Obesity, Heart Disease Now Major Developing World Problems, Report Says
(More than 12 million lives being lost annually, U.N. health agency
says) (2810)

A global health assessment shows that cardiovascular (CV) disease and
the risk factors that cause it are more widespread in the developing
world than previously thought. The World Health Organization (WHO)
finds that more than 12 million people die each year as a result of
heart disease and strokes, according to an October 17 press release.
About half of those deaths could be prevented with wider availability
of drugs and greater promotion of healthy lifestyles and preventive
health care, the report says.

"The world once thought of CV disease as a Western problem, but
clearly this is not the case," said Anthony Rodgers, M.D., Ph.D., of
the University of Auckland, New Zealand and a WHO consultant who is
one of the report's main writers. "We can no longer frame diseases in
terms of where they occur but, rather, with what frequency they occur
in any given population."

The findings on CV disease are part of the WHO's annual World Health
Report 2002, which is to be released in its entirety later this month.

Wider use of commonly available drugs could accomplish a great deal in
reducing the death toll, but preventive measures are most effective
and less expensive, the report says. It recommends broad health
promotion campaigns to reduce smoking, increase exercise and lessen
salt and fat in the diet.

"Prevention is the key to lowering the global disease burden of heart
attacks and strokes," says Dr Gro Brundtland, director-general of WHO.
"The ideal strategy for many countries would be to devote many more
resources to introduce broad measures that can benefit the whole
population and at the same time target those at elevated risk with the
combination of pills."
In tandem with the WHO recommendations, the Bush administration is
making preventive health care a priority, allocating $20,000 million
to such programs in the 2003 budget. In a September speech, Secretary
of Health and Human Services Tommy G. Thompson said, "Poor eating
habits and inactivity are self-destructive. They shorten the
life-span. They erode the quality of life. And they burden our health
care system that in many ways is already stretched far too thin."
Following is the text of the WHO press release:

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Cardiovascular Death And Disability Can Be Reduced More Than 50

More people at risk than previously thought, particularly in
developing world Conditions could be controlled quickly with medical,
social interventions

More than 50 percent of deaths and disability from heart disease and
strokes, which together kill more than 12 million people world-wide
each year, can be cut by a combination of simple, cost effective
national efforts and individual actions to reduce major risk factors
such as high blood pressure, high cholesterol, obesity and smoking,
the World Health Organization (WHO) says.

Most of the benefits from these combined interventions can be achieved
within five years of their implementation, since the progression of
cardiovascular (CV) disease is relatively easily interrupted.

If no action is taken to improve cardiovascular health and current
trends continue, WHO estimates that 25 per cent more healthy life
years will be lost to cardiovascular disease globally by 2020. The
brunt of this increase will be borne by developing countries.

These findings come from the first-ever global analysis of disease
burden due to major CV risks: high blood pressure, high cholesterol,
tobacco, obesity, physical inactivity and low consumption of fruits
and vegetables. They are contained in the upcoming World Health Report
2002: reducing risks, promoting healthy life, to be released at the
end of this month.

One major finding of the report is that blood pressure alone causes
about 50 percent of CV disease world-wide. Cholesterol causes about
one-third. Inactive lifestyles, tobacco use and low fruit and
vegetable intake account for 20 percent each. (These percentages add
up to more than 100 percent because some risks overlap. One individual
could be at risk from cholesterol alone, while another could be at
risk from cholesterol and blood pressure together.) It was estimated
that about nine million deaths and more than 75 million lost healthy
life years annually were due to unfavourable levels of blood pressure
or cholesterol.

Overall approximately 75 percent of CV disease can be attributed to
the established risks assessed in the report, far higher than the
one-third to one-half commonly thought. The burden is about equally
shared among men and women.

In total, 10-30 percent of adults in almost all countries suffer from
high blood pressure, but a further 50-60 percent would be in better
health if they had lower blood pressure. Even small reductions in
blood pressure for this "silent majority" would reduce their hearth
attack and stroke risk. A very similar pattern occurs for cholesterol.

"The global disease burden due to blood pressure is twice as much as
previously thought," says Gro Harlem Brundtland, M.D.,
Director-General of WHO. "This reflects recent findings on how
strongly blood pressure is linked to disease in many diverse
populations around the globe and the realization that most people have
sub-optimal levels."

The most immediate improvements in cardiovascular health can be
achieved with a combination of drugs -- statins for cholesterol
lowering and low-doses of common blood pressure lowering drugs and
aspirin -- given daily to people at elevated risk of heart attack and
stroke. This highly effective combination therapy could be much more
widely used in the industrialized world, and is increasingly
affordable in the developing world.

"This drug combination could cut death and disability rates from CV
disease by more than 50 percent among people at risk of cardiovascular
disease," says Christopher Murray, MD, Ph.D., Executive Director of
the Cluster on Evidence and Information Policy at WHO. "More people at
elevated risk for CV disease should start taking the combination now,
before they have heart attacks or strokes."

