Summary

Cardiovascular disease (CVD)1 is often thought to be a problem of wealthy, industrialized nations. In fact, as the leading cause of death worldwide, CVD now has a major impact not only on developed2 nations but also on low and middle income countries,3 where it accounts for nearly 30 percent of all deaths. The increased prevalence of risk factors for CVD and related chronic diseases4 in developing countries, including tobacco use, unhealthy dietary changes, reduced physical activity, increasing blood lipids, and hypertension, reflects significant global changes in behavior and lifestyle. These changes now threaten once-low-risk regions, a shift that is accelerated by industrialization, urbanization, and globalization. The potentially devastating effects of these trends are magnified by a deleterious economic impact on nations and households, where poverty can be both a contributing cause and a consequence of chronic diseases. The accelerating

1

The term “cardiovascular disease” is used throughout the report to refer to cardiac disease, vascular diseases of the brain and kidney, and peripheral vascular disease. The report’s main focus is on the major contributors to global CVD mortality, coronary heart disease and stroke, and on the major modifiable risk factors for cardiovascular diseases.

2

The terms “developed” and “high income countries” are used interchangeably throughout the report to refer to countries classified by the World Bank as high income economies (see Appendix E for 2009 classifications).

3

The terms “developing” and “low and middle income countries” are used interchangeably throughout the report to refer to countries classified by the World Bank as low, lower middle, and upper middle income economies (see Appendix E for 2009 classifications).

4

The term “chronic diseases” is used throughout the report to refer to CVD and the following related chronic diseases that share many common risk factors: diabetes, cancer, and chronic respiratory disease.



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Summary C ardiovascular disease (CVD)1 is often thought to be a problem of wealthy, industrialized nations. In fact, as the leading cause of death worldwide, CVD now has a major impact not only on developed2 nations but also on low and middle income countries,3 where it accounts for nearly 30 percent of all deaths. The increased prevalence of risk factors for CVD and related chronic diseases4 in developing countries, including tobacco use, unhealthy dietary changes, reduced physical activity, increasing blood lipids, and hypertension, reflects significant global changes in behav- ior and lifestyle. These changes now threaten once-low-risk regions, a shift that is accelerated by industrialization, urbanization, and globalization. The potentially devastating effects of these trends are magnified by a deleterious economic impact on nations and households, where poverty can be both a contributing cause and a consequence of chronic diseases. The accelerating 1 The term “cardiovascular disease” is used throughout the report to refer to cardiac disease, vascular diseases of the brain and kidney, and peripheral vascular disease. The report’s main focus is on the major contributors to global CVD mortality, coronary heart disease and stroke, and on the major modifiable risk factors for cardiovascular diseases. 2 The terms “developed” and “high income countries” are used interchangeably throughout the report to refer to countries classified by the World Bank as high income economies (see Appendix E for 2009 classifications). 3 The terms “developing” and “low and middle income countries” are used interchangeably throughout the report to refer to countries classified by the World Bank as low, lower middle, and upper middle income economies (see Appendix E for 2009 classifications). 4 The term “chronic diseases” is used throughout the report to refer to CVD and the fol- lowing related chronic diseases that share many common risk factors: diabetes, cancer, and chronic respiratory disease. 

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD rates of unrecognized and inadequately addressed CVD and related chronic diseases in both men and women in low and middle income countries are cause for immediate action. In the past several decades increasing attention has been given to the emergence of chronic diseases as a threat to low and middle income coun- tries. Substantive efforts to more accurately document and draw attention to the economic and health burden have led to a growing recognition that CVD and related chronic diseases need to be on the health agenda for all nations. At the international level, there have been several landmark docu- ments produced to translate this recognition into calls for action and to develop strategies and policy frameworks. Despite this progress, there remains a profound mismatch between the compelling evidence documenting the health and economic burden of CVD and the lack of concrete steps to increase investment and implement CVD prevention and disease management efforts in developing countries. To help catalyze the action needed, the U.S. National Heart, Lung, and Blood Institute (NHLBI) sponsored this study of the evolving global epidemic of CVD. The Institute of Medicine convened the Committee on Preventing the Global Epidemic of Cardiovascular Disease: Meeting the Challenges in Developing Countries to assess the current tools for CVD control and the knowledge and strategies pertinent to their implementation. The commit- tee was charged with evaluating the available evidence to offer conclusions and recommendations to reduce the global burden of CVD, with an em- phasis on developing guidance for partnership and collaborations among a range of public- and private-sector entities involved with global health and development. In response to its charge, the committee undertook an examination of the current state of efforts to reduce the global epidemic of CVD based on a review of the available literature and of information gathered from vari- ous stakeholders in CVD and global health. In this analysis, the committee evaluated why there has not been more action to address chronic diseases and assessed the available evidence on intervention approaches to prevent and manage CVD, emphasizing knowledge and strategies pertinent to their implementation in low and middle income countries. Through careful con- sideration of the evidence and a thorough deliberation process, the commit- tee drew conclusions about the necessary next steps to move forward. Prior reports have identified general priorities and recommended a wide range of possible actions for a multitude of stakeholders; indeed, the findings and conclusions of this report reinforce many of those messages and priorities. In this report’s recommendations, however, the committee has emphasized advancing the field beyond messages about broad concep- tual solutions and has identified a limited set of specific actions targeted to specific stakeholders. These actions are intended to encourage a sufficient

