40-Year CHD Mortality Trends and the Role of Risk Factors in Mortality Decline: The North Karelia Project Experience

Going from Primary to Primordial Prevention: Is the Juice Worth the Squeeze?

PURPOSE OF REVIEW

While primary prevention strategies target individuals who are at high risk of cardiovascular disease, there is rising interest towards primordial prevention that focuses on preventing the development of risk factors upstream of disease detection. Therefore, we review the advantages of primordial prevention interventions on minimizing future cardiovascular events.

RECENT FINDINGS

Primordial prevention of atherosclerotic cardiovascular disease involves behavioral, genetic, and environmental strategies, starting from fetal/infant health and continuing throughout childhood and young adulthood. Early interventions focusing on modifiable risk factors such as physical inactivity, non-ideal body weight, smoking, and environmental pollutants are important towards preventing the initial occurrence of risk factors such as hypertension, dyslipidemia, and diabetes to ultimately reduce cardiovascular disease. Implementing primordial prevention strategies early on in life can minimize cardiovascular events and lead to healthy aging in the population. Future studies can further evaluate the effectiveness of various primordial prevention strategies.

Population-based approaches for reducing stroke risk: an update on their success and the challenges ahead

INTRODUCTION

Stroke is a significant public health challenge as it is the second most common cause of death and the third leading cause of disability globally. Additionally, stroke incidence and the number of stroke deaths have been rising. Efforts to prevent stroke have been made, including high-risk approaches where patients are screened for cardiovascular risk factors, and population-based approaches which attempt to reduce stroke rates by improving overall population health.

AREAS COVERED

We summarize studies of population-based approaches to stroke prevention involving greater than 1,000 participants identified on a PubMed database search. Based on these programs, challenges of population-based stroke prevention programs are discussed and potential keys to success are highlighted.

EXPERT OPINION

Population-based stroke prevention programs face challenges including cost and interest of the public and certain stakeholders. Additionally, secular trends for improvement in risk factors and catastrophic adverse environmental circumstances add to the complexity of analyzing program success. Factors leading to successful programs include validated digital solutions for self-monitoring of risks, backing by global policy and legislation, flexibility to the needs of the population, intersectoral programs, community engagement, information dissemination back to the populations, and high-risk screening to develop a complementary combination approach to stroke prevention.

Non-High-Density Lipoprotein Cholesterol Levels From Childhood to Adulthood and Cardiovascular Disease Events

Importance

Elevated non-high-density lipoprotein cholesterol (non-HDL-C; a recommended measure of lipid-related cardiovascular risk) is common in children and increases risk of adult cardiovascular disease (CVD). Whether resolution of elevated childhood non-HDL-C levels by adulthood is associated with reduced risk of clinical CVD events is unknown.

Objective

To examine the associations of non-HDL-C status between childhood and adulthood with incident CVD events.

Design, Setting, and Participants

Individual participant data from 6 prospective cohorts of children (mean age at baseline, 10.7 years) in the US and Finland. Recruitment took place between 1970 and 1996, with a final follow-up in 2019.

Exposures

Child (age 3-19 years) and adult (age 20-40 years) non-HDL-C age- and sex-specific z scores and categories according to clinical guideline-recommended cutoffs for dyslipidemia.

Main Outcomes and Measures

Incident fatal and nonfatal CVD events adjudicated by medical records.

Results

Over a mean length of follow-up of 8.9 years after age 40 years, 147 CVD events occurred among 5121 participants (60% women; 15% Black). Both childhood and adult non-HDL-C levels were associated with increased risk of CVD events (hazard ratio [HR], 1.42 [95% CI, 1.18-1.70] and HR, 1.50 [95% CI, 1.26-1.78] for a 1-unit increase in z score, respectively), but the association for childhood non-HDL-C was reduced when adjusted for adult levels (HR, 1.12 [95% CI, 0.89-1.41]). A complementary analysis showed that both childhood non-HDL-C levels and the change between childhood and adulthood were independently associated with the outcome, suggesting that from a preventive perspective, both childhood non-HDL-C levels and the change into adulthood are informative. Compared with those whose non-HDL-C levels remained within the guideline-recommended range in childhood and adulthood, participants who had incident non-HDL-C dyslipidemia from childhood to adulthood and those with persistent dyslipidemia had increased risks of CVD events (HR, 2.17 [95% CI, 1.00-4.69] and HR, 5.17 [95% CI, 2.80-9.56], respectively). Individuals who had dyslipidemic non-HDL-C in childhood but whose non-HDL-C levels were within the guideline-recommended range in adulthood did not have a significantly increased risk (HR, 1.13 [95% CI, 0.50-2.56]).

Conclusions and Relevance

Individuals with persistent non-HDL-C dyslipidemia from childhood to adulthood had an increased risk of CVD events, but those in whom dyslipidemic non-HDL-C levels resolve by adulthood have similar risk to individuals who were never dyslipidemic. These findings suggest that interventions to prevent and reduce elevated childhood non-HDL-C levels may help prevent premature CVD.

