries on the validity of that data. Nonetheless, the CVD mortality rankings were consistent with what is known about life expectancy. Keys have shown that for countries where infectious diseases is minor contributor to mortality, intercountry differences in life expectancy are principally due to mortality from CVD. Total CVD and diabetes mortality was lower in Japan and Hong Kong than in Singapore, with Australia occupying an intennediate position. This is also their ranking for life expectancy. Further, the limited data on prevalence of risk factors is reasonable consistent with the observed mortality patterns. The recognized coronary heart disease risk factors are higher in the nations with higher mortality from CHD and stroke deaths are more common in nations which have a high prevalence of hypertension. Of importance is the fact that very high CYD/diabetes mortality is occurring in many economically underdeveloped nations. The secondary prevention and treatment of these conditions is very costly and likely to beyond the capacity of many countries. The implications of this for the nations concerned, and for prevention and control strategies coordinated by WHO, need to be considered. 2.2.2 CVD incidence and case-fatality data Data on trends in CHD and stroke incidence and case-fatality trends are available from Australia, China and New Zealand. from centres which are part of the WHO Monica Project. Although the final results of this project are still under discussion by the investigators it is possible to summarize some of the results from centres in Newcastle, Perth, Auckland and Beijing. The incidence rates and trends parallel the mortality data and there is little relationship between case-fatality and mortality trends, especially for CHD. Preliminary published data from eight Monica centres, including the three Australian centres, suggests an association between trends in risk factor scores and mortality trends. Final results of the Monica Project will be available in 1998. 2.2.3 Prevalence of diabetes Data on the prevalence of diabetes in most of the countries of the Western Pacific Region have been collected over the last 20 years. The rates range from virtually zero in the Papua New Guinea highlands, even as recently as 1991, to around 30% in Australian Aborigines, Nauruans and the people of Koki settlement in Port Moresby, Papua New Guinea. Compared with the prevalence of diabetes amongst urban Australians (about 4%), rates in Japan (10.9%), the Republic of Korea (9.1 %), and Singapore (8.9%) are high. Currently such high rates of diabetes are not seen in China, with the exception of 6.7% reported in an urban community, being
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generally in very recent surveys around 3%. However, high diabetes prevalence in migrant Chinese in Singapore (12.8% in 1993) and Mauritius (15-16% in 1992) indicates the potential for increases in diabetes prevalence in China which could translate into enormous absolute numbers of people with diabetes. The difference between rural and urban populations seen in Kiribati (3.6% vs 7.7%), Malaysia (6.7% vs 8.2%), Papua New Guinea (eg. 12.4% Wanigela vs 30.1% Koki), Vanuatu (1.0% vs 2.1% in men and 0.9% vs 12.1% in women) and Western Samoa (6.5% vs 16.0%), plus the increase in prevalence over time, as evidenced in Western Samoa, also suggest an increase in diabetes prevalence within the Region as lifestyles change to include less physical activity and a greater abundance of energy dense foods. With age being a major determinant of type 2 diabetes risk, changes in the age structure of populations, as life expectancies improve, will likely lead to increases in diabetes prevalence even without other changes. While the available data indicate quite dramatic differences in the prevalence of diabetes between countries, it must be remembered that the surveys were conducted at different times, in different age groups, and sometimes using different methodologies. Therefore direct comparison of the reported rates is not always possible. Nevertheless the trend of a regionwide increase in diabetes prevalence is of undisputed concern for public health. Type I and type 2 diabetes are not differentiated in many of the published studies, but type 2 diabetes is believed to make up more than 90% of the cases in countries of the region. Increases in type I diabetes prevalence, if observed, are thought to be more associated with improved treatment and better survival than genuine increases of the disease incidence. However, such increases will contribute only minimally to overall increases in rates of diabetes. 2.2.4 Prevalence of CVD and diabetes risk factors In a broad sense, the prevalence of CVD and diabetes risk factors, where this has been measured, follows the distribution of mortality, although intriguing exceptions are evident. Serum cholesterol levels are higher in Australia, New Zealand and Singapore, where CHD mortality rates are relatively high, than in Hong Kong and Japan which have low CHD mortality rates. Obesity is also more prevalent in the Pacific Islands where diabetes mortality is high. Smoking is common, especially in men, in all countries. However, fOl most countries there is insufficient (standardized) risk factor data and the collection of such data is a priority.
3.
IMPLEMENTATION OF CVD AND DIABETES PREVENTION PROGRAMMES
3.1
The community-based intervention programmes
Development of community-based programmes is a significant and fundamental approach for prevention and control of CVD and diabetes. In spite of that the results of some communitybased intervention programmes for the prevention and control of CVD and diabetes have not been satisfactoT), especially in the context of rapidly declining national trends in CHD and stroke mortality rates in some developed countries, there have been many successful projects, for example, the project in North Karelia, Finland, especially in its earliest years of operation, and the more recent experience from the Mauritius and the Tianjin NCD Health Promotion Project in China, both part of the WHO project on integrated prevention ofNCD. With improvements in community health services and community involvement, primary prevention, such as non-smoking campaigns, promotion of healthy diets and physical exercises, and
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secondary prevention of hypertension can be successfully carried out. National policies on prevention and control ofNCD could be effectively implemented at grassroots level through the application of the community-based approach. 3.2 The promotion of protective factors
3.2.1 Physical activity There are limited standardized data on physical activity patterns in the Region. However, it appears that relatively low levels of habitual physical activity are increasingly common in most, but not all, countries and areas of the Region as a consequence of urbanization and industrialization. There is now convincing epidemiological evidence that physical inactivity is an important cause of several NCDs including CHD, stroke, diabetes, osteoporosis and some cancers. Multiple obstacles exist to the adoption and maintenance of habitual physical activity patterns throughout the life course. A range of interventions, from the individual level to the policy level, is likely to have the most beneficial effect although limited evidence is available to guide policy. There is a clear need to emphasize interventions directed towards environmental changes which will facilitate physical activity. 3.2.2 Traditional food habits A great deal is known about how nutritional factors affect pathways to CVD. However, these associations have both a broader sociocultural context and there is a complex molecularnutritional interplay on etiology of CVD. With this understanding, a food-based and cuisine approach to Dietary Guidelines (FBDGs, food-based dietary guidelines) was advanced by WHO and FAO following the Cyprus Report of 1995. These guidelines have the advantage of linking contemporary nutrition and health science with traditional and emergent cuisine, while respecting local knowledge, and minimizing the risk of unintended consequences. Optimizing health by nutritional means is nevertheless contingent on food security, affordability and safety; on associated lifestyles, especially physical activity and avoidance of substance abuse; on expression of the social role of food; and on ecosystem integrity. In these respects, the most basic FBDG is to achieve a varied food intake of small serving sizes and to maintain the social function of food (and related social activity) and biodiversity. FBOGs is an important integrated approach for prevention ofNCD and nutrition related diseases. For FBDGS to be useful to communities, successive steps are required: (i) (ii)
Community assessment, with technical support, of nutritional and health needs; Development of preferred cuisine{s) on the basis of the community's traditional food pattern, foods of interest from other cuisine along with new food products, given contemporary scientific evidence, and taking into account economic and environmental factors; A set of guidelines for eating in food term, and relevant to health; Simple indices of food intake (e.g. food 'variety scores, food traditionallity scores, cultural marker food intakes) which can be used for monitoring the use of FBDG of individuals in a community.