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 SUMMARY shift in the global health and development agenda to facilitate critical next steps that will build toward the eventual goal of widespread dissemination and implementation of evidence-based programs, policies, and other tools to address CVD and related chronic diseases in developing countries. ACTIONS TO REDUCE THE GLOBAL BURDEN OF CVD The actions needed for an individual to prevent and treat CVD are deceptively straightforward: eat a healthy diet, remain physically active throughout life, don’t use tobacco, and seek health care regularly. The real- ity is much more complex. Behavior change is difficult, individual choices are influenced by broader social and environmental factors, and many peo- ple do not have the resources or access to seek appropriate health care. Solutions can also seem simple at the level of governments and other organizations. Declarations have called on governments to invest more in CVD, to develop laws to protect health, and to ensure access to services to meet the cardiovascular health needs of people. International conference recommendations have demanded that food companies restrict marketing of certain products to children; eliminate transfats and reduce saturated fat, unhealthy oils, sugar, and salt in their products; and make healthy foods more affordable and available. In reality, however, governments and donors need to balance many competing priorities in the allocation of resources, and the level of capacity and infrastructure to support action varies among countries. Context is also critical; programs and policies that have worked in one environment may not work in another. The health systems infrastruc- ture in many countries is insufficient to support chronic disease prevention, treatment, and management. Companies are obligated and motivated to meet the needs of their shareholders even when willing to collaborate to work toward public health goals. These realities have often not been fully considered in the effort to draw attention to the compelling burden of CVD and to call for action. Along with the need to recognize these realities in the effort to imple- ment policies and programs, the committee identified several key barriers to progress in controlling the global epidemic of CVD. There is concern that attention to CVD would detract from other health needs; there is uncer- tainty about the effectiveness and feasibility of policies, programs, and ser- vices in the contexts in which they need to be implemented; efforts among stakeholders are fragmented and there is a need for focused leadership and collaboration centered on clearly defined goals and outcomes; there is a lack of financial, individual, and institutional resources; and there is insufficient capacity to meet CVD needs in low and middle income countries, including health workforce and infrastructure capacity as well as implementation and enforcement capacity for policies and regulatory approaches.

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD The committee also identified several essential functions that are needed to overcome these barriers. These include advocacy and leadership at global and national levels, developing policy, program implementation, capacity building, research focusing on evaluating approaches in developing coun- tries that are context specific and culturally relevant, ongoing monitoring and evaluation, and funding. Success will require resources—financial, technical, and human—and the combined efforts of many players sustained over many years. The following summarizes the committee’s conclusions and recommendations about these barriers and how to overcome them by strengthening these essential functions. Aligning Chronic Disease Needs with Health and Development Priorities Global health and development stakeholders and national governments in the developing world face important challenges that remain far from ad- equately managed, such as basic economic development priorities, poverty alleviation, hunger reduction, and a range of health issues in areas such as infectious disease and maternal and child health. In addition, the state of the global economy affects the resources of both donor countries and gov- ernments in low and middle income countries. As a result, decision makers face very difficult choices about resource allocation. Rather than competing against existing priorities, leaders in the effort to reduce the burden of CVD and related chronic diseases at both global and local levels need to better communicate the importance of integrating attention to these diseases within other health and development needs. Better alignment among these priorities, as described in this report, has the potential to synergistically improve economic and health status. Furthermore, this can help ensure that current and future health and development efforts do not inadvertently worsen the growing epidemic of chronic diseases. In order to lay the groundwork to achieve this synergy, governments in low and middle income countries, global health funders, and development agencies need to give CVD and related chronic diseases more equal footing as a development and health priority. Currently, however, most agencies providing development assistance do not include chronic diseases as an area of emphasis. Given the compelling health and economic burden, these agencies will not truly meet their goals of improving health and well-being worldwide without committing to address chronic diseases in alignment with their evolving global health priorities. Leadership in eliminating this gap at these agencies is a critical first step to encourage a greater emphasis on chronic diseases among all stakeholders.