Smart Anklet Use to Measure Vascular Health Benefits of Preventive Intervention in a Nature-Based Environment-A Pilot Study

The present study aimed to investigate the associations between nature-based intervention and peripheral pulse characteristics of patients with PAOD using new smart technology specifically designed for this purpose. A longitudinal panel study performed between 1 January 2022 and 31 December 2022 included 32 patients diagnosed with peripheral arterial occlusive disease (PAOD) who were treated in the vascular surgeons' hospital "Dobb" in Valjevo. These patients were exposed for six months to moderate-intensity physical activity (MPA) in a nature-based environment. They practiced 150 to 300 min of walking 6 km/h and cycling activities (16-20 km/h) weekly as recommended for patients with chronic conditions and those living with disability. Univariate logistic regression analysis was used to identify factors associated with major improvements in peripheral pulse characteristics of patients with PAOD. After six months of MPA, half of the patients (50%, 16/32) achieved minor, and half of them major improvements in peripheral pulse characteristics. The major improvements were associated with current smoking (OR = 9.53; 95%CI = 1.85-49.20), diabetes (OR = 4.84; 95%CI = 1.09-21.58) and cardiac failure, and concurrent pulmonary disease and diabetes (OR = 2.03; 95%CI = 1.01-4.11). Our pilot study showed that patients with PAOD along with other chronic conditions and risk factors benefited more from continuous physical activity in a nature-based environment.

Regional and temporal differences in the associations between cardiovascular disease and its classic risk factors: An analysis of 49 cohorts from 11 European countries

AIMS

The regional and temporal differences in the associations between cardiovascular disease (CVD) and its classic risk factors are unknown. The current study examined these associations in different European regions over a 30-year period.

METHODS

The study sample comprised 553818 individuals from 49 cohorts in 11 European countries (baseline: 1982-2012) who were followed up for a maximum of 10 years. Risk factors (sex, smoking, diabetes, non-HDL [high-density lipoprotein] cholesterol, systolic blood pressure [BP], and body mass index [BMI]) and CVD events (coronary heart disease or stroke) were harmonized across cohorts. Risk factor-outcome associations were analysed using multivariable-adjusted Cox regression models, and differences in associations were assessed using meta-regression.

RESULTS

The differences in the risk factor-CVD associations between central Europe, northern Europe, southern Europe, and the United Kingdom were generally small. Men had a slightly higher hazard ratio (HR) in southern Europe (p = 0.043 for overall difference) and those with diabetes had a slightly lower HR in central Europe (p = 0.022 for overall difference) compared with the other regions. Of the six CVD risk factors, minor HR decreases per decade were observed for non-HDL cholesterol (7% per mmol/L; 95% confidence interval [CI], 3-10%) and systolic BP (4% per 20 mmHg; 95% CI, 1-8%), while a minor HR increase per decade was observed for BMI (7% per 10 kg/m2; 95% CI, 1-13%).

CONCLUSION

The results demonstrate that all classic CVD risk factors are still relevant in Europe, irrespective of regional area. Preventive strategies should focus on risk factors with the greatest population attributable risk.

Epidemiological Trends in Cardiovascular Disease Mortality Attributable to Modifiable Risk Factors and Its Association with Sociodemographic Transitions across BRICS-Plus Countries

BRICS-Plus countries (Brazil, Russia, India, China, South Africa, and 30 other countries) is a group of 35 countries with emerging economies making up more than half of the world's population. We explored epidemiological trends of cardiovascular disease (CVD) mortality attributable to modifiable risk factors and its association with period and birth cohort effects and sociodemographic index (SDI) across BRICS-Plus countries by using joinpoint regression and age-period-cohort modeling from 1990 to 2019. Between 1990 and 2019, the all-ages CVD deaths increased by 85.2% (6.1 million to 11.3 million) across BRICS-Plus countries. The CVD age-standardized mortality rate attributable to dietary risks and smoking significantly decreased across BRICS-Plus countries, with some exceptions. However, four-fifths of BRICS-Plus countries observed a remarkable increasing trend of high body mass-index (BMI)-related CVD deaths, in particular, among younger adults (25-49 years). Early birth cohorts and individuals aged greater than 50 years showed a higher risk of CVD mortality. Both the China-ASEAN FTA and Mercosur regions stand out for their successful sociodemographic transition, with a significant reduction in CVD mortality over the study period. Singapore and Brazil achieved great progress in CVD mortality reduction and the other BRICS-Plus countries should follow their lead in adopting public health policies and initiatives into practice.

The digitized chronic disease management model: scalable strategies for implementing standardized healthcare and big data analytics in Shanghai

Background

Chronic disease management (CDM) falls under production relations, and digital technology belongs to the realm of productivity. Production relations must adapt to the development of productivity. Simultaneously, the prevalence and burden of chronic diseases are becoming increasingly severe, leveraging digital technology to innovate chronic disease management model is essential.

Methods

The model was built to cover experts in a number of fields, including administrative officials, public health experts, information technology staff, clinical experts, general practitioners, nurses, metrologists. Integration of multiple big data platforms such as General Practitioner Contract Platform, Integrated Community Multimorbidity Management System and Municipal and District-Level Health Information Comprehensive Platform. This study fully analyzes the organizational structure, participants, service objects, facilities and equipment, digital technology, operation process, etc., required for new model in the era of big data.