(iii) (iv)
It is acknowledged and emphasized that there are various food patterns which humans may assume with similarly favourable health outcomes. The Working Group reviewed and endorsed a draft of Food-based dietary guidelines for the Western Pacific: Nutrition in transition
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-application to emergent chronic noncommunicable diseases prepared by the WHO Regional Office for the Western Pacific. The draft should be finalized, with necessary additions suggested by the working group, edited and published for implementation in the Region. 3.3 The control of individual risk factors
3.3.1 Hypertension The prevalence of hypertension is high in most countries and areas ofthe Region and the degree of control of established hypertension, despite considerable costs to health services, is relatively low. Hypertension is an important causal risk factor for stroke (both haemorrhage and ischaemic) and coronary heart disease in the Region. Epidemiological studies in the Region and elsewhere, suggests that the increase of blood pressure with age and the development of hypertension are not inevitable. Risk factors for hypertension include excessive sodium intake and reduced potassium intake, overweight, physical inactivity, and excessive alcohol intake. Despite this evidence, the primary prevention of hypertension has not yet been seriously addressed. A small decline in population blood pressure levels would have an important effect on population CVD rates. Most attention has been directed to the treatment (secondary prevention) of established hypertension, primarily by pharmaceutical and, to a lesser extent, non-pharmaceutical means. The costs of managing established hypertension will place a considerable burden on the health services of most countries and areas in the Region. The problem of identifying the hypertensive individual is a major concern. Identifying a positive family history for primary prevention of hypertension is imperative. One of sociocultural characteristics in the Region is an emphasis on being more family-centred rather than individualistic, therefore, strategies on hypertension prevention and control should include identifying the family who smokes, who overeats and who is not physically active. Various guidelines have been developed for the management of hypertension and increasingly, these guidelines consider the absolute risk ofCVD events due to a combination of risk factors, rather than blood pressure levels alone, as a guide to management decisions. 3.3.2 Tobacco smoking Tobacco use is an addictive and hazardous substance and an important cause ofCVD and other NCD in most countries and areas ofthe Region and an important cause of diabetic complications. In all countries of the Region, smoking is common, especially in men, although the prevalence rates varies markedly among countries. In many countries, smoking prevalence has fallen, especially in socially advantaged men. In many countries smoking is increasing in teenagers. WHO has identified all the elements of a comprehensive tobacco control policy which, if implemented in its entirety, is likely to reduce smoking in all segments of the population. A comprehensive policy includes: increased taxation on tobacco products; a complete legislative ban on direct and indirect advertizing of products of the tobacco industry; legislation to reduce exposure to passive smoking in workplaces and public places; legislative restrictions on the sale of cigarettes to children; and health promotion and educational programmes. Tobacco control is an important aspect of integrated prevention and control programmes. Various models exist for integrating tobacco control with other prevention programmes. The appropriate model will depend on the local situation and priorities.
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3.3.3 Obesity Obesity is rising in prevalence in the Region. The risks of obesity include not only cardiovascular disease and diabetes, but also numerous other causes of morbidity. Obesity is a recognized risk factor for hypertension; diabetes mellitus and dyslipidaemic states and is also an independent risk factor for vascular disease. Assessment of obesity is difficult and complex. Factors contributing to this include variations in lean body mass (for example ethnic variations), duration of obesity, age of onset of obesity, rates of change of body weight and perhaps most importantly, distribution of obesity. Central (visceral) obesity conveys greater risk than lower-body obesity. The development of central obesity may involve additional factors over and above diet. Examples of these factors include hormonal influences, alcohol, physical inacti\ity and (probably) environmental stress. Control of obesity requires recognition of these factors so that recommendations can be made which are tailored appropriately to the local community. Preventive approaches include targeting of entire populations or of high-risk groups (e.g. children) or individuals. Behavioural modification must take due account of cultural factors. Governmental support is essential including fiscal policy, urban design and transportation policy to facilitate walking, recreation and play, legislation for advertizing control and food labelling. All available means should be used to promote a healthy lifestyle including publicity campaigns, mass media and support from influential groups or individuals. A combination of approaches gives the greatest likelihood of success. Expectations and targets should be reasonable and not punitive. Publicity campaigns can be kept simple and should include measures aimed at physical activity levels as well as diet management. Education at all levels of society is essential and should emphasize the particular importance of education of children. In societies undergoing rapid urbanization, advice aimed at maintaining traditional lifestyles and diets may be most successful. 3.4 Diabetes prevention and control
Diabetes affects an increasing number of people in the Westem Pacific Region and is responsible for considerable health care and personal costs. Diabetes and its complications will continue to increase with the ageing of populations, more sedentary lifestyles, adoption of affluent diets and increasing overweight - unless effective action is taken. The prevention and control of diabetes needs to receive the highest priority and should be integrated with screening, prevention and control of other NCDs. Effective, culturally appropriated intervention strategies based on a community approach which also address the social environment of the community at risk need to be implemented and evaluated, especially in populations with high rates ofNCD prevalence. The classification of diabetes and recommendations for diabetes screening are currently under revision. The forthcoming recommendations for screening might have to be adapted for the population under study. Diabetes care and prevention of diabetes-related complications need to evolve around integrated management and abandon acute care principles and should maximize cooperation and collaboration between patients, their families, and professional care providers. Health information systems are an essential part of improving diabetes care to facilitate monitoring complication screening and evaluate metabolic control. To strengthen the success of prevention, a change in the understanding of diabetes needs to be considered and an ecological model of diabetes introduced. This model shifts the emphasis of diabetes from being intra-individually centred on metabolic defects and genetic
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mutations, towards it being a variation of a physiological response to a pathological (diabetogenic/obesogenic) environment. This shift opens intervention strategies towards a more integrated public health approach which parallels the epidemiological triad (host/vehicle/environment). The epidemiological triad has been proven to be a robust model in addressing obesity. The emphasis on a supportive environment for integrated prevention and control programmes tries to address inefficiencies of programmes restricted to education strategies or pharmaceutical lowering of blood glucose levels.
4.
THE DEVELOPMENT OF NATIONAL PREVENTION AND CONTROL POLICIES AND PROGRAMMES
The experience from Singapore provided the basis for discussion of the development of national prevention and control policies and programmes against CVD and diabetes in the Region. Although Singapore has special social, economic, cultural and political features, several important lessons can be drawn from the efforts made in Singapore over the last two decades to prevent and control CVD and diabetes. The major lessons are: • Strong and sustained political commitment and support is important to the control programme. Political support can be stimulated by health professionals; it is important to raise awareness of politicians and the general public in promotion of healthy lifestyles and prevention of NCO through advocacy and health campaigns. Responsibility for prevention programmes must be multidisciplinary and multisectoral, health sector needs to work actively and closely with other sectors concerned to develop health-related policies. Physical and financial barriers to healthy living must be removed, especially for the socially disadvantaged. Healthy living should be integrated into all phases and all walks of life, and supportive environments must be provided. Special efforts must be directed towards promoting healthy living habits in children and young people. Targets must be set for population risk-factor levels. Regular monitoring of risk-factor trends and disease outcomes, and evaluation of all aspects of the programmes are required. In the control programmes for CVD and diabetes, a good standard of medical care should be provided, maximizing care at the primary health level and using the appropriate level of personnel for the appropriate level of care.