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 SUMMARY Recommendation 1: Recognize Chronic Diseases as a Development Assistance Priority Multilateral5 and bilateral6 development agencies that do not already do so should explicitly include CVD and related chronic diseases as an area of focus for technical assistance, capacity building, program implementation, impact assessment of development projects, funding, and other areas of activity. Evidence-Based and Locally Relevant Solutions Stakeholders of all kinds, from national governments to development agencies and other donors, who have committed to taking action to ad- dress the global burden of chronic diseases will need to carefully assess the needs of the population they are targeting, the state of current efforts, the available capacity and infrastructure, and the political will to support the available opportunities for action. This assessment will inform priorities and should lead to specific and realistic goals for intervention strategies that are adapted to local baseline capacity and burden of disease and designed to improve that baseline over time. These goals will determine choices about the implementation of both evidence-based policies and programs and also capacity building efforts. Ongoing evaluation of implemented strategies will allow policy makers and other stakeholders to determine if implemented actions are having the intended effect and meeting the defined goals, and to reassess needs, capacity, and priorities over time. Given limited resources to allocate to CVD, developing country govern- ments and other stakeholders will want to focus efforts on goals that prom- ise to be economically feasible, have the highest likelihood of intervention success, and have the largest impact on morbidity. Successes in reducing the burden of CVD in many high income countries provide considerable knowledge about how to manage disease and reduce the major behavioral and biological risk factors for CVD, which are well-described and largely consistent worldwide. However, much of this knowledge is not easily trans- lated into solutions for the developing world. Low and middle and income countries have resource constraints, cultural contexts, social structures, and social and behavioral norms that are distinct from high income countries 5 The term “multilateral development agencies” is used throughout the recommendations to refer to international, multilateral entities that provide health and development assistance, such as the World Health Organization and World Bank and regional development banks. 6 The term “bilateral development agencies” is used throughout the recommendations to refer to national agencies that provide foreign development assistance, such as the U.S. Agency for International Development (USAID) in the United States and analogous agencies in other G20 countries.

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD and distinct among different developing countries. The goal of simply implementing solutions drawn directly from best practices in high income countries is a siren song; this approach will not be compelling to policy makers in low and middle income countries or to the agencies that provide external assistance to these countries. While the needs, capacity, and priorities will vary across countries, the available intervention and economic evidence suggests that substantial progress in reducing CVD can be made in the near term through strategies to reduce tobacco use; to reduce salt consumption; and to improve deliv- ery of clinical prevention in high-risk patients. These goals have credible evidence for lowered CVD morbidity, demonstrated likelihood of cost- effectiveness, and examples of successful implementation of programs with the potential to be adapted for low and middle income countries. To achieve successful adaptation and implementation of these priority approaches and to move toward a sufficient knowledge base to implement other promising strategies in the longer term, real work lies ahead to build on the knowledge derived from existing best practices in CVD and on practical knowledge that can be gleaned from successful implementation ex- perience in other areas of global health. Together, these can be the basis to establish what works for CVD within local realities in relevant settings and then to disseminate those findings among countries with similar epidemics and similar infrastructure, resources, and cultural environments. To these ends, the committee makes recommendations in the following areas. Better Local Data A first step for governments and program implementers is to determine the extent and nature of cardiovascular risk in their local population and to assess their needs and capacity to address CVD and related chronic diseases. Improved population data are crucial to compel action, to inform local pri- orities, and to measure the impact of implemented policies and programs. Recommendation 2: Improve Local Data National and subnational governments7 should create and maintain health surveillance systems to monitor and more effectively control chronic diseases. Ideally, these systems should report on cause-specific mortality and the primary determinants of CVD. To strengthen existing initiatives, multilateral development agencies and World Health Orga- 7 The term “national and subnational governments” is used throughout the recommenda- tions to refer to national governments and/or governments below the level of the national government, such as provinces, territories, districts, municipalities, cities, and states within federal systems.

