Editorial Hypertension and Diabetes: Entry Points for Prevention and Control...

Hindawi Publishing CorporationInternational Journal of HypertensionVolume 2013, Article ID 878460, 3 pageshttp://dx.doi.org/10.1155/2013/878460

EditorialHypertension and Diabetes: Entry Points for Prevention andControl of the Global Cardiovascular Epidemic

Shanthi Mendis,1 Eoin O’Brien,2 Yackoob Kassim Seedat,3 and Salim Yusuf4

1 Management of Noncommunicable Diseases, World Health Organization, Geneva 1211, Switzerland2 Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Ireland3Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Congella, Durban, South Africa4 Population Health Research Institute, McMaster University, Canada

Correspondence should be addressed to Shanthi Mendis; [email protected]

Received 10 February 2013; Accepted 10 February 2013

Copyright © 2013 Shanthi Mendis et al.This is an open access article distributed under the Creative CommonsAttribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Complications of hypertension are associated with an esti-mated 9.4 million deaths worldwide every year [1]. In 2008,globally, the overall prevalence of hypertension (includingthose on medication for high blood pressure) in adultsaged 25 and over was around 40% [2]. On average, globalpopulation systolic blood pressure decreased slightly between1980 and 2008 [3, 4], although the worldwide prevalence ofobesity has nearly doubled during this period. In 2008, theglobal prevalence of high cholesterol was 40% and prevalenceof diabetes was 10% in adults over 25 years [1].

Most people with diabetes and hypertension also haveother cardiovascular risk factors such as raised lipids [1, 2].To reduce the prevalence and consequences of hypertensionand diabetes a complimentary mixture of population-wideand individual interventions is required. To ensure optimalcoverage of the population with these interventions imple-mentation of public health policies has to be complimentedwith a health system which addresses hypertension throughaffordable strategies [2, 5]. An approach that relies mainly onthe overall risk of individuals is likely to bemore cost effectivethan one focused solely on blood pressure levels or targets.

There are many barriers to the control of hypertensionand diabetes in low- and middle-income countries. Theyinclude the double burden of communicable and noncom-municable diseases, inadequate investment in health andprevention, fragile health systems particularly at primary carelevel, and lack of ormaldistribution of healthworkers. Severalcountries spend less than 50USD per capita per year on

health.This low level of investment is inadequate to effectivelyaddress noncommunicable diseases in a sustainable manner[2].

To address cardiovascular disease, diabetes, and noncom-municable diseases a set of core interventions (Table 1) havebeen identifiedwhich are highly cost effective, affordable, andfeasible to implement even in resource-constrained settings[6]. These interventions address diabetes, hypertension, andtheir key underlying risk factors—unhealthy diet, harmfuluse of alcohol, and physical inactivity. Some of these inter-ventions are feasible in primary care even in low-resourcesettings. For example, people at risk of heart attacks andstroke usually have amodest elevation ofmultiple risk factors,such as smoking, raised blood pressure, raised cholesterol,and/or diabetes. Such people who have medium or highcardiovascular risk can be treated with a multidrug regimenand behavioral modification to reduce the risk of developingfuture heart attacks, strokes, cardiac failure, and kidneydisease. This integrated intervention applied to individualswith an overall moderate or high cardiovascular risk basedon integrating risk based on age or several risk factors is morecost effective than conventional vertical approaches to single-risk-factor interventions [5].

Further, the development and deployment of a cadreof nonphysician health workers, by removing cultural andlegal barriers, will facilitate screening for hypertension anddiabetes. This can lead to prescribing a limited numberof safe, proven, and affordable medicines by nonphysician

2 International Journal of Hypertension

Table 1: A core set of very cost-effective interventions for prevention and control of noncommunicable diseases including cardiovasculardisease [6].

NCD core intervention set (best buys)

Reducing tobacco use(i) Excise tax increases;(ii) smoke-free indoor workplaces and public places;(iii) health information and warnings about tobaco;(iv) bans on advertising and promotion

Population-based interventions addressing NCDrisk factors

Reducing harmful alcoholuse

(i) Excise tax increases on alcoholic beverages;(ii) comprehensive restrictions and bans on alcoholmarketing;(iii) restrictions on the availability of retailed alcohol

Promoting healthy dietsand promoting physicalactivity

(i) Salt reduction when high, reduced salt content inprocessed foods;(ii) replacement of transfats with polyunsaturated fats;(iii) public awareness media campaign about diet andphysical activity

Individual-based interventions addressing NCDsin primary care

Reducing complications inindividuals with CVD anddiabetes

(i) Drug therapy (including glycaemic control fordiabetes mellitus) to individuals who have had a heartattack or stroke, and to persons with a high risk (>30%)of a CVD event in the next 10 years;(ii) providing aspirin to people having an acute heartattack.

health workers [7, 8]. Protocols and tools to estimate costof implementation have also been developed to facilitatedelivery of these very cost-effective interventions [9, 10].WHO estimates show that to implement the interventionslisted in the table for all low- and middle-income countries,the cost of implementation per head of population is low[6]. It amounts to an annual investment of under US$ 1in low-income countries, US$ 1.50 in lower middle-incomecountries, and US$ 3 in upper middle-income countries [6].Expressed as a proportion of current health spending, the costof implementation amounts to 4% in low-income countries,2% in lower middle-income countries, and less than 1% inupper middle-income countries [4].