This drug combination would cost less than US$14 to treat each person
annually. Although this is a very low cost, it might not be affordable
to poor countries facing the traditional burdens posed by communicable
diseases and the growing burden of non-communicable and chronic
diseases. New resources would need to be found if the opportunities
presented by this combination are to be fully realized. The recent WHO
Commission on Macroeconomics and Health highlighted the need for major
new injections of resources from high income countries. The World
Health Report 2002 also urges countries to adopt policies and programs
to promote population-wide interventions like reducing salt in
processed foods, cutting dietary fat, encouraging exercise and higher
consumption of fruits and vegetables and lowering smoking.

The fact that the vast majority of adults world-wide have blood
pressure and cholesterol that are not optimal for health has clear
implications for governments, which have the capacity to address the
root causes with population-wide measures. Such efforts will also
require increased access to cost-effective medications for those at
elevated risk.

"Prevention is the key to lowering the global disease burden of heart
attacks and strokes," says Dr Brundtland. "The ideal strategy for many
countries would be to devote many more resources to introduce broad
measures that can benefit the whole population and at the same time
target those at elevated risk with the combination of pills."

"Our new research finds that many established approaches to cutting CV
disease risk factors are very inexpensive, so that even countries with
limited health budgets can implement them and cut their CV disease
rate by 50 per cent,” says Derek Yach, M.D., Executive Director of
the Cluster on Non-communicable Diseases and Mental Health. "In
addition, established drug treatments are increasingly affordable in
middle and low-income countries, as effective drugs come off patent."

WHO has developed a first-ever system of identifying and reporting
cost-effective health interventions consistently across settings that
it calls CHOICE (CHOosing Interventions that are Cost-Effective).
Various CHOICE options are contained in a new statistical database
that is also a part of the World Health Report 2002. These
interventions can be implemented on an a la carte basis, depending on
each country's individual circumstances.

CV Disease: No Longer a "Western" Problem

The Report shows for the first time that most of the global burden due
to CV risks occurs in the developing world. This is a result of
already high and increasing risk factor levels (e.g. high cholesterol)
and large and ageing populations. Tobacco, blood pressure and
cholesterol are leading risks in industrialized countries, together
accounting for more than a quarter of lost healthy life years. But
they also feature prominently in the top risks in middle income
countries and are beginning to appear in the leading risks of poorer
developing countries.

"We are seeing that conditions like high blood pressure and high
cholesterol are much more prominent in developing countries than
previously thought and contribute significantly to their overall
disease burden," says Anthony Rodgers, M.D., Ph.D., of the University
of Auckland, New Zealand and a WHO consultant who is one of the
report's main writers. "The world once thought of CV disease as a
Western problem, but clearly this is not the case. We can no longer
frame diseases in terms of where they occur, but rather with what
frequency they occur in any given population."

"The need to control CV disease is especially important in poor
countries, because its places a double burden on national health
systems, which must simultaneously deal with the infectious diseases
found primarily in these countries as well as newer cardiovascular
conditions," says Dr. Brundtland. "In the new mega-cities of the
developing world, we see massive illness due to under-nutrition side
by side with poor cardiovascular health."

The trend toward increased CV disease in developing countries may be
particularly dangerous to the lower end of the socio-economic
spectrum. In industrialized countries, CV disease once afflicted
wealthier people in disproportionate numbers. However, as knowledge of
cardiovascular health increased, the wealthy were able to reduce the
frequency that they suffer from these conditions while incidence of CV
disease increased among the poor and minorities. If this trend repeats
in the developing countries, the very poorest of the world's poor will
be the ones most at risk.

Population-Wide Interventions Should be Given Priority

While very effective, the combination of pills alone should not be
considered the exclusive or even the primary means of reducing
cardiovascular risks. Population-wide interventions are the most
cost-effective methods of reducing risk among an entire population.
They should be the first to be considered in all settings.

In many countries, too much focus is being placed on one-on-one
interventions among people at medium risk for CV disease, Dr. Murray
says. A much better use of resources would be to focus on those at
elevated risk and to use other resources to introduce population-wide
efforts to reduce risk factors through multiple economic and
educational policies and programs.

The WHO report also questions the accepted common threshold labels
such as "hypertension." The report outlines the increasingly clear
evidence that health risks are not restricted to those above these
thresholds. Rather, the vast majority of people would benefit from
lower levels, as the risks are continuous. In fact, cholesterol and
blood pressure measurements that are considered "average" are actually
usually too high for good health.