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 SUMMARY nization (WHO) (through, for example, the Health Metrics Network and regional chronic disease network, NCDnet) as well as bilateral public health agencies8 (such as the Centers for Disease Control and Prevention [CDC] in the United States) and bilateral development agen- cies (such as USAID) should support chronic disease surveillance as part of financial and technical assistance for developing and implement- ing health information systems. Governments should allocate funds and build capacity for long-term sustainability of disease surveillance that includes chronic diseases. Policy Approaches Based on Local Priorities One of the primary goals in meeting the challenges of CVD is to cre- ate environments that support and empower individual behavior choices that help prevent the acquisition and augmentation of risk. In countries that have adequate regulatory and enforcement capacity, policy makers have a range of policy solutions they can implement to target local priori- ties and goals. Because the determinants of CVD extend beyond the realm of the health sector, coordinated approaches are needed so that policies in nonhealth sectors of government, such as agriculture, urban planning, transportation, and education, can be developed synergistically with health policies to reduce, or at least not adversely affect, risk for CVD. In addition to coordinating among different sectors of government, policies in each of these domains can be developed with input from civil society and the private sector. This coordinated, intersectoral approach can help determine the balance of regulatory measures, incentives, and voluntary measures that is likely to be most effective and realistic in the local political and governmental context, especially when the feasibility of policy changes is challenged by economic aims that may be in conflict with goals for improv- ing health outcomes. A policy approach supported by a strong evidence base in high income countries is implementation of the Framework Convention for Tobacco Control, which emphasizes measures such as taxation; protection from ex- posure to tobacco smoke; health warnings and public awareness campaigns; tobacco cessation services; and controls on tobacco advertising, illicit trade, and sales to minors. In addition, a collection of successful strategies to reduce salt in the food supply and in consumption in high income settings could potentially be adapted to low and middle income settings and are already being initiated in some developing countries. Analogous efforts 8 The term “bilateral public health agencies” is used throughout the recommendations to refer to national public health agencies such as the Centers for Disease Control and Prevention (CDC) in the United States and analogous agencies in other G20 countries.

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD could be explored to reduce consumption of other unhealthy dietary com- ponents, including saturated fats and transfats, unhealthy oils, and sugars. Agriculture policies could also be considered, where feasible, to avoid over- production of meat and unhealthy oils and to encourage greater production of healthy foods such as fruits and vegetables. Finally, for those countries on the verge of rapid urbanization, policies for future urban planning could promote physical activity and improve access to healthy food sources. Many of these policies would be in synergy with aims to minimize potential negative environmental and safety effects of rapid urban development. Health communications and education efforts at the population level are another strategy to affect CVD-related behaviors. Public communica- tion interventions that are coordinated with the policy changes selected by government authorities can enhance the effectiveness of both approaches. In addition to promoting behavior change, communication programs and engagement with the media can be used to build public support for policy changes. The feasibility and effectiveness of policy approaches and health com- munications efforts to reduce CVD in low and middle income settings must be ascertained. It is therefore crucial that government authorities, with external technical and financial assistance when needed, implement both the initiatives and the necessary mechanisms for monitoring, evaluation, and transparent reporting of their effects. This will inform ongoing action within countries and help build a global knowledge base of feasible and effective approaches. Recommendation 3: Implement Policies to Promote Cardiovascular Health To expand current or introduce new population-wide efforts to pro- mote cardiovascular health and to reduce risk for CVD and related chronic diseases, national and subnational governments should adapt and implement evidence-based, effective policies based on local pri- orities. These policies may include laws, regulations, changes to fiscal policy, and incentives to encourage private-sector alignment. To maxi- mize impact, efforts to introduce policies should be accompanied by sustained health communication campaigns focused on the same targets of intervention as the selected policies. Improved Health Care Delivery Clinical interventions can provide treatment for CVD as well as control of biological risk factors such as elevated blood pressure, blood lipids, and blood glucose for both individuals already diagnosed with CVD and those

