Mediterranean studies of cardiovascular disease and hyperglycemia: analytical modeling of population socio-economic transitions (MedCHAMPS)—rationale and methods

Objectives

In response to the escalating epidemic of cardiovascular disease (CVD) in the Mediterranean Region (MR), an international collaboration aiming at understanding the burden of CVD and evaluating cost-effective strategies to combat it was recently established. This paper describes the rationale and methods of the project MedCHAMPS to disseminate this successful experience.

Methods

The framework of MedCHAMPS is exceptional in combining multiple disciplines (e.g. epidemiology, anthropology, economics), countries [Turkey, Syria, occupied Palestinian territory (oPt), Tunisia, UK, Ireland], research methods (situational and policy analysis, quantitative and qualitative studies, statistical modeling), and involving local stakeholders at all levels to assess trends of CVD/diabetes in the society and attributes of the local health care systems to provide optimal policy recommendations to reduce the burden of CVD/diabetes.

Results and conclusions

MedCHAMPS provides policy makers in the MR and beyond needed guidance about the burden of CVD, and best cost-effective ways to combat it. Our approach of building developed–developing countries collaboration also provides a roadmap for other researchers seeking to build research base into CVD epidemiology and prevention in developing countries.     

Improving Women's Cardiovascular Health: A Position Statement From the International Council on Women's Health Issues

Cardiovascular disease (CVD) is the number one killer of women worldwide, and it remains the primary cause of death and disability in both developed and developing countries. The International Council on Women's Health Issues is an international nonprofit association dedicated to the goals of promoting the health, health care, and the well-being of women. Based on the outcomes of a facilitated discussion at its 18th biannual meeting, delegates aim to raise awareness about the potent influence of gender-specific factors on the development, progression, and outcomes of CVD. Key recommendations for decreasing the burden of CVD are also discussed.     

Improving Women's Cardiovascular Health: A Position Statement From the International Council on Women's Health Issues

Cardiovascular disease (CVD) is the number one killer of women worldwide, and it remains the primary cause of death and disability in both developed and developing countries. The International Council on Women's Health Issues is an international nonprofit association dedicated to the goals of promoting the health, health care, and the well-being of women. Based on the outcomes of a facilitated discussion at its 18th biannual meeting, delegates aim to raise awareness about the potent influence of gender-specific factors on the development, progression, and outcomes of CVD. Key recommendations for decreasing the burden of CVD are also discussed.     

Forecasting chronic disease risks in developing countries

Declining fertility and infant mortality has caused the population in many developing countries to age. Population ageing can produce a rapid shift in the predominant public health problems from infant mortality and infectious diseases to chronic disease mortality at later ages. Designing public health strategies to deal with the health consequences of population ageing in developing countries is difficult both because of a remaining burden of infectious diseases and because of changes in life style associated with economic development that may raise chronic disease risks. Because there are few longitudinal studies of chronic disease risks in developing countries, we investigate the use of a planning and forecasting model, which combines data from multiple sources, in six developing countries.     

Epidemiological and nutrition transition in developing countries: impact on human health and development

Whereas common infectious and parasitic diseases such as malaria and the HIV/AIDS pandemic remain major unresolved health problems in many developing countries, emerging non-communicable diseases relating to diet and lifestyle have been increasing over the last two decades, thus creating a double burden of disease and impacting negatively on already over-stretched health services in these countries. Prevalence rates for type 2 diabetes mellitus and CVD in sub-Saharan Africa have seen a 10-fold increase in the last 20 years. In the Arab Gulf current prevalence rates are between 25 and 35% for the adult population, whilst evidence of the metabolic syndrome is emerging in children and adolescents. The present review focuses on the concept of the epidemiological and nutritional transition. It looks at historical trends in socio-economic status and lifestyle and trends in nutrition-related non-communicable diseases over the last two decades, particularly in developing countries with rising income levels, as well as the other extreme of poverty, chronic hunger and coping strategies and metabolic adaptations in fetal life that predispose to non-communicable disease risk in later life. The role of preventable environmental risk factors for obesity and the metabolic syndrome in developing countries is emphasized and also these challenges are related to meeting the millennium development goals. The possible implications of these changing trends for human and economic development in poorly-resourced healthcare settings and the implications for nutrition training are also discussed.     