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•
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5.
DEVELOPMENT OF INTEGRATED APPROACHES AND A PLAN FOR THE INTEGRA TED PREVENTION AND CONTROL OF CVD AND DIABETES
5.1
Definition of integrated prevention
The working group discussed the meaning of the term "integrated prevention" and agreed that it referred primarily to the fact that most NCDs share common risk factors such as tobacco smoking, inappropriate nutrition and physical inactivity This commonality justifies a comprehensive approach to the prevention and control of these risk factors with the aim of reducing mortality and morbidity from a range ofNCD. Other meanings of the term "integrated prevention" include integration of programmes: within the health sector; across sectors; and between primary, secondary and tertiary prevention, and health promotion and disease prevention strategies. 5.2 Justification
The integrated approach is justified primarily by the commonality of risk factors, but also because it unifies health professionals and the health sector, mobilizes community support and resources, makes better use of limited health resoure-es, improves communication between different categories of health professionals, is practicable, has long term health benefits and improves quality of life - especially of the older populations, and thus may reduce the health service costs. It also helps develop professional knowledge and skills; the primary health care system: favourable environmental conditions; community health workers. 5.3 Barriers
Barriers to the integrated approach are health system issues such as status and orientation towards curative medicine; a lack of leadership, knowledge and budget; and competing priorities in different disciplines, and between preventive and clinical sectors. Additional barriers may be: the perceived effectiveness of vertical programmes; traditional beliefs and cultural background; lack of co-ordination: opposing commercial interests in certain aspects of lifestyle; and a lack of direct evidence of benefits of healthy lifestyles. NCDs are often not considered to influence quality of life, and fatalism can hinder progress. At the same time, this approach may require new skills for health workers, increase workloads. and can be seen as a threat to individual medical disciplines. 5.4 Counter arguments
Three main counter arguments to integrated prevention and control programmes were discussed: the perceived lack of advantage of the integrated approach; the diversity ofNCDs requiring a diversity of approaches; and the perceived effectiveness of the vertical diseasespecific approach. Rebuttal of these arguments includes the fact that: (1) There is convincing direct and indirect supportive evidence from national experiences (e.g. Singapore) and demonstration projects in a variety of situations of the effectiveness of this approach. The diversity of approaches required, because of the heterogeneity ofNCDs, is a challenge, but does not negate the need for an integrated approach, as the risk factors for many of the NCDs are common.
(2)
- \I -
(3)
The vertical approach has been effective for communicable diseases, however, it is inherently inefficient in terms of resources.
The fundamental justification for the integrated approach is that it will be the most effective and efficient approach to preventing the economic and social burdens of CVD and diabetes epidemics.
5.5.
Principles of action 5.5.1 Leadership of integrated programmes should come initially from the public health sector. It is imperative that the medical profession and other health professionals an! strong and visible supporters of this approach to prevention. Integrated programmes require strong community support and must reflect the priorities of communities. In many situations, the community will initiate and sustain these programmes, as ownership at the community/individual level seems to be critical for sustainability 5.5.3 The integrated approach focuses on the common risk factors of CVD and diabetes, such as tobacco smoking, physical inactivity and inappropriate food patterns. Multiple strategies are required. 5.5.4 Fundamental to integrated prevention is the need for intersectoral action which, although led by the health sector, involves many other relevant sectors such as finance, food and agriculture, education. transport, the environmental sectors. mass media and legislation. 5.5.~
).6.
Stratcl!.ies
A variety of strategies are required for successful integrated prevention and control programmes and these strategies will be influenced by the local situation. The strategies will be directed towards the promotion of non-smoking and physical activity, and by maintenance of healthy traditional cuisine. The strategies will emphasize individual responsibility for health in the context of supportive environments. 5.7 Implementation
In the implementation of integrated prevention and control programmes several complimentary actions are required. Implementation relies on leadership from within the health system. which in turn may require education from the public health perspective. All policies must be based on the totality of evidence - local, national and international. It is rccoglllzed that evidence in support of primary prevention will never be, and should not need be, at the same level as that which supports some aspects of secondary and tertiary prevention. Informed judgements will be required. Above all, population-wide interventions must be safe. Demonstration projects may be useful but are often hindered by a lack of attention to po\\erfulnational policy initiatives such as legislation. A key component of prevention programmes is the development of protocols and guidelines which are responsive to the local situation. including resource availability. Professional education is critical to the successful implementation of prevention programmes. Demonstration projects often begin the dissemination of this education.
- 12 -
Partnerships are required for the implementation and long-term success of integrated programmes. A full range of government, nongovernmental, and community organizations should be formally and informally linked. Partnerships are also helpful at national, regional and international levels. From the beginning, formal evaluation should become an essential component of integrated programmes. Evaluation includes formative, process, and outcome assessments. 5.8. Development of networks
In the determ ination, promotion and monitoring and further development of the regional plan for integrated prevention ofNCDs, information technology, particularly Internet-based, should be used. A network of participants with e-mail addresses, and an interactive home page, would give the project dynamism and make it operational on a daily basis. 5.9 Regional plan for integrated prevention and control ofCVD and diabetes
A draft plan has been developed by the working group and should be further improved and finalized. The regional plan should be endorsed and implemented by WHO Regional Office for the Western Pacific. and it could serve as guidance for development of integrated projects at country level (Annex 4).
6.
RESEARCH AGENDA
Several important research issues were identified by the working group including: the need for validation of routinely available mortality data, especially in the older age groups; further etiological studies; the development of standard monitoring methods for tracking the epidemics ofCVD and diabetes in a timely and efficient manner; the need for standardized riskfactor data, including food patterns on appropriate age-specific samples of the population; the economic costs of CVD and diabetes in the Region; the effects of rapid social, economic and cultural changes on the emergence of CVD and diabetes; and the most cost effective prevention and control strategies.
7.