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 SUMMARY at high risk, ideally in the context of a supportive environment created by policy and health communication initiatives to address behavioral risk by promoting healthy individual choices and appropriate self-care. However, implementation of these effective approaches requires an adequate system of organizations, institutions, and resources to meet health needs. Many countries lack this health systems infrastructure. In this aspect, strategies to reduce the burden of chronic diseases can be coordinated with, rather than compete against, efforts in other areas of global health. Therefore, the CVD community should seek opportunities to create stronger inter- actions with existing major global initiatives that are increasing support for broad health systems strengthening as part of their current mission, such as the International Health Partnership; the U.S. HIV/AIDS programs implemented under the President’s Emergency Plan for AIDS Relief; the Global Fund for AIDS, Tuberculosis and Malaria; and the Global Alliance for Vaccines and Immunization. Such an integrated approach dovetails with current efforts to transition from costly, disease-specific approaches toward more efficient approaches that promote better primary health care to meet a range of health needs. It also fits into a shift in the global health paradigm from acute, short-term interventions to longer-term investments in overall health. In particular, a critical component to make it feasible to reduce the burden of CVD is an adequate and appropriately trained local workforce to initiate and sustain intervention efforts. Therefore, as part of current and future strategies to strengthen the overall health and public health workforce in low and middle income countries, international and national CVD stakeholders need to work to build capacity in the areas of cardiovas- cular health promotion, CVD prevention, CVD clinical services, and CVD- related research. In particular, capacity building could include enhancing curricular development to include chronic diseases in training programs in clinical, public health, research, economic, epidemiology, behavioral, health promotion, and health communications disciplines. In addition to building local workforce capacity, strengthening health systems to better meet the needs of both chronic disease and other health needs in low and middle income countries will require low-cost approaches to deliver high-quality care by improving equitable access to affordable health services and essential medicines, diagnostics, and technologies for prevention and treatment; monitoring clinical practice and improving the quality of care; introducing risk-pooling mechanisms for financing health services; and using information technologies. In addition, the chronic disease community needs to actively engage in current and future health systems strengthening efforts in low and middle income countries not only to improve prevention and care for CVD and related chronic diseases but also to contribute chronic care expertise to help

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0 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD develop solutions for infectious diseases that require chronic management, such as HIV/AIDS and tuberculosis. Recommendation 4: Include Chronic Diseases in Health Systems Strengthening Current and future efforts to strengthen health systems and health care delivery funded and implemented by multilateral agencies, bilateral public health and development agencies, leading international nongov- ernmental organizations (NGOs),9 and national and subnational health authorities should include attention to evidence-based prevention, di- agnosis, and management of CVD. This should include developing and evaluating approaches to build local workforce capacity and to implement services for CVD that are integrated with primary health care services, management of chronic infectious diseases, and maternal and child health. Coordination of National and Subnational Approaches The breadth of the many determinants that affect CVD means that these efforts must extend beyond the public health and health care sectors to include authorities throughout the whole of government in a coordinated intersectoral approach. For example, strategies to reduce tobacco use or salt consumption will require actions by a range of governmental agencies (health, agriculture, finance, broadcasting, education) as well as private- sector producers and retailers. The political will to support and the exper- tise to implement such a broad effort cannot depend on the Ministry of Health alone. To coordinate these efforts, ensure the allocation of necessary resources, and have the best chance for real impact requires a mechanism at a level that is insulated from the relative influence of different ministries within the government. Coordination and communication within a whole- of-government approach also needs to include legislatures in order to pass laws needed to implement policies and, in some cases, to initiate changes in the activities of executive agencies. In addition, these efforts must be coordinated with stakeholders in the private sector and civil society as well as donors and agencies providing external development assistance. A useful model for this approach comes from successful efforts to achieve national coordination of efforts in the fight against HIV/AIDS. 9 The term “leading international nongovernmental organizations” is used throughout the recommendations to refer to NGOs with a mission to address CVD and/or related chronic diseases, such as the World Heart Federation and the World Hypertension League, as well as those with a mission to advance global health more broadly, such as the International Union for Health Promotion and Education and the Global Forum for Health Research.

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 SUMMARY Recommendation 5: Improve National Coordination for Chronic Diseases National governments should establish a commission that reports to a high-level cabinet authority with the specific aim of coordinating the implementation of efforts to address the needs of chronic care and chronic disease in all policies. This authority should serve as a mecha- nism for communicating and coordinating among relevant executive agencies (e.g., health, agriculture, education, and transportation) as well as legislative bodies, civil society, the private sector, and foreign de- velopment assistance agencies. These commissions should be modeled on current national HIV/AIDS commissions and could be integrated with these commissions where they already exist. Generating Evidence for Locally Relevant CVD Programs Local realities affect the planning, implementation, effectiveness, and sustainability of approaches to prevent and manage CVD. High-quality evaluations of programs are needed in settings that are analogous to those in which they are intended to be implemented in order to generate knowl- edge about what is not only effective but also feasible. The approaches that need to be evaluated are broad and include population surveillance meth- ods; population-based health promotion and CVD prevention approaches; health education; financing of health care, interventions and incentives to improve the quality of care, models for efficient delivery, and integration of health care services; and integrated community-based approaches. The health sector and public health community in high income coun- tries also stand to learn from what works in resource-constrained contexts in low and middle income countries. Developed countries are urgently in need of effective and affordable solutions for CVD, which remains a major health burden, especially for those populations most susceptible to health disparities. Recommendation 6: Research to Assess What Works in Different Settings The National Heart, Lung, and Blood Institute (NHLBI) and its partners in the newly created Global Alliance for Chronic Disease, along with other research funders10 and bilateral public health agencies, should pri- oritize research to determine what intervention approaches will be most 10 The term “research funders” is used throughout the recommendations to refer to mul- tilateral and bilateral health agencies as well as foundations and other nongovernmental organizations that fund global health research.