Ageing, lifestyle modifications, and cardiovascular disease in developing countries

Developing countries face the double menace of still prevalent infectious diseases and increasing cardiovascular disease (CVD) with epidemic proportions in the near future, linked to demographic changes (expansion and ageing), and to urbanisation and lifestyle modifications. It is estimated that the elderly population will increase globally (over 80% during the next 25 years), with a large share of this rise in the developing world because of expanding populations. Increasing longevity prolongs the time exposure to risk factors, resulting in a greater probability of CVD. As a paradox, increased longevity due to improved social and economical conditions associated with lifestyle changes in the direction of a rich diet and sedentary habits in the last century, is one of the main contributors to the incremental trend in CVD. The variable increase rate of CVD in different nations may reflect different stages of "epidemiological transition" and it is probable that the relatively slow changes seen in developing populations through the epidemiological transition may occur at an accelerated pace in individuals migrating from nations in need to affluent societies (i.e. Hispanics to the USA, Africans to Europe). Because of restrained economic conditions in the developing world, the greatest gains in controlling the CVD epidemic lies in its prevention. Healthy foods should be widely available and affordable, and healthy dietary practices such as increased consumption of fresh fruits and vegetables, reduced consumption of saturated fat, salt, and simple sugars, may be promoted in all populations. Specific strategies for smoking and overweight control may be regulation of marketed tobacco and unhealthy fast food and promotion of an active lifestyle. Greater longevity and economic progress are accompanied by an increasing burden of CVD and other chronic diseases with an important decrease in quality of life, which should question the benefit of these additional years without quality.     

Research capacity strengthening in the South

Active promotion of evidence-based decision-making at all levels of the health field is a necessary step in the direction of improving the health of the population. Recent studies have shown that the burden of disease in developing countries is high particularly the burden of infectious, communicable and non-communicable diseases and health problems of mothers and children. There is presently, a mismatch between this increased disease and health burden and the technical and human capacity of developing countries to use existing knowledge and to generate new knowledge to combat these diseases and health problems. It is therefore necessary to assist developing countries to build indigenous research capability so they can undertake studies in their own national settings the results of which will lead to the development of appropriate control strategies in their countries. Building indigenous research capacity will enable developing country scientists to translate results of studies carried out elsewhere into their individual national settings. Eventually results of such studies will increase the global knowledge base about the particular health problems and contribute to finding appropriate solutions to them. The research will, finally, increase knowledge-based decision-making by their health leadership of the country. This paper has set out to describe some experiences in capacity strengthening over the last few decades and to propose from these, mechanisms for building these capacities in a sustainable manner. This paper has described the steps in capability strengthening with special emphasis on identification of trainees, their training and deployment on return. The paper has described mechanisms of research sustainability including creation of suitable career structures, remuneration of researchers and the importance of building up suitable infrastructure for research to meet increasing demands and competence. The place of partnerships South-South, South-North and networking has been stressed. Finally, the paper calls for greater involvement by policy makers in developing countries in the entire capacity building process. They should set highly focussed research priorities, identify competence not already existing and proceed to fill these gaps along the lines described.     

Community-based noncommunicable disease interventions: lessons from developed countries for developing ones.

Community-based programmes for prevention and control of cardiovascular diseases (CVD) started in Europe and the USA in the early 1970s. High mortality from CVD in Finland led to the start of the North Karelia Project. Since then, a vast amount of scientific literature has accumulated to present results and discuss experience. The results indicate that heart health programmes have a high degree of generalizability, are cost-effective and can influence health policy. In the 1980s the focus of programmes expanded from CVD to noncommunicable diseases (NCD), mainly because of the common risk factors. Attention has now turned to promoting this approach in developing countries, where the prevalence of NCD is growing. Theory and experience show that community-based NCD programmes should be planned, run and evaluated according to clear principles and rules, collaborate with all sectors of the community, and maintain close contact with the national authorities. In view of the burden of disease they represent and of globalization, there is a great need for international collaboration. Practical networks with common guidelines but adaptable to local cultures in a flexible way have proved to be very useful.     

The double burden of communicable and non-communicable diseases in developing countries

Now, at the dawn of the third millennium, non-communicable diseases are sweeping the entire globe. There is an increasing trend in developing countries, where the demographic and socio-economic transition imposes more constraints on dealing with the double burden of infectious and non-infectious diseases in a poor environment, characterized by ill-health systems. It is predicted that, by 2020, non-communicable diseases will cause seven out of every ten deaths in developing countries. Among non-communicable diseases, special attention is devoted to cardiovascular disease, diabetes, cancer and chronic pulmonary disease. The burden of these conditions affects countries worldwide but with a growing trend in developing countries. Preventative strategies must take into account the growing trend of risk factors correlated to these diseases. In parallel, despite the success of vaccination programmes for polio and some childhood diseases, other diseases like AIDS, tuberculosis, malaria and dengue are still out of control in many regions of the globe. This paper is a brief review of recent literature dealing with communicable and non-communicable diseases in developing countries. It gives a global view of the main diseases and their impact on populations living in low- and middle-income nations.     