CONCLUSIONS AND RECOMMENDATIONS
7.1
Conclusions
The working group analysed the situation in the Region with regard to CVD and diabetes and considered the available routine statistics. epidemiological data, health service structures and capacity, and related social, economic and cultural issues. The working group recognized that aspects of the CVD and diabetes situation in tile Region are different to those in other Regions and that more research is required. The working group viewed with alarm the already high and increasingly diverse burden ofCVD and diabetes in most countries of the Region, including the developing countries. The treatment and long-term management of this disease burden will impose unsustainable economic costs on health services of all countries. In addition. the individual and family suffering caused by the epidemics of CVD and diabetes are huge. The only sustainable approach to these epidemics in the medium and long term is through
- 13 -
primary prevention. The working group concluded that current knowledge is sufficient to undertake the urgently required action to prevent and control the Regional epidemics ofCVD and diabetes. The desired action should take the form of integrated prevention and control programmes appropriate to local situations. The main justification for this integrated approach is the common risk factors for CVD and diabetes and other NCD such as some cancers, chronic obstructive respiratory diseases and some musculoskeletal disorders. Further justification is the imp0l1ance of integrating activities within the health sector, across relevant sectors, between leyels of prevention (primary, secondary and tertiary), and between health promotion and disease pre\ention strategies. Short-term. medium-term and long-term goals have been specified in a regional plan for integrated prevention and control ofCVD and diabetes with the long term objective of reversing the rising burden ofCVD and diabetes in the Region. 7.2 (I) Recommendations The integrated prevention and control ofCVD and diabetes should be given a higher priority at both country and regional levels. There is scope for greater interaction between activities and programmes within WHO, to increase the impact of the regional Nell horbms ill health approaches. A draft regional plan for integrated prevention and control ofCVD and diabetes has been developed, with specified and timed targets, for discussion with Member States, with the aim of involving governments and developing a momentum to prevent and control epidemics ofCVD and diabetes. This regional plan should be finalized and implemented. National technical expertise at all levels of the health system should be strengthened through training in CVD and diabetes epidemiology, prevention and control and, more generally, in public health and health promotion. More support should be provided to countries through training and the preparation of suitable materials. National food-based dietary guidelines, based on the Food Based Dietary Guidelines (FBDGs) for Western Pacific: Nutrition in Transition - Application to Emergent Chronic Noncommunicable diseases, which was endorsed by the Working Group, should be developed and implemented. WHO should develop a framework for regional monitoring of the introduction of FBDGs and trends in the use of appropriate traditional foods. International collaboration should be strengthened, and institutional support should be sought, for the development of a state-of-the-art information technology network to facilitate integrated prevention and control of NCD. Baseline disease and risk-factor data on suitable population samples are essential. Standardized methods for CVD, diabetes and risk factor data collection and quality control have been developed by WHO and should form the basis of all monitoring and evaluation systems in the Region. The dcvdopment of simpl ified and appropriate mon itoring systems for disease trends and food patterns and other risk factors in countries with limited resources should be supported. The CVD and diabetes epidemiological situation, including food and risk-factor patterns, and prevention and control programmes, should be regularly monitored and evaluated at country and regional level approximately every five years.
(2)
(3)
(4)
(5)
(6)
(7)
- 14 -
(8)
Tobacco control, national eating habits and the maintenance of regular physical activity should be given high priority in all countries. A full range of policies based on the Regional Plan for Tobacco or Healthfor 1995-1999 and the FBDGsfor Western Pacific should be implemented. Guidelines which incorporate the concept of absolute risk and take into account the availability of resources should be considered for the control of specific risk factors. WHO should stimulate the development of these guidelines. The integration of CYO and diabetes prevention and control activities into all levels of the health system should be supported, particularly into primary health care. Redefinition of the roles of primary health care workers should be a priority for action to retlect recent advances in knowledge on prevention and control strategies and methods. All Member States should establish national integrated CYO and diabetes prevention and control programmes as an integral part of national health planning. Establishment of a national coordinating committee headed by a member of the health sector and formed by representatives of related sectors, and the setting of achievable goals over the short. medium and long term should be major components. Because of the major cultural variations in the Region and the emerging problems of obesity, assessment of obesity should an important part in the assessment of major risk factors for cardiovascular diseases and diabetes and development of the preventive programme. Although many of the underlying causes of CYO and diabetes are known and are qualitatively similar in all countries of the Region. Further research should be supported to monitor changes in the relative importance of protective factors and risk factors for noncommunicable diseases and their complications, and the most cost-effective prevention and control strategies.
(9)
(10)
(I I)
( 12)
( 13)
- 15 -
ANNEX I OPENING REMARKS BY THE REGIONAL DIRECTOR AT THE WORKING GROUP ON INTEGRA TED PREVENTION AND CONTROL OF CARDIOVASCULAR DISEASES AND DIABETES KUALA LUMPUR, MALAYSIA, 17-21 NOVEMBER 1997
I.ADIES AND GENTLEMEN, I am pleased to welcome you all to this working group on integrated prevention and C(lntrol of cardiovascular diseases and diabetes. The prevention and control of cardiovascular diseases and diabetes is an extremely important area of WHO's work in the Western Pacific Region. so we shall be paying great attention to your discussions over the next five days. Cardiovascular diseases are one of the three leading causes of deaths in 32 of the Region's 36 countries and areas. No fewer than three million deaths per year are due to these diseases in the Region. The prevalence of hypertension exceeds 10% in 19 countries and areas. The morbidity and mOl1ality due to coronary heart diseases are now rising in many developing countries of the Region. Stroke remains common and mortality rates from stroke in developing countries are often double those in developed countries. In China. about I million people each year die from strokes. Diabetes is now one of the most daunting challenges to public health in the Region. This is hoth because its prevalence is increasing rapidly and because the complications associated \I ith the disease impose a heavy hurden on the health care system. Recent data show that the prevalence of diabetes exceeds 8% in 13 countries and areas of the Region. There is particularly high prevalence in Pacific island countries. The current number of diabetics in the Region is estimated to be over 30 million and is expected to be 56 million by the year 2025. Decades of research have shown conclusively that cigarette smoking. high blood pressure, an unhealthy diet, obesity, excessive alcohol consumption and physical inactivity are major risk factors of cardiovascular diseases. Some of these factors are also associated with diabetes. They arise from unhealthy lifestyles and behaviours which can be modified hy properly developed community-based prevention. WHO estimates that at least half of all cardiovascular diseases and many cases of diabetes are preventable. It is, therefore, very encouraging to see that numbers of deaths from cardiovascular diseases and stroke are declining in some developed countries, such as Australia, Japan, and New Zealand, as a result of long-term health education and community-based prevention. However, increases in life expectancy. and rapid changes in lifestyles and environments mean that many of these risk factors are still increasing in many developing countries of the Region. New health isslles require new approaches. In this Region, we propose a people-centred, human development approach. It reflects the recognition that lives are led in complex and changing circumstances. It requires that individuals, the family and the community take more responsibility than ever before to help themselves avoid disease and to develop lifestyles and environments that support positive health. For their part, governments mllst ensure that appropriate policies and adequate services are in place. This approach is detailed in the regional policy framework, New hori::olls ill health. Based on this approach, strategies for the prevention and control of cardiovascular diseases and diabetes must take into account the larger context in which people live and work. In particular, emphasis should be placed on integration of programmes on prevention and control of cardiovascular diseases and diabetes. Integrated prevention and control has been recognized as an efficient and effective way to reduce the burden of these diseases.