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD effective and feasible to implement in low and middle income countries, including adaptations based on demonstrated success in high income countries. Using appropriate rigorous evaluation methodologies, this research should be conducted in partnership with local governments, academic and public health researchers, nongovernmental organiza- tions, and communities. This will serve to promote appropriate inter- vention approaches for local cultural contexts and resource constraints and to strengthen local research capacity. A. Implementation research should be a priority in research funding for global chronic disease. B. Research support for intervention and implementation research should include explicit funding for economic evaluation. C. Research should include assessments of and approaches to improve clinical, public health, and research training programs in both de- veloped and developing countries to ultimately improve the status of global chronic disease training. D. Research should involve multiple disciplines, such as agriculture, environment, urban planning, and behavioral and social sciences, through integrated funding sources with research funders in these disciplines. A goal of this multidisciplinary research should be to advance intersectoral evaluation methodologies. E. In the interests of developing better models for prevention and care in the United States, U.S. agencies that support research and pro- gram implementation should coordinate to evaluate the potential for interventions funded through their global health activities to be adapted and applied in the United States. Dissemination and Practice-Based Evidence Efforts to address CVD are being implemented in many developing countries. These efforts offer the potential to contribute to the available knowledge base of feasible and effective solutions for CVD in low and mid- dle income countries. However, there is insufficient evaluation and report- ing of these programs and policies, and inadequate systematic mechanisms for disseminating what has worked in one context to other similar contexts. Regional coordination can provide a much-needed mechanism for countries to build their knowledge base through innovation and evaluation, to share knowledge and technical capacity among countries with similar epidemics, resources, and cultural conditions, and to help build international support for national-based solutions.

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 SUMMARY Recommendation 7: Disseminate Knowledge and Innovation Among Similar Countries Regional organizations, such as professional organizations, WHO ob- servatories and chronic disease networks, regional and subregional development banks, and regional political and economic organizations should continue and expand regional11 mechanisms for reporting on trends in CVD and disseminating successful intervention approaches. These efforts should be supported by leading international NGOs, de- velopment and public health agencies, and research funders (including the Global Alliance for Chronic Disease). The goal should be to maxi- mize communication and coordination among countries with similar epidemics, resources, and cultural conditions in order to encourage and standardize evaluation, help determine locally appropriate best prac- tices, encourage innovation, and promote dissemination of knowledge. These mechanisms may include, for example, regional meetings for researchers, program managers, and policy makers; regionally focused publications; and registries of practice-based evidence. Prevention Early in Life Accumulation of cardiovascular risk begins early in life, and evidence on rising rates of childhood obesity and youth smoking in low and middle income countries as well as emerging evidence on the effects of early nu- trition on later cardiovascular health support the value of starting health promotion efforts during pregnancy and early childhood and continuing prevention efforts throughout the life course. Thus, prevention early in life warrants special attention within the implementation of many of the rec- ommendations in this report, especially those focusing on research efforts and integration with existing health systems strengthening efforts. This will allow progress toward a true life-course approach to promoting cardio- vascular health. In particular, maternal and child health programs offer an opportunity to provide care that not only takes into account shorter-term childhood outcomes but also includes greater attention to future lifelong health, including cardiovascular health. In addition to efforts to reduce risk for child obesity and prevent initiation of tobacco use, emerging evidence on the effects of early nutrition on later cardiovascular health means that the CVD and maternal and child health communities need to work together more closely to ensure that food and nutrition programs for undernour- ished children do not inadvertently contribute to long-term chronic disease 11 The term “regional” is not meant to limit mechanisms for coordination and dissemination to geographical groupings. These mechanisms could, where appropriate, also include group- ings by, for example, risk profile, political system, or economic development status.

