Promoting Cardiovascular Health in the Developing World

A Critical Challenge to Achieve Global Health

Committee on Preventing the Global Epidemic of Cardiovascular Disease: Meeting the Challenges in Developing Countries

Board on Global Health

Valentín Fuster and Bridget B. Kelly, Editors

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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Committee on Preventing the Global Epidemic of Cardiovascular Disease: Meeting the Challenges in Developing Countries Board on Global Health Valentín Fuster and Bridget B. Kelly, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract No. N01-OD-4-2139, Task Order No. 206, between the National Academy of Sciences and the National Institutes of Health. Any opinions, findings, conclusions, or recommendations expressed in this publica- tion are those of the author(s) and do not necessarily reflect the view of the organi- zations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-14774-3 International Standard Book Number-10: 0-309-14774-3 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap. edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON PREVENTING THE GLOBAL EPIDEMIC OF CARDIOVASCULAR DISEASE: MEETING THE CHALLENGES IN DEVELOPING COUNTRIES VALENTÍN FUSTER (Chair), Mount Sinai Heart ARUN CHOCKALINGAM (through January 2010), Faculty of Health Sciences, Simon Fraser University CIRO A. DE QUADROS, Albert B. Sabin Vaccine Institute JOHN W. FARQUHAR, Stanford Prevention Research Center, Stanford University School of Medicine ROBERT C. HORNIK, The Annenberg School for Communication, University of Pennsylvania FRANK B. HU, Departments of Nutrition and Epidemiology, Harvard School of Public Health PETER R. LAMPTEY, Family Health International JEAN CLAUDE MBANYA, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I ANNE MILLS, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine JAGAT NARULA, Division of Cardiology, University of California, Irvine School of Medicine RACHEL A. NUGENT, Center for Global Development JOHN W. PEABODY, Institute for Global Health, University of California, San Francisco K. SRINATH REDDY, Public Health Foundation of India SYLVIE STACHENKO, The School of Public Health, University of Alberta DEREK YACH, PepsiCo Study Staff BRIDGET B. KELLY, Study Director/Program Officer COLLIN WEINBERGER, Research Associate (from April 2009) RACHEL JACKSON, Research Associate (through February 2009) LOUISE JORDAN, Research Assistant KRISTEN DANFORTH, Senior Program Assistant JULIE WILTSHIRE, Financial Associate PATRICK KELLEY, Director, Board on Global Health v

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Robert Beaglehole, School of Population Health, University of Auckland, New Zealand Tom Coates, David Geffen School of Medicine, University of California, Los Angeles Susan J. Crockett, Bell Institute of Health and Nutrition Martha N. Hill, Johns Hopkins University School of Nursing James Hospedales, Pan American Health Organization/World Health Organization Dean Jamison, Institute for Health Metrics and Evaluation, University of Washington Katherine Marconi, Department of Management and Finance, University of Maryland University College Bongani Mayosi, University of Capetown, Department of Medicine Anthony Mbewu, South African Medical Research Council vii

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viii REVIEWERS Pekka Puska, National Institute for Health and Welfare, Finland Ricardo Uauy, London School of Hygiene and Tropical Medicine Suwit Wibulpolprasert, Ministry of Public Health, Thailand Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by David R. Challoner, Vice President for Health Affairs, Emeritus, University of Florida and Harlan M. Krumholz, Yale University School of Medicine. Appointed by the National Research Council and Institute of Medicine, they were responsible for mak- ing certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface A bout 10 years ago, in an address as the newly appointed President of the American Heart Association (AHA), I alluded to three seri- ous challenges facing the field of cardiovascular disease: (1) How to support and energize research, which is so crucial to preventing the still-evolving epidemic of cardiovascular disease (CVD)? (2) Is it realistic to expect that this global epidemic can be lessened or avoided solely by professional and public education, or is there a need for more aggressive implementation strategies at a global level? (3) Would a more integrated and cooperative global approach, involving many if not all of the national and international organizations represented at the AHA Scientific Ses - sions, maximize the effectiveness of individual organizations and their volunteers? Some of my colleagues diplomatically questioned the arguments of my speech, arguing that the AHA should focus its attention on the United States as the primary objective. At that time, my answer did not differ from the answer I would provide today, although now in much stronger terms after having been exposed even more thoroughly to the realities of the epidemic in low- and middle-income countries as President of the World Heart Federation. Over two-thirds of deaths attributable to CVD world- wide occur in low and middle income countries. Therefore, if the goal of the cardiovascular community is truly to achieve cardiovascular health, I see a clear responsibility to think and act globally, beyond the borders of high income countries. Aging of populations, globalization, and rapid urbanization are chang- ing disease patterns around the world. The epidemiological transition to ix