- 16 Annex 1
Integrated prevention and control of cardiovascular diseases and diabetes requires joint actions 10 reduce major risk factors which are common to cardiovascular diseases, diabetes and other noncommunicable diseases in all relevant groups of society. It involves a combination of disease prevention with health promotion, curative and rehabilitative services. It emphasizes incorporating prevention and control of cardiovascular diseases and diabetes into national and city-specific development plans. Among other matters, this working group will discuss a draft regional plan of work which includes all the necessary components for integrating prevention and control of programmes for these two diseases. Your work in this area will be particularly impllrtant to provide guidance in the use of the plan for development and implementation of the integrated approach at country level. Integrating programmes on cardiovascular diseases and diabetes is. ho\\e\'er, only one strategy for combating these two diseases. The de\'elopment of comprehensi\'t~ national pol icies and pr')grammes. promotion of healthy lifestyles, the education of health \\ orkers and the enhancement of primary health care and community action all have important roles to play. You \\ ill be discussing all of the areas over the next tive days. This working group will review the epidemiology of these diseases, identify approaches to further develop national policies and programmes. and recommend appropriate strategies for further actions. With your rich experience and knO\\ ledge in your own specialties. I believe that you will ach ie\'c signiticant insights into integrated prevention and control of cal'diO\ ascular diseases and diabetes. I am vcry mllch looking forward to hearing your conclusions and recommendations. linally. I \\ould like to express m) sincere thanks to the members of the working group w\..ing time to share their experience and expertise. and to the Institute for Medical Research and the Ministry of Health in Malaysia for their support for the working group. I wish you a successful meeting and an enjoyable stay in Kuala Lumpur. I'll('
- 17 ANNEX 2
LIST OF TEMPORARY ADVISERS, CONSULTANTS SECRETARIAT AND OBSERVERS
1. TEMPORARY ADVISERS
Dr Ramon F. Abarqucz, Jr. President The Philippine Society of Hypertension Unit 33, Facilities Centre 548 Shaw Boulevard, City of Mandaluyong Manila Philippines Fax: 6325311281 Tel: (632) 531-1204/9214087
Professor Clive Cockram Department of Medicine Chinese University of Hong Kong Prince of Wales Hospital Shatin, New Territories Hong Kong Fax: 26373852 Tel: 26451699 E-mail: cscockram@cuhk.edu.hk
[)r Margaret Cornelius Acting Assistant Director Primary and Preventive Health Services - NCDs Ministry of Health and Social Welfare Kaunikuila House, Flagstaff Box 2223. Government Bids. Suva, Fiji Fax: 679306163 Tel: 306 177
Dr Maximilian de Courten Medical Epidemiologist International Diabetes Institute 260 Kooyong Road. Caulfield Victoria 3162 Australia Fax: 0392585090 Tel: 039258 5050 E-mail: maxdc@vaxc.cc.monash.edu.au
- 18 Annex 2
Dr Terence Dwyer Director Menzies Centre for Population Health Research University of Tasmania The Menzies Bldg., 17 Liverpool Street G.P.O. Box 252C, Hobart Tasmania 700 I. Australia Fax: 03 62357704 Tel: 03 62357700 Dr Shanta C. Emmanuel Director, Family Health Service Primary Health Division Ministry of Health College of Medicine Building 16 College Road, Singapore Republic of Singapore Fax. (065) 3235363 Tel (065) 3259042 Dr Ki-Soon Kim Professor, Department of Preventive Medicine and Community Ilcalth (,hosun Universit~ Medical College 375 Seosuk-dong, Dong gu K"aIH!J u. Republic of Korea Fax: 0622258293 Tel: 0622203574 Professor Pham Gia Khai Director, Viet Nam National Heart Institute Bachmai Hospital Hanoi Viet Nam Fax: (844) 8691607 Tel: 844 8694572 Dr Wan NazaimoOD Head, Division of Endocrinology Institute for Medical Research lalan Pahang, 50588 Kuala Lumpur Malaysia Fax: 03 2938306 Tel: 03 4402329 E-mail: nazaimon@imr.imr.gov.m)
- 19-
Annex 2
Dr Zainal Ariffin Omar Assistant Director Division of Diseast:s Control Noncommunicable Diseases Section Ministry of Health Blok E, Jalan Dungun Bukit Damansara Kuala Lumpur 50490 Malaysia Fax: 603 2561566 Tel: 603 2540088 E-mail: zainal@dph.gov.my Dr Teruichi Shimomitsu Director and Professor Department of Preventive Medicine and Public Health Tokyo Medical College 6-1-1, Shinjuku. Shinjuku-ku Tokyo 160, Japan Fax: 81 3 3226 5277 Tel: 81353794339 E-mail: tshimol?L·tokyo-med.ac.jp Dr Yukio Yamori Professor Graduate School of Human and Environmental Studies Kyoto University, Yoshida Nihonmatsu-cho Sakyo-ku, Kvoto 606 Japan Fax: 8 I 75 7532997 Tel: 81 75 7536880 Dr Yao Chonghua Vice Director Beijing Institute of Heart, Lung and Blood Vessel Diseases Andingmenwai Beijing 100029 China Fax: 64219691 Tel: 64252765 Dr Zhang Anyu President Chinese Chroni~ Diseases Prevention and Control Society Tianjin Medic21lJniversity No. 22 Qixiangtai Road, Heping District Tianjin 300070 China Fax: 0086 22 3359429 Tel: same as above
- 20 Annex 2 2. CONSULTANTS
Professor Mark Wahlqvist Professor and Head Department of Medicine Monash Medical Centre 246 Clayton Road, Clayton Melbourne. Victoria 3168 Australia Fax: 007 613 550 5524 Tel: 6135505525 E-mail: Mark.Wahlqvist@med.monash.edu.au Dr Robert Beaglehole Professor and Head Department of Community Health University of Auckland Auckland Ne\\ Zealand Fa.\.: 0064 3737503 Tel: 006493737599 E-Il1ai I: r.beaglehole:qauckland.c.nz
3. SECRETARIAT
Dr M.S. Tsechkovski Director. Noncommunicable Diseases WHO Headquarters Geneva Switzerland Fa.\.: 4122 7910746 Tel: 4122 3471/3470 Dr Ingrid Martin Responsible Officer. Cardiovascular Diseases WHO Headquarters Geneva Switzerland Fa.\.: 4122 791 0746 Tel: 4122 791344113516 E-mail: martiniilt.who.ch Dr Han Tieru (Operational Officer) Regional Adviser in Noncommunicable Diseases WHO Western Pacific Regional Office U.N. Avenue. Ermita Manila Philippines Fax no: (632) 526 0362 Tel.: (632) 5289986 E-mail: tieruh(<i.who.org.ph
- 21 -
Ann ex 2 Dr David Scrimgeour Medical Off icer . NC O in the South Pacific Off ice of the WHO Rep rese ntat ive 3rd Flo or YW CA Bui ldin g Suk una Park Suva Fiji Fax: 679 300 462 Tel: 679 394 911 E-mail: c/ow hos Pi{z .is.c om. fj 4. OBSERVERS
Dr Lye Munn Sann Institllte for Medical Research lala n Pah ang 50588 Kuala Lum pur Mal ays ia Fax: 603 293 830 6 Tel: 03 4402315 Dr Zakiah Ismail Institute for Medical Res earc h lala n Pah ang 50588 Kua la Lum pur Mal ays ia Fax: 603 293 830 6 Tel: 034 402 315 Dr Tee E. Siong Institute for Medical Research lala n Pah ang 50588 Kuala Lum pur Mal ays ia Fax: 603 293 830 6 Tel: 034 402 315
- 23 -
ANNEX 3
PROVISIONAL AGENDA
I.
Opening ceremony Adoption of agenda
3. 4.
Global trends in cardiovascular diseases and diabetes and WHO global strategies for noncommunicable diseases prevention and control R..:\ ie\\ of epidemiological situation on cardiovascular diseases and diabetes in WIIO Western Pacific Region Cherview of the Regional programmes on prevention and control of cardiovascular diseases and diabetes Assessment of the implementation of the programmes on prevention and control of cardiovascular diseases and diabetes with emphasis on development of methods for strengthening: - Community-based interventions
5.