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD risk. Reproductive health and family planning programs are also an avenue both to address prenatal risks for CVD and to promote cardiovascular health among women. Other approaches with some success in high income countries and emerging potential for low and middle income countries in- clude education initiatives targeted to children and school-based programs, which need to be an area of emphasis in future research efforts. Adolescents and young adults could also be targeted to take advantage of their potential to serve as powerful advocates for change. Organizing Global Solutions Although the importance of local solutions cannot be overstated, ac- tive engagement of international partners is also critical to the success of global CVD control efforts. The process of translating goals into action is a complex, difficult, and long-term effort that succeeds when groups work together. Successful partnerships should include a clear articulation of roles, agreement on targets, and transparent monitoring. Such partnerships have proven highly effective at mobilizing commitments toward the prevention and treatment of infectious diseases. Current global efforts toward CVD prevention and control, however, lack widespread, coordinated action. A broad vision for collaboration and partnership is now required to elevate CVD within the global health agenda and to effectively organize the many committed stakeholders to implement and be accountable for action. This vision is centered on the need to accommodate the realities of tight global health budgets and multiple competing priorities and to strike a balance between integrated and disease-specific approaches. Many chronic diseases, such as diabetes, cancer, and chronic respiratory illnesses, share common behavioral risk factors with CVD, including tobacco use, dietary factors, and physical inactivity. Organizations focused on these chronic diseases can jointly support approaches for reduction of shared risk fac- tors, while at the same time retaining disease-specific programs, especially in the areas of research and technical expertise for clinical prevention and treatment. Most chronic diseases—and indeed many communicable diseases—also share the same social determinants. In addition, as described earlier, the determinants of CVD and related chronic diseases extend beyond the realm of the health sector. Thus, an integrated approach focused on health promo- tion is warranted, with partnerships across sectors such as health, agricul- ture, development, civil society, and the private sector. The common goals of shared risk-factor reduction and modifying social determinants for health promotion thus create a frame in which CVD and non-CVD organizations can concentrate their efforts and maximize the impact of their resources.

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 SUMMARY Role of the Private Sector Many intervention approaches designed to change the interrelated de- terminants that affect chronic diseases are more likely to succeed if public education and government policies and regulations are complemented by the voluntary collaboration of the private sector. These collaborations can serve to achieve health aims if agreements and negotiations are conducted transparently on public health terms under clear ethical guidelines, and if they establish defined goals and timelines that are assessed using inde- pendent monitoring mechanisms. Under these circumstances, motivated private-sector leaders at the multinational, national, and local levels in the food industry; in the pharmaceutical, biotechnology, and medical device industry; and in the business community have the potential to be power- ful partners in the public health challenge to reduce the burden of CVD. The food industry (including manufacturers, retailers, and food service companies) can be engaged to expand and intensify collaboration with in- ternational public-sector efforts to reduce dietary intake of salt, saturated fats, transfats, unhealthy oils, and sugars in both adults and children, and to fully implement marketing restrictions on unhealthy products. Phar- maceutical, biotechnology, medical device, and information technology companies can be enlisted to develop, provide, and distribute safe, effec- tive, and affordable diagnostics, therapeutics, and other technologies to improve prevention, detection, and treatment of CVD in low and middle income countries. Global and local businesses can also provide support for implementation of worksite prevention programs. Recommendation 8: Collaborate to Improve Diets WHO, the World Heart Federation, the International Food and Bever- age Association, and the World Economic Forum, in conjunction with select leading international NGOs and select governments from devel- oped and developing countries, should coordinate an international ef- fort to develop collaborative strategies to reduce dietary intake of salt, sugar, saturated fats, and transfats in both adults and children. This process should include stakeholders from the public health community and multinational food corporations as well as the food services in- dustry and retailers. This effort should include strategies that take into account local food production and sales. Recommendation 9: Collaborate to Improve Access to CVD Diagnos- tics, Medicines, and Technologies National and subnational governments should lead, negotiate, and implement a plan to reduce the costs of and ensure equitable access to