Pertussis in Africa: Findings and recommendations of the Global Pertussis Initiative (GPI)

Pertussis remains a major cause of morbidity and mortality, particularly in infants and young children, and despite the availability of vaccines and pertinent national and international guidelines. The disease burden is more severe in low- and middle-income countries (LMICs), especially in the African continent. Pertussis is more prevalent among young infants in Africa. Poor or no pertussis surveillance, lack of disease awareness, diagnostic limitations, and competing health priorities are considered key contributory factors for this high pertussis burden in Africa. Most African countries use whole-cell pertussis (wP) vaccines, but coverage with three primary doses of diphtheria–tetanus–pertussis vaccines falls short of the World Health Organization’s recommended goal of >90%. The Global Pertussis Initiative (GPI) works toward developing recommendations through systematic evaluation and prioritization of strategies to prevent pertussis-related infant and child deaths, as well as reducing global disease burden to acceptable national, regional, and local levels. For countries using wP vaccines, the GPI recommends continuing to use wP to improve primary and toddler booster vaccination coverage. Vaccination during pregnancy is the next priority when acellular pertussis (aP) vaccines and other resources are available that directly protect newborns too young to be vaccinated, followed by, in order of priority, booster doses in older children, adolescents, healthcare workers and finally, all adults. Improved surveillance should be a high priority for African LMICs assessing true disease burden and vaccine effectiveness to inform policy. More research is warranted to evaluate the safety and efficacy of wP and aP vaccines and strategies, and to determine their optimal use.     

Cohort studies around the world: methodologies, research questions and integration to address the emerging global epidemic of chronic diseases

With ageing populations, increased economic prosperity and the ensuing lifestyle changes, there has been a dramatic increase in the burden of chronic non-communicable diseases in countries of the developing world. The distribution of risk factors for chronic diseases among populations in developing countries has traditionally been very different from that in their Western counterparts, thus resulting in considerable variation in disease distribution in these settings. However, with the increase in globalization along with rapid advancements in technology, many developing countries are now faced with the challenge of a dual disease burden, battling existing communicable infectious diseases as well as the emerging epidemic of non-communicable chronic diseases. This paper highlights the need for multiple cohort studies on chronic diseases around the world, and explores some of the challenges in establishing and maintaining these studies in resource-constrained settings.     

An overview of cardiovascular disease burden in the United States

Cardiovascular disease (CVD) is the leading cause of death and a major cause of disability worldwide. In the United States, CVD accounted for 34.4 percent of the 2.4 million deaths in 2003 and remain a major cause of health disparities and rising health care costs. In 2006, health care spending and lost productivity from CVD exceeded 400 billion dollars. The aging population, obesity epidemic, underuse of prevention strategies, and suboptimal control of risk factors could exacerbate the future CVD burden. Increased adherence to clinical and community-level guidelines and renewed emphasis on policy, environmental, and lifestyle changes will be crucial for its effective prevention and control.     

通过开展减盐行动控制我国心血管疾病流行的可行性与必要性

本研究通过分析我国居民食盐摄入量水平及变化趋势,以及食盐与高血压等心血管疾病的相关性,探讨在我国通过减少食盐摄入控制心血管疾病流行的可行性和必要性。1982—2002年,我国居民食盐摄入量一直远远高于世界卫生组织推荐摄入标准;与世界其它国家相比,我国居民食盐摄入也处于相对较高水平。食盐摄入量与高血压等心血管疾病密切相关,而心血管疾病导致了我国沉重的经济负担。因此,目前在我国通过开展减盐行动控制心血管疾病十分必要,应该以准确掌握摄入水平、争取食品生产加工企业参与、食盐替代品研究推广等可行性措施为重点做好减盐工作。     

The burden of pneumococcal disease among adults in developed and developing countries: what is and is not known

The burden of pneumococcal disease among adults in developed countries is neither widely known nor appreciated. The incidence of pneumococcal pneumonia is uncertain because a precise diagnosis cannot be obtained for most patients. Population-based data on invasive pneumococcal disease (e.g., bacteraemia and meningitis) suggest an annual incidence in all developed countries of ≥15–20 cases per 100,000 persons of all ages and ≥50 cases per 100,000 elderly adults (≥65 years). In developing countries there are no population-based data on the burden of pneumococcal disease among adults. Studies of high risk groups, hospital-based studies, vaccine efficacy trials, extrapolations from surveillance of “native populations” in developed countries, and demographic studies in developing regions all suggest a high burden of disease. The broad variation in these estimates, however, indicates that better studies are needed. Increased use of pneumococcal vaccines among adults in all countries will depend on better scientific and public understanding of the burden of pneumococcal disease. In developing countries, intensive community-based studies of the impact of pneumococcal disease, or, alternatively, a “vaccine probe” approach, in which a population is vaccinated and the reduction in pneumonia is compared with that in a control population, could give more accurate estimates of the burden of disease and of the potential effectiveness of pneumococcal vaccination among adults.     