6.
- 1-1) pertension control Diabetes prevention and control - Modification of unhealthy lifestyles and behaviours Smoking control Physical exercise Obesity and reduction of weight 7. 8. 9. 10. II. 12. Further development of the national programmes and enhancing capacity of de\elopment of health policies Rc\ie\\ of the draft Regional dietary guidelines for prevention and control of noncommunicable diseases Dcve lopment of appropriate strategies and a plan for integrated prevention and control of cardimascular diseases and diabetes within the context of primary health care Conclusions and recommendations Finalization of recommendations Closing ceremony
- 25 -
ANNEX 4
Draft Regional Plan for Integrated Prevention and Control Of Cardiovascular Disease and Diabetes WHO, WPRO (A Working Group on the Integrated Prevention and Control of Cardiovascular Disease and Diabetes met in Kuala Lumpur in November 1997, and endorsed this Regional Plan and suggestetl that the draft Plan be further revised and finalized for implementation.) 1.
Health situation analysis
The cDuntries and areas Dfthe Western Pacific RegiDn Dfthe World Health OrganizatiDn have great diversity in geDgraphic and populatiDn size. climate, ethnic composition and sDcial. eCDnDmic and cultural characteristics. In parallel with a rapid health transition occurring in the RegiDn. the burden of noncommunicable diseases (NCD) is increasing in all countries, especially the burden frDm CYD and diabetes. This burden is experienced in terms Df premature mDrtality, morbidity and disability and pDses major. but unquantafiable. social, persDnal and economic costs Dn all societies in the RegiDn. ND cDuntry in the Region can afford the existing burden ofCYD and diabetes and the projected increase in the burden from these diseases. 1.1 The Global Context of CYD and Diabetes
('YD and diabetes are major causes of premature mDrtality, mDrbidity and disability in countries. It has been estimated that of the total of 15 million CYD deaths worldwide each year. approximately 10 million occur in developing countries. Globally there are more deaths each year frDm cDronary heart disease (CHD), approximately 7 million. than from stroke, about 4.5 million each year, although the relative importance Df CHD and stroke varies between countries. In many countries in Asia and the Pacific. stroke especially haemDrrhagic strDke. is much more common than CHD. It has been estimated that by the year 2020 CHD and stroke will be the first and secDnd leading causes of death globally and leading causes of disability adjusted life years lost. AlthDu~h there are many uncertainties in these estimates. they dD indicate the approximate order ()fmagnitude of the likely future burden trolll CVD and diabetes. mo~t
The prevalence of diabetes in adults wDrldwide in 1995 was estimated to be 4.0% and is expected to rise to 5.4% by the year 2025 on the basis of demographic changes alone. It is likely that these estimates may be conservative since they do not consider the impact of increasing urbanizatiDn and industrializatiDn and the widespread trend towards increasing average popUlation weight levels. This glDbal cDntext confirms the urgency for effective and efficient prevention and control programmes fDr CYD and diabetes. 1.2 RegiDnal CYD and Diabetes situation
Cardiovascular diseases are one of the three leading causes of death in 32 of the Region's 36 countries and areas. No fewer than 3 million deaths per year are due to these diseases in the Region. Age-adjusted mDrtality from CYD is now higher in many developing countries in the Region than in the developed countries. The prevalence of hypertension exceeds 10 % in 19 .:ou,l1rics and areas. This significantly contributes to the rates of strDke. cDronary heart disease, hea,1 lailure and renal failure. The morbidity and mortality due to coronary heart disease are no\> rising in many developing countries of the Region. Stroke remains common and is responsible fDr much death and disability. In China. it has been estimated that there are 1.6 million new cases of stroke each year, and about I milliDn deaths.
- 26-
Annex 4 Diabetes is now one of the most daunting challenges to public health in the Region. This is both because its prevalence is increasing rapidly and because the complications associated with the diabetes impose a heavy burden on the health care system and on the quality of life of individuals, with diabetes being a major cause of blindness, renal failure and lower limb amputations. Recent data show that the prevalence of diabetes exceeds 8% in 13 countries and areas of the Region. The prevalence of diabetes is increasing in countries in which significant socio-economic changes are occurring. There is particularly high prevalence in Pacific islands countries. The current number of diabetics in the Region is estimated to be 30 millions. It is estimated that by the year 2025, there will be at least 55 million adults with diabetes in the Region, there will be about 38 million adults with diabetes in China, with another 9 million in Japan. The totality of epidemiological evidence combined with clinical, laboratory and experimental data provides convincing evidence that the prevention of the CVD and diabetes epidemics is achievable. hi some countries of the Region considerable progress has been made in the prevention and control, especially of CVD, with a consequent increase in the life expectancy of middle aged and older men and women. However, there is still much scope for extending the benefits from existing knowledge to all sections of society in all countries in the Rcgion. 2. Urgency for de\"Clopment and implementation of integrated prevention and control of CVD and diabetes
rhcre is an urgcnt need for a more comprehensive Regional response to the epidemic of cardio\ascular disease and diabetes. Given the commonality of antecedents for these diseases. it is apprupriate to take an integrated approach to their prevention and control. An integrated approach should be a more effective way of reducing the impact of CVD and diabetes. It is also impol1ant that national policies and programmes be established in each country. which recognize the pal1icular features of the epidemiology of CVD and diabetes and their risk factors in the c"untry. This Regional plan provides a guideline for strategies to be adopted, mechanisms for providing support at a regional level. and regional targets to be reached in the short-term. the medium term, and the long-term. more importantly for development of integrated activities at country level. Implementation of this plan needs long term efforts to achieve reduction of incidence. mortality and the social and economic burden of cardiovascular diseases and diabetes epidemics. 3. 3.1 Strategies and approaches Development of national policies and programmes on prevention and control ofCVD and diabetes • Harnessing political leadership and support plays a crucial catalytic role in the formulation and implementation of the policies and programmes. Advocacy is needed to emphasize the magnitude and impact of the diseases and the availability of costeffective interventions. NGOs and public health professionals have an important role in developing this political support. A high level focal point should be appointed in the Ministry of Health for planning, implementation, evaluation and coordination of the national programmes. Links should be established with other relevalH government agencies and organizations such as the National Food and Nutrition Committee. tobacco control committee. national sport commission. health education and promotion agencies. National Diabetes Associations and Heart Foundations or their equivalents.
•
- 27 Annex 4 • National coordinating mechanisms should be established for coordination and evaluation of the related national policies. The leadership of establishing these mechanisms, where they do not exist, should come from the Ministry of Health. Related policy initiatives should be carefully studied and coordinated with sectors concerned, and technical guidance for development of health policies should be developed. Basic components of development of the national programme are situation analysis, setting priorities, setting measurable and achievable goals and targets, development of appropriate strategies, and evaluation. Allocation of financial resources, and establishment of partnerships beyond the health sector, are also essential. A national programme on prevention and control ofCVD and diabetes should be formulated and implemented as an integral part of national health plan. In some countries and areas, CVD and diabetes prevention and control may be part of a broader noncommunicable disease prevention and control programme.