"CV disease risk often falls along a standard bell curve, with the
vast majority of the population at some elevated risk of CV disease
and only a few with very high or very low risk," says Dr. Rodgers.
"The most inexpensive means of reducing CV disease in a given country
is to move the entire population to a lower risk zone through public
education and government-led interventions. This is particularly true
in poor countries that may have more difficulty affording widespread
medical treatments, despite their decreasing costs."

Modern-day conditions frequently mean that individuals, particularly
the poor in developing world cities, often have little control
themselves over the major risk factors. For example, urban poor often
can only buy high-fat and high-salt processed foods. Many processed
foods -- breads, soups, meats, etc. -- have salt concentrations
approaching or even exceeding that found in seawater.

For example, when their sodium content is compared to that of
seawater, which has 1g of sodium per 100g:

--Bread and crackers are about 50 percent as salty;

--Cornflakes are about 100 percent as salty;

--Soups are up to 300 percent as salty;

--Sausages are 50-150 percent as salty;

As a result, salt intakes are usually very high and, in industrialized
countries, more than 75 per cent is usually from processed foods.

Targeted Medical Interventions: Inexpensive, Yet Powerful

An "absolute risk approach" to managing blood pressure and cholesterol
is also very cost-effective in all regions and has the potential to
lead to dramatic reductions in ischaemic heart disease and stroke.
This involves people at elevated risk of vascular disease being
provided with "low dose combination treatment" -- a combination of
multiple drugs including blood pressure lowering pills, statins and
aspirin. This reflects recent evidence that such therapy benefits all
groups at elevated risk, even those with average or below average
blood pressure or cholesterol.

Side effects from these drugs exist, but they are less than generally
perceived, and can be minimized with low-dose combinations. The
benefits will considerably outweigh any harm in those at elevated risk
of vascular disease.

This report will likely challenge current priorities for health
systems in many countries:

Few governments have yet to develop successful collaboration with the
food industry to reduce salt and high fat in processed food.

The report calls for new strategies and new thinking. It is
increasingly clear that people at elevated risk benefit from combined,
multi-modal treatment, largely irrespective of what initially caused
their risk to be high, and what their current risk factor levels are.
This is a paradigm shift for many doctors.

WHO also suggests that the large resources now devoted to detecting,
treating and monitoring people at comparatively low risk of heart
disease or stroke be reduced, while greater resources be given to
those with multiple risk factors who are at the highest risk, who are
now often under-treated.

CHOICE: Finding the Most Cost-Effective Method

The WHO CHOICE project reports that several established approaches to
CV disease risk factor management easily meet international standards
for cost-effectiveness, even in the poorest countries of the world.
"Take tobacco taxes, for example," says Dr Murray. "Countries that
raise their tobacco taxes dramatically witness an almost immediate
reduction in tobacco use and have corresponding improvements in
cardiovascular health very quickly. A seven-dollar pack of cigarettes
will go a long way toward persuading smokers to quit and non-smokers
not to start."

Governments, industry and civil society can work together to enable
the behavioural changes necessary to reduce risk among entire
populations. The best approaches will be different from country to
country, and many lessons can be learned from past experiences. Some
of the successes include:

-- In the United Kingdom, a government-promoted program in consort
with the food and drink manufacturing industry successfully reduced
salt content in almost a quarter of manufactured foods. This occurred
gradually over several years and examples included an agreement among
members of the Bakers Federation and reductions within products
produced by several major supermarket chains.

-- In Mauritius, cholesterol reduction was achieved largely by a
government-led effort switching the main source of cooking oil from
palm to soya bean oil.

-- Korea has worked to retain elements of the traditional diet. Civil
society and government initiatives led mass media campaigns, such as
television programs, to promote local foods, traditional cooking
methods and the need to support local farmers.

-- In Japan, government-led health education campaigns and increased
blood pressure treatment have reduced blood pressure population-wide,
and stroke rates have fallen by more than 70 percent.

-- In Finland, community based interventions, including health
education and nutrition labelling, led to population-wide reductions
in cholesterol and many other risks, closely followed by a precipitous
decline in heart disease. 4

-- In the USA, a decrease in saturated fat intake in the late 1960s
began the large decline in coronary heart disease (CHD) deaths seen in
the last few decades there.

-- In New Zealand, introduction of a recognizable food labelling logos
for healthier foods led many companies to reformulate their products.
The benefits included large decreases in the salt content of processed

"If we consider the dramatic improvement in cardiovascular health
that, for example, the Japanese and the Finns have experienced in the
last few decades, we can see that entire populations have been able to
significantly improve their situations without any change in their
gene pool," says Dr Murray. "Clearly diet, exercise and a reduction in
tobacco and alcohol intake are the most important factors to

The World Health Report 2002 is focusing on risks to health. It will
rank the top global risk factors and outline cost effective measures
for reducing risks, showing in detail the reductions in death and
disability that can result from a risk-focused approach to health
issues. The Report will be launched 30 October.

Copyright 2002 World Health Organization

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