Hepatitis A and B in children and adolescents--what can we learn from Puglia (Italy) and Catalonia (Spain)?

Viral hepatitis remains a major contributor to the global disease burden. Mass immunisation strategies against hepatitis B have been adopted by more than 90 developing and industrialised countries. Countries with low hepatitis A endemicity are experiencing cyclical outbreaks and an epidemiological shift, with larger numbers of individuals at risk of infection at an older age, resulting in increased morbidity. The high cost of outbreaks in these countries has made immunisation strategies cost-effective. The development of a vaccine against hepatitis A and a combined vaccine against hepatitis A and hepatitis B offers potentially exciting opportunities for a preventative approach in areas of both low and high endemicity. Existing mass immunisation programmes against hepatitis B will facilitate the adoption of joint strategies illustrated by the examples of Puglia (Italy) and Catalonia (Spain).     

Comparison of Cardiac Risk Scores among the East Mediterranean and South Asian Population

BackgroundCardiovascular disease (CVD) is a global burden particularly in developing countries necessitates the periodical monitoring for these vulnerable population. This study aimed to compare four tools to measure the CVD risk between the East Mediterranean and South Asian population.MethodsThis retrospective analysis included 139 patients from East Mediterranean (n=90) and South Asians (n=49) ethnicity who were admitted during the one-year period in a multi-specialty tertiary care hospital located in Tabuk, Saudi Arabia. Four different tools currently in use across the world were used to analyses the CVD risk.ResultsAtherosclerotic Cardiovascular Disease (ASCVD) from American College of Cardiology/American Heart Association (ACC/AHA) was found to be significant (P=0.0000) than World Health Organization/International Society of Hypertension (WHO/ISH) and Framingham Risk Score (FRS) European SCORE (Systematic Coronary Risk Evaluation) memo card from European Society of Cardiology risk prediction charts. Meanwhile, FRS looks equally good as it detects 44.89% of South Asian study population with >10% CVD risk while ACC/AHA detects 46.93%.ConclusionThe present study recommends ACC/AHA cardiac risk estimator to identify the CVD risk in East Mediterranean population. However, the South Asian population needed a population-based tool to assess the accurate CVD risk.     

How the Health Care System Can Influence Cardiovascular Disease Risk Factors

Only a small fraction of the health-care dollar is directed toward lifestyle changes that would reduce the social burden from cardiovascular diseases (CVD). Here we discuss the challenge, opportunity, methods, and potential for managed care to implement risk reduction strategies and preventive care. A systematic team approach involving nurses, nutritionists, exercise physiologists, and behavioral experts has been shown to be effective, along with physicians, in reducing CVD risk. This approach is increasingly accepted by and practiced in the CVD community and the managed care industry.     

Dysglycemia and Abnormal Adiposity Drivers of Cardiometabolic-Based Chronic Disease in the Czech Population: Biological,Behavioral, and Cultural/Social Determinants of Health

In contrast to the decreasing burden related to cardiovascular disease (CVD), the burden related to dysglycemia and adiposity complications is increasing in Czechia, and local drivers must be identified. A comprehensive literature review was performed to evaluate biological, behavioral, and environmental drivers of dysglycemia and abnormal adiposity in Czechia. Additionally, the structure of the Czech healthcare system was described. The prevalence of obesity in men and diabetes in both sexes has been increasing over the past 30 years. Possible reasons include the Eastern European eating pattern, high prevalence of physical inactivity and health illiteracy, education, and income-related health inequalities. Despite the advanced healthcare system based on the compulsory insurance model with free-for-service healthcare and a wide range of health-promoting initiatives, more effective strategies to tackle the adiposity/dysglycemia are needed. In conclusion, the disease burden related to dysglycemia and adiposity in Czechia remains high but is not translated into greater CVD. This discordant relationship likely depends more on other factors, such as improvements in dyslipidemia and hypertension control. A reconceptualization of abnormal adiposity and dysglycemia into a more actionable cardiometabolic-based chronic disease model is needed to improve the approach to these conditions. This review can serve as a platform to investigate causal mechanisms and secure effective management of cardiometabolic-based chronic disease.