•
•
•
3.2
Epidemiological assessment and monitoring • Epidemiological assessment and monitoring of CVD and diabetes should be regularly undertaken at regional and country levels. Baseline data such as total mortality from CVD. mortality from CHD and cerebrovascular diseases, prevalence of hypertension, rheumatic heart disease and diabetes, and risk factor prevalence, should be collected as basic requirements for development and evaluation of national policies and programmes and for advocacy to governments and the general public. It is important that appropriate methodologies of data collection, analysis and monitoring should be developed and standardized (taking into account the resources available) and training provided in the implementation of these methodologies.
•
•
3.3
Primary prevention and promotion of healthy lifestyles and behaviours • The fu II range of the strategies for primary prevention, secondary prevention and tertiary prevention should be employed. The emphasis should be on primary prevention and in particular, on the population approach to primary prevention. Primary prevention should focus on modification of unhealthy lifestyles and behaviours, such as non-smoking, changing unhealthy diet, strengthening physical exercise and moderate alcohol drinking etc. The development of approaches to primary prevention of CVD and diabetes should include the recognition that CVD and diabetes result from the interaction between individuals and their environment (including genetic, cultural, social, political and economic components of the environmet:t). Development of supportive environment is important. Health promotion, emphasizing the environmental determinants of behaviour, is a basic approach to prevention and control of CVD and diabetes, and should include legislative and tiscal approaches where appropriate.
•
•
!
- 28 -
Annex 4 • Public awareness on risk factors for CYD and diabetes, and primary preventive measures should be raised by production and dissemination of sufficient information through mass media, health campaigns, public information systems and school education. Promotion of healthy lifestyles and behaviours should be integrated into other health promoting initiatives (such as Healthy Islands. Healthy Cities, health-promoting schools and health-promoting worksites and primary health care setting). Individuals. family and community play an important role in adoption of healthy lifestyles and prevention of these diseases. Special programmes for the young and old people may be required.
•
•
3.4
Development of secondary and tertiary prevention for control of established diseases and their complications
Secondary prel'entitlll • Clear guidelines should be developed for screening for non-insulin dependent diabetes (NIDDM) and hypertension. including the target group. frequency of screening. diagnostic interpretation of test results. follow-up required for abnormal results. etc. Goals should be established for screening levels to be achieved. People with diabetes. hypertension or heart disease should have access to treatment services. Treatment services should be integrated into the whole health care system, including primary health care. Guidelines for the management of diabetes and its complications, hypertension, cerebrovascular disease and chest pain. for health workers at all levels should be developed and regularly updated. Appropriate educational resources for patients with diabete~ or CVD including written material. and audio-visual aids should be available to health workers at all levels to assist in patient education. An appropriate supply of drugs and equipment to all health facilities. to ensure that the above activities can be undertaken. should be maintained.
•
•
•
•
Tertiary prevention • Guidelines should include frequency of screening people with diabetes complications, and the management of diabetic foot ulcers or infections, diabetic micro- or macroalbuminaria, and cerebrovascular accidents. Referral policies should be developed. appropriate facilities should be available to ensure rapid transfer to the most apprcpriate facility for emergency such as acute myocardial infarction. For countries \\ho refer some patients for tertiary care to other countries. there should be clear policies on the eligibility for such transfers.
•
- 29Annex 4
•
Appropriate hospital-based facilities for the management of complications of diabetes and CVD should be available. In countries where certain facilities are not available. arrangements should be made for visiting specialist teams to overcome the deficiency. Appropriate hospital or community based rehabilitation facilities for amputees and people who have suffered a stroke should be available.
• 3.5
Development of integrated approach for prevention and control of CVD and diabetes
•
Health sectors should actively pursue multisectoral and multidisciplinary collaborations. Common concerns will create the basis for development of important partnerships, especially agriculture, food industry, commerce. education. environment. mass media, economic and financial planning etc. Multisectoral coordinating mechanisms should be established at different levels as appropriate - national. provincial. county, district and community - to support development of the related health polices and implementation of the integrated programmes. The CV D and diabetes programme managers should be encouraged to work more closely with other related technical programme managers. such as nutrition, health promotion. primary health care. health for the elderly. etc. The integrated approach focuses on the common risk factors ofCVD and diabetes such as tobacco smoking. physical inactivity. an inappropriate food patterns. Integrated approach will emphasize individual responsibility for health in the context of supportive environments. Integration of the programme should be done within heath sel:tGr across sectors. between primary prevention. secondary and tertiary prevention. and between health promotion and disease prevention. Development of guidelines for integrated approach should be responsive to the local situation and country needs.
•
•
•
•
•
3.6
Community-based programme on prevention and control of cardiovascular diseases and diabetes • It is important to fully involve the community in appropriate aspects ofthe programme. Community leaders. community committees, women's and religious groups all can play important roles.
•
Community-based programme should he technically supported in a two-way interaction in which both the communiry sector and the health sector should respect each others views and be mutually supportive. Development of a demonstration project in a pilot area especially in countries with large populations may be appropriate. Development of community health services should be strengthened in terms of training and other facilities. and the knowledge and skills of community health workers in prevention. diagnosis and treatment of CVD and diabetes should be further developed.
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Annex 4 3.7 Strengthening prevention and control of CYD and diabetes in primary health care • The role, of primary health workers should be carefully studied and redefined as appropri<lte to include prevention and control of CYD and diabetes. Priman Ilealth care workers should receive adequate and appropriate training in providin the best le\·el of medical and preventive care for cardiovascular diseases and diab<.:tes at ambulatory level, including the development of skills in patient education and counselling. Guidelines on prevention and control of noncommunicable diseases in primary health care should be developed.
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3.8
Coordinating and providing technical support and guidance • Acti\e collaboration \\ ith major regional health institutions. WHO collaborating centn:s, nongmernmental organizations are required to strengthen activities in the prngralllmc areas. Technical support to the governments for development and implementation of the pl\lgramme should be provided. Important technical information and literature on appropriate intervention mcthodologies should be produced and disseminated. Comprehensive guide Iincs on prevention and control of CYD and rliahetes for all health \\orkers withiu the health care system should be developed. reSi..1UfCeS
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Dc\ clopnlcnt of IHunan •
for
prt'\'entil1Il
and control of CVD and diabetes
Training should focus on trainers at subregional, national and provincial levels. Trainers could further organize local training. Priority for training should be given on development of integrated preventive programmes, epidemiological methodologies and health promotion.
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3.10
Research and information exchange • Epidemiological research should the changing relative importance of protective factors and risk factors of NCO, establishment of a monitoring system for at least of a sample of the population. which ideally should be economical in terms of financial resources and human resources. and as Illuch as possible integrated \\ ith the existing health service delivery. Health system research should focus on the most cost effective prevention and control strategies, strengthening the efficiency and effectiveness of primary health care and the integration of the NCO control programme into the primary health care system. Qualitative research should address the cultural behaviour of different populations and means to improve it.
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Annex 4 • Facilitation of major activities on information exchange at country and regional levels and the further study on development of information network in noncommunicable diseases through information technologies.
4.
Goal. Objectives and Targets Goal
To prevent or delay the onset of cardiovascular diseases and diabetes, and their complications, and improve their management to enhance the quality of life and productive lives in older age.