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x PREFACE a high chronic disease burden is occurring at a particularly rapid rate in developing countries. Thus, solutions for low and middle income countries need to be initiated within a short time frame, which represents an impor- tant public health challenge, given that these regions have fewer resources and greater health inequities than high income countries. If this challenge is not met, it will be impossible to achieve better health worldwide. Therefore, just as it is incumbent upon the cardiovascular community in high income countries to think and act globally, it is also incumbent upon the global health community to act upon the needs of cardiovascular disease. This recognition of the need for action from leaders in both cardiovas- cular disease and global health served as motivation to accept the Institute of Medicine’s invitation to chair this ad hoc committee, which was charged to study the evolving global epidemic of CVD and to offer conclusions and recommendations pertinent to its control. Since the inception of this study, the committee recognized that it faced a broad task and a complex problem. At our first meeting it became clear that my colleagues shared one of my primary concerns: after substantive efforts of nearly two decades in which convened committees and documents have portrayed the evolving health and economic burden of CVD, in what way could our committee contribute toward a solution? Thus, the committee took on as a driving force the task of evaluating the factors contributing to the profound mismatch or “action gap” between the compelling evidence that had been articulated in previ- ous efforts and the lack of concrete steps to implement actions. Our goal became to identify the necessary next steps to move forward and to define a framework in which to implement these steps. We approached the task systematically, meeting four times in person, including two public sessions in which a number of additional experts in various fields were gathered to help inform our deliberations. These meetings were supplemented by countless ongoing deliberations through phone calls and email exchanges. Since the very beginning of our “run,” our outstanding study director from the IOM staff, Bridget Kelly, focused our efforts toward a limited number of feasible recommendations which, of course, progressively evolved as we reached our final conclusions over time. This report reflects the path the committee followed. We reviewed the compelling epidemiological and economic evidence, which we found provides a clear mandate for action. We recognized the need for measure- ment and evaluation to truly understand the local nature of the epidemic and how best to intervene in ways that are locally relevant. We reconciled our “dream” of an ideal vision to promote cardiovascular health with our understanding of the pragmatic considerations of implementing interven- tions in low and middle income countries and the limited documentation and evaluation of successful strategies in these settings. Importantly, the

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xi PREFACE committee chose to highlight the emerging importance of targeting mothers, children, youth, and young adults for prevention interventions in order to achieve long-term success in promoting cardiovascular health and reducing the burden of CVD. Ultimately, the committee recognized that success in overcoming the burden of CVD will require the combined efforts of many players sustained over many years. Success is possible if the major stakeholders in CVD, related chronic diseases, and other areas of global health can be organized at global, national, and local levels to implement the necessary actions to control the global epidemic of CVD. It is the hope of all involved in this project that this report will prove to be a catalyst for action in the next stage of progress in the fight against global cardiovascular disease. I would like to thank the members of the committee for their devotion of time and energy to this project. It was a privilege and a pleasure to work with my fellow committee members, to learn from them in their respective areas of expertise, and to engage with them in hearty discourse about the issues at hand. Many other experts also gave generously of their time and expertise to contribute to our information-gathering, and their contribu- tions are deeply appreciated. The many other individuals who played a role in this process are listed in the acknowledgments on the following page, and I would like to add a special note of gratitude to the Institute of Medicine and especially to Bridget Kelly, Collin Weinberger, Louise Jordan, and Kristen Danforth, members of the project staff, for their laudable ef- forts shepherding and supporting the committee through every aspect of this process. Valentín Fuster, Chair Committee on Preventing the Global Epidemic of Cardiovascular Disease: Meeting the Challenges in Developing Countries

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Acknowledgments T he Committee is deeply appreciative of the many valuable contri- butions from those who assisted with this project. First, the Com- mittee would like to thank the National Heart, Lung, and Blood Institute for funding this study, and Zhi-Jie Zheng and Elizabeth Nabel for their guidance and support. The committee benefited enormously from the generously given time and expertise of the speakers and panelists at public information-gathering sessions. These individuals are listed in full in Appendix C. Several authors wrote papers for the committee, which were immensely helpful to the committee’s deliberations: Thomas Gaziano and Grace Kim; Alejandro Jadad; Stephen Jan and Alison Hayes; Marie-Claude Jean and Louise St-Pierre; Mehmood Khan and George Mensah; Jeff Luck and Riti Shimkhada; and Marc Suhrcke, Till Boluarte, and Louis Niessen. The committee would also like to thank Dorothy Chyung and Rajesh Vedanthan, who contributed research and writing support to committee members during this process. In addition, Morgan Heller helped in the early stages of the project as an intern at the Institute of Medicine. Belis Aladag and Laura Samuel each spent time with the committee and project staff as part of their training and education programs; both went above and beyond all expectations, and their valuable research, writing, and analytic contributions to the project were very much appreciated. A number of individuals were crucial to the administrative and logisti- cal success of this project. For their patience and help coordinating sched- ules and facilitating communication, the committee would like to thank Jennifer W. Tsai, Alanur Inal-Veith, Chellam Chellappan, Brian Shaw, Julia Addae-Mintah, Immaculate Kofie, Sarah Toming, Lucy Gonzales, Jasmine xiii

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xiv ACKNOWLEDGMENTS Samuel, Lisa Nordin, Marie Viau, Ann LaBombardi, and Josie Kummer. In addition, Anthony Mavrogiannis and the staff at Kentlands Travel de- serve mention for their much-appreciated persistence and problem-solving in working with the often complex travel needs and requirements of this project. Finally, the committee conveys its gratitude and appreciation for the hard work and professionalism of the many staff of the Institute of Medi- cine and the National Academies who had a hand in every stage of this project. In particular, the committee would like to express its thanks for the excellent work of the study director, Bridget Kelly, and all the members of the project team who provided research, writing, analytic, and administra- tive support: Kristen Danforth, Louise Jordan, Collin Weinberger, Rachel Jackson, and Julie Wiltshire. The committee is also grateful for the support of Patrick Kelley, director of the Board on Global Health, who provided guidance and wisdom at critical stages of the project.

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Contents Summary 1 1 Introduction 19 2 Epidemiology of Cardiovascular Disease 49 3 Development and Cardiovascular Disease 125 4 Measurement and Evaluation 149 5 Reducing the Burden of Cardiovascular Disease: Intervention Approaches 185 6 Cardiovascular Health Promotion Early in Life 275 7 Making Choices to Reduce the Burden of Cardiovascular Disease 317 8 Framework for Action 373 APPENDIXES A Statement of Task 437 B Committee and Staff Biographies 439 C Public Session Agendas 451 D Acronyms and Abbreviations 459 E World Bank Income Classifications 463 xv

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