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD affordable diagnostics, essential medicines, and other preventive and treatment technologies for CVD. This process should involve stakehold- ers from multilateral and bilateral development agencies; CVD-related professional societies; public and private payers; pharmaceutical, bio- technology, medical device, and information technology companies; and experts on health care systems and financing. Deliberate attention should be given to public–private partnerships and to ensuring appro- priate, rational use of these technologies. Increased Resources Increasing the allocation of resources for chronic diseases will be fun- damental to an advancement of the global scope and scale necessary to control the CVD epidemic. Most organizations investing in global health currently focus the vast majority of funds toward acute health needs and chronic infectious diseases. However, given the alarming trends in disease burden, funders need to take chronic noncommunicable diseases into ac- count to truly improve health globally. This investment could occur as an expansion of their primary global health mission and also as part of exist- ing programs where objectives overlap and minimal new investment would be needed, such as early prevention maternal and child health programs; chronic care models for infectious and noninfectious disease; health systems strengthening; and health and economic development. In order to marshal the resources needed to implement actions that are aligned with the priori- ties outlined in this report, CVD and other chronic disease stakeholders need to build a case for investment by more effectively communicating with existing and potential new funders. Recommendation 10: Advocate for Chronic Diseases as a Funding Priority Leading international and national NGOs and professional societies related to CVD and other chronic diseases should work together to advocate to private foundations, charities, governmental agencies, and private donors to prioritize funding and other resources for specific initiatives to control the global epidemic of CVD and related chronic diseases. To advocate successfully, these organizations should consider (1) raising awareness about the population health and economic impact and the potential for improved outcomes with health promotion and chronic disease prevention and treatment initiatives, (2) advocating for health promotion and chronic disease prevention policies at national and subnational levels of government, (3) engaging the media about policy priorities related to chronic disease control, and (4) highlighting

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 SUMMARY the importance of translating research into effective individual- and population-level interventions. To support these efforts to better mobilize and align resources to meet the pressing burden of CVD and related chronic diseases, the level of invest- ment required for this critical priority in global health needs to be defined more clearly. There is a need for high-quality analyses of the gap between current resources and intervention efforts and future needs and interven- tion opportunities. This will help inform the best balance of intervention approaches for future investments and resource allocation, including health promotion, prevention, treatment, and disease management. Conducting such analysis at the country level in low and middle income countries will be an important planning tool for national and subnational governments as well as for funders and development agencies. Recommendation 11: Define Resource Needs The Global Alliance for Chronic Disease should commission and coor- dinate case studies of the CVD financing needs for five to seven coun- tries representing different geographical regions, stages of the CVD epidemic, and stages of development. These studies should require a comprehensive assessment of the future financial and other resource needs within the health, public health, and agricultural systems to prevent and reduce the burden of CVD and related chronic diseases. Several scenarios for different prevention and treatment efforts, train- ing and capacity building efforts, technology choices, and demographic trends should be evaluated. These assessments should explicitly estab- lish the gap between current investments and future investment needs, focusing on how to maximize population health gains. These initial case studies should establish an analytical framework with the goal of expanding beyond the initial pilot countries. Global Reporting and Dialog Progress on CVD requires that many players better coordinate their efforts, define clear goals, communicate shared messages through multiple channels from the community to the global level, and take decisive action together on the areas identified in this report. Although regional, national, and subnational actions will be the foundation for successful implementa- tion of efforts to reduce the burden of CVD, global coordination is also critical. To accomplish this, a consistent reporting mechanism at the global level is needed to track progress, to stimulate ongoing dialog about strate- gies and priorities, and to continue to galvanize stakeholders at all levels.

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD This global mechanism can be built upon ongoing efforts by WHO to re- port on the global status of noncommunicable diseases, including develop- ing guidance for surveillance systems and standardizing core indicators. Recommendation 12: Report on Global Progress WHO should produce and present to the World Health Assembly a biannual World Heart Health Report within the existing framework of reporting mechanisms for its Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. The goal of this report should be to provide objective data to track progress in the global effort against CVD and to stimulate policy dialog. These efforts should be designed not only for global monitoring but also to build capacity and support planning and evaluation at the national level in low and middle income countries. Financial support should come from the Global Alliance for Chronic Disease, with operational support from the CDC. The reporting process should involve national governments from high, middle, and low income countries; leading international NGOs; industry alliances; and development agencies. An initial goal of this global reporting mechanism should be to develop or select standardized indicators and methods for measurement, leverag- ing existing instruments where available. These would be recommended to countries, health systems, and prevention programs to maximize the global comparability of the data they collect. CONCLUSION Ultimately, the committee concluded that better control of CVD and related chronic diseases worldwide, and particularly in developing coun- tries, is eminently possible. However, to achieve that goal will require sus- tained efforts, strong leadership, collaboration among stakeholders based on clearly defined goals and outcomes, and an investment of financial, tech- nical, and human resources. Rather than competing against other global health and development priorities, the CVD community needs to engage policy makers and global health colleagues to integrate attention to CVD within existing global health missions and efforts because, given the high and growing burden, it will be impossible to achieve global health without better efforts to promote cardiovascular health.