Specific goals Medium -term (10 years) • 30 % of countries and areas will have demonstrated a reduction in rates of risk factors, rates of CVD and diabetes. Long-term (20 year) • 60 % of countries and areas will have demonstrated a reduction in rates of risk factors, rates of CVD and diabetes.
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Annex 4
Objective 1 To establish national policies and plans for the integrated prevention and control of cardiovascular diseases and diabetes.
Targets Short-term target (5 years) • 60 % of countries and areas will have established focal points in ministries of health and coordinating mechanisms with other sectors for prevention and control of cardiovascular disease and diabetes. 60 % of the countries and areas will have developed national policies and programmes for CVD or diabetes control, or an integrated programme on prevention and control of NCO, or include NCO prevention and control as components of the national health plan.
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Medium-term targets (to-year) • 75 % of countries and areas will have established focal points in ministries of health and coordinating mechanisms with other sectors for prevention and control of cardiovascular disease and diabetes. 75 % of the countries and areas will have developed national policies and programmes for CVD or diabetes control, or an integrated programme on prevention and control of NCO. or include NCD prevention and control as components of the national health plan.
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Long-term target (20 year) • 90 % of countries and areas will have established focal points in ministries of health and coordinating mechanisms with other sectors for prevention and control of cardiovascular disease and diabetes. 90 % of the countries and areas will have developed national policies and programmes for CVD or diabetes control, or an integrated programme on prevention and control ofNCD. or include NCD prevention and control as components of the national health plan.
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Priorities • To strengthen national capacity in development of national policies and programmes for integrated prevention and control ofCVD and diabetes through development of technical guidelines, training and providing consultant services. To support development of political leadership at country level through various advocacy and health campaigns on prevention and control ofCVD and diabetes and healthy lifestyles. To identifY focal points of governments and support establishment of multi sectoral and multidisciplinary coordinating bodies for prevention and control ofCVD and diabetes at country leve I.
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Annex 4
Objective 2 To establish and strengthen appropriate epidemiological surveillance and monitoring systems for cardiovascular diseases and diabetes and their risk factors.
Targets Short-term target (5 year) • 60 % of countries and areas will have assessed the magnitude and impact ofCYD and diabetes problems, and will have a data collection and monitoring system.
Medium-term target (10 year) • 75 % of countries and areas will have assessed the magnitude and impact of CYD and diabetes problems, and will have a data collection and monitoring system.
Long-term target (20 year) • 90% of countries and areas will have assessed the magnitude and impact ofCYD and diabetes problems, and will have a data collection and monitoring system.
Priorities • To strengthen the technical training in epidemiological assessment and monitoring on cardiovascular diseases and diabetes. To introduce the standardized methods for data collection, analysis and quality control, and a standardized indicators for the programmes. To develop simplified and appropriate monitoring system for disease trends and risk factors at country and Regional level. To regularly review and support review of epidemiological situation and progresses made for prevention and control of CYD and diabetes at country and Regional level. 10 further review, publish a Regional profile on CYD and diabetes in 1998.
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Annex 4
Objective 3
ro dcvelop the integrated programmes for the prevention of cardiovascular disease and diabet~s.
including activities on the promotion of healthy lifestyles.
Targets Short-term target (5 year) • 60 % of countries and areas would have developed and implemented integrated activities 011 promotion of healthy lifestyles and prevention and control of CYD and diabetes. Medium-term targets (10 year) • 100 % of countries and areas \\ ould have developed and implemented integrated acti\ities on promotion of healthy lifestyles and prevention and control of CYO and diabetes.
Priorities • To strengthen the promotion of healthy lifestyles through production and dissemination of public information and support of health campaigns. place special emphasis on lk"elopment of policies and supportive environment. Subject to availability of funds. a Pacific workshop on promotion of healthy lifestyles and prevention of NCO will be llrganized in 1999. To enhance primary prevention with emphasis on tobacco control. national eating habits and regular physical exercise for integrated activities.
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1"0 dc\elop and disseminate appropriate technical guidelines on integrated approach. - 1998: WPRO Guidelines on prevention of NCO through health promotion. 1999: WPRO Food-based dietary guidelines for prevention and control of NCO. 10 develop demonstration projects in selected countries. To closely work with other technical programmes such as tobacco control. school health and nutrition. and health service development; to integrate activities of CYO and diabetes control into health promoting initiatives. To strengthen the school based programme on rheumatic fever and rheumatic heart diseases, particularly intensify the secondary prevention in school.
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Annex 4
Objective 4 To build up the prevention and control of cardiovascular disease and diabetes in existing health care system, particularly, primary health care.
Targets Short-term target (5 year) • 60 % of countries and areas would have developed and implemented integrated programmes on prevention and control ofCVD and diabetes in existing health care system, involving primary health care workers.
Medium term target (10 year) • 75 % of countries and areas would have developed and implemented the integrated programmes on prevention and control of CVD and diabetes in existing health care system. Primary health care is a major component of the programmes.
Long-term target (20 year) • 90 % of countries and areas would have developed and implemented the integrated programme on prevention and control of CVD and diabetes in existing health care system. Primary health care is a major component of the programmes.
Priorities • To define the roles of primary health care workers in CVD and diabetes, and develop a manual on prevention and control of NCO in primary health care in 1999. To strengthen community-based prevention and control of CVD and diabetes through training of primary health workers. To establish demonstration projects in selected countries in collaboration with health service development programme.
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Annex 4
Objective 5 To establish secondary and tertiary prevention for control of established diseases and their complications, particularly hypertension and diabetes.
Targets Short term targets (5 years) • 60 % of countries and areas would have developed community-based programmes on hypertension and diabetes management.
Medium term targets(lO years) • 75% of countries and areas would have developed community-based programmes on hypertension control and diabetes management with substantial increase of control rate and reduction of complications.
Long term targets (20 years) • 90 no of countries and areas would have nationwide programmes on hypertension and diabetes management which demonstrate reduction of complications and increase of control ratc.
Priorities • (\) dC\'elop technical guidelines on hypertension control and diabetes management in co mll1u n ity.
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1'0 establish and strengthen cOll1munity-based projects on hypertension and diabetes management in selected countries. To strengthen international collaboration, research and information exchange in the Region. Subject to availability of the funds, a Regional workshops in the hypertension control in primary health care will be held in 2000.
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Annex 4
Objective 6 To establish a regional network including an Internet network for technical collaboration and information exchange in the areas ofCVD and diabetes.
Targets 3-year target • To establish and strengthen a regional network in integrated prevention and control of CVD and diabetes through collaboration among major health institutions and WHO collaborating centres and technical experts.
5-year target • To develop an information network on prevention and control ofNCD through Internet technology.
Priorities • • To establish and distribute a list of e-mail addresses and websites for all collaborators. To discuss and select one or two institutions as coordinating information centres for the network. To develop a consensus on strengthening information exchanges through the network and prepare regular newsletters of the network by the coordinating centres.
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Objective 7 To strengthen coordination with international information exchanges (meetings and training) and research.
Priorities • To actively coordinate with health institutions. WHO collaborating centres and major nongovernmental organizations in prevention and control of CVD and diabetes particularly for appropriate technology transfer and information exchange in the field. To strengthen regional capacities in epidemiological research, and support to health system research related to priorities of CVD and diabetes control.
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