The special issue aims to highlight solutions that aredesigned to address the global cardiovascular epidemic.

It contains three original research articles and one review.S. Tiptaradol and W. Aekplakhorn estimated the prevalenceof coexistence of diabetes and hypertension and the propor-tion of awareness, treatment, and control of both conditionsusing data from Thai National Health Examination SurveyIII. They found that about half of the diabetes patientsalso had hypertension, conversely about 14% of hypertensivepatients had diabetes, and that more than 80% were unawareof having both conditions.

M. Chiha and colleagues focused on type 2 diabetesmellitus as a risk factor for coronary heart disease. Theysummarize the mechanisms of atherogenesis in diabetes, theimpact of hypertension, the treatment goals in diabetes, andthe epidemiologic consequences of diabetes and heart diseaseon a global scale. They reported that diabetes mellitus isassociated with an increased risk of cardiovascular deathand a higher incidence of cardiovascular diseases includingcoronary artery disease.They highlighted the need for appro-priate screening to help better manage the cardiovascular

events in people with diabetes. I. Codreanu and othersshowcased the International Society of Nephrology (ISN),Global Outreach Program, aimed at building capacity fordetecting and managing chronic kidney disease and itscomplications in low- and middle-income countries usingthe work done in the Republic of Moldova. They concludedthat individuals with hypertension and diabetes should bescreened for the coexistence of renal abnormalities, with theintention of developing disease-specific healthcare interven-tions to reduce CV morbidity and mortality and preventrenal disease progression. S. Mendis and colleagues reportedon a cross-sectional study conducted in eight low- andmiddle-income countries to evaluate the capacity of primarycare facilities to implement basic interventions to addressmajor noncommunicable diseases, including cardiovasculardiseases and diabetes.They identified major deficits in healthfinancing, access to basic technologies and medicines, medi-cal information systems, and the health workforce.

This special issue is released at an opportune momentbecause the theme of the World Health Day on April 7, 2013,is focusing on hypertension to prevent heart attacks andstrokes. The issue reiterates the contribution of raised bloodpressure and diabetes to the global cardiovascular diseaseburden, the necessity to recognize the close associationbetween hypertension, diabetes, renal disease, and other riskfactors on health outcomes, and the need to strengthen healthsystems in low- and middle-income countries in order toscale up prevention and control of hypertension, diabetes,and other noncommunicable diseases.

As countries develop the Action Plan for Preventionand Control of Noncommunicable Diseases 2013–2025 inresponse to the recommendations of the Political Declarationof the United Nations General Assembly on NCDs [11], anemphasis on affordable interventions is essential to efficiently

International Journal of Hypertension 3

tackle the growing burden from NCDs, particularly in low-and middle-income countries.

Shanthi MendisEoin O’Brien

Yackoob Kassim SeedatSalim Yusuf

References

[1] S. S. Lim, T. Vos, A. D. Flaxman et al., “A comparative riskassessment of burden of disease and injury attributable to 67risk factors and risk factor clusters in 21 regions, 1990–2010: asystematic analysis for theGlobal Burden ofDisease study 2010,”The Lancet, vol. 380, no. 9859, pp. 2224–2260, 2012.

[2] World Health Organization, Global Status Report on Noncom-municable Diseases 2010, WHO, Geneva, Switzerland, 2010.

[3] G. Danaei, M. M. Finucane, J. K. Lin et al., “National, regional,and global trends in systolic blood pressure since 1980: system-atic analysis of health examination surveys and epidemiologicalstudies with 786 country-years and 5⋅4 million participants,”The Lancet, vol. 377, no. 9765, pp. 568–577, 2011.

[4] S. S. Anand and S. Yusuf, “Stemming the global tsunami ofcardiovascular disease,”The Lancet, vol. 377, no. 9765, pp. 529–532, 2011.

[5] R. Ndindjock, J. Gedeon, S. Mendis, F. Paccaud, and P. Bovet,“Potential impact of single-risk-factor versus total risk manage-ment for the prevention of cardiovascular events in Seychelles,”Bulletin of theWorldHealthOrganization, vol. 89, no. 4, pp. 286–295, 2011.

[6] Scaling Up Action Against Noncommunicable Diseases: HowMuch Will It Cost? World Health Organization, Geneva,Switzerland, 2011.

[7] G. Parati, M. O. Kilama, A. Faini et al., “A new solar-poweredblood pressure measuring device for low-resource settings,”Hypertension, vol. 56, no. 6, pp. 1047–1053, 2010.

[8] D. O. Abegunde, B. Shengelia, A. Luyten et al., “Can non-physician health-care workers assess and manage cardiovas-cular risk in primary care?” Bulletin of the World HealthOrganization, vol. 85, no. 6, pp. 432–440, 2007.

[9] World Health Organization, Package of Essential Noncommu-nicable Disease Interventions for Primary Health Care, WHO,Geneva, Switzerland, 2010.

[10] WorldHealthOrganization, Prevention and Control of Noncom-municable Diseases: Guidelines for Primary Health Care in LowResource Settings 2012, WHO, Geneva, Switzerland, 2010.

[11] United Nations General Assembly, Political Declaration ofthe High -Level Meeting of the General Assembly on thePrevention and Control of Noncommunicable Diseases, 2011,http://www.un.org/ga/search/view doc.asp?symbol=A/66/L.

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