Results

Based on information technology, we build Integrated Community Multimorbidity Care Model (ICMCM). This model is based on big data, is driven by "technology + mechanism," and uses digital technology as a tool to achieve the integration of services, technology integration, and data integration, thereby providing patients with comprehensive people-centered services. In order to promote the implementation of the ICMCM, Shanghai has established an integrated chronic disease management information system, clarified the role of each module and institution, and achieved horizontal and vertical integration of data and services. Moreover, we adopt standardized service processes and accurate blood pressure and blood glucose measurement equipment to provide services for patients and upload data in real time. On the basis of Integrated Community Multimorbidity Care Model, a platform and index system have been established, and the platform's multidimensional cross-evaluation and indicators are used for management and visual display.

Conclusions

The Integrated Community Multimorbidity Care Model guides chronic disease management in other countries and regions. We have utilized models to achieve a combination of services and management that provide a grip on chronic disease management.

Adult-Onset Neuroepidemiology in Finland: Lessons to Learn and Work to Do

Finland is a relatively small genetic isolate with a genetically non-homogenous population. Available Finnish data on neuroepidemiology of adult-onset disorders are limited, and this paper describes the conclusions that can be drawn and their implications. Apparently, Finnish people have a (relatively) high risk of developing Unverricht-Lundborg disease (EPM1), Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS), Spinal muscular atrophy, Jokela type (SMAJ) and adult-onset dystonia. On the other hand, some disorders, such as Friedreich's ataxia (FRDA) and Wilson's disease (WD), are almost absent or completely absent in the population. Valid and timely data concerning even many common disorders, such as stroke, migraine, neuropathy, Alzheimer's disease and Parkinson's disease, are unavailable, and there are virtually no data on many less-common neurological disorders, such as neurosarcoidosis or autoimmune encephalitides. There also appear to be marked regional differences in the incidence and prevalence of many diseases, suggesting that non-granular nationwide data may be misleading in many cases. Concentrated efforts to advance neuroepidemiological research in the country would be of clinical, administrative and scientific benefit, but currently, all progress is blocked by administrative and financial obstacles.

Incidence of seropositive rheumatoid arthritis in population-based studies in Northern Savo, Finland, during 1980-2020

The objective is to evaluate the incidence of seropositive rheumatoid arthritis (RA) over 40-year period in Northern Savo, Finland. Data on new seropositive RA patients according to the American College of Rheumatology (ACR) 1987 classification criteria were collected in 2020-2021. In 2020 data on tobacco exposure, patient-reported dental health and living in residences with fluoridated tap water were gathered. Incidence rates were estimated and age- and gender-adjusted to Northern Savo population. The results were compared with data acquired in studies from 1980, 1990, 2000, and 2010. In 2020, 46 seropositive RA patients (21 females and 25 males) were recorded. The crude incidence of seropositive RA fulfilling the ACR 87 criteria in 2020 was 22.3 (95% CI 16.3 to 29.8)/100 000 and age and gender-adjusted 22.3 (95% CI 15.9 to 28.8)/100 000. Tobacco exposure > 5 pack years occurred 18% of females and 56% of males. Only 16% of males were full dentate. A total of 242 incident seropositive RA (age ≥ 16 years, 55% females) were identified in all study years. No differences in the gender-specific incidence rates in each cohort or in incidence between the studies every 10 years were recorded. The incidence of seropositive RA decreased in the age group < 55 years, p = 0.003. There was no change in the incidence of seropositive RA between genders or the study years. A declining trend for occurrence of seropositive RA in the young and early middle-aged population may reflect change in risk factors.

Addressing global disparities in blood pressure control: perspectives of the International Society of Hypertension

ABSTRACT

Raised blood pressure (BP) is the leading cause of preventable death in the world. Yet, its global prevalence is increasing, and it remains poorly detected, treated, and controlled in both high- and low-resource settings. From the perspective of members of the International Society of Hypertension based in all regions, we reflect on the past, present, and future of hypertension care, highlighting key challenges and opportunities, which are often region-specific. We report that most countries failed to show sufficient improvements in BP control rates over the past three decades, with greater improvements mainly seen in some high-income countries, also reflected in substantial reductions in the burden of cardiovascular disease and deaths. Globally, there are significant inequities and disparities based on resources, sociodemographic environment, and race with subsequent disproportionate hypertension-related outcomes. Additional unique challenges in specific regions include conflict, wars, migration, unemployment, rapid urbanization, extremely limited funding, pollution, COVID-19-related restrictions and inequalities, obesity, and excessive salt and alcohol intake. Immediate action is needed to address suboptimal hypertension care and related disparities on a global scale. We propose a Global Hypertension Care Taskforce including multiple stakeholders and societies to identify and implement actions in reducing inequities, addressing social, commercial, and environmental determinants, and strengthening health systems implement a well-designed customized quality-of-care improvement framework.

Pre-eclampsia and cardiovascular risk: a long-term nationwide cohort study on over 120 000 Finnish women

OBJECTIVES

To investigate the impact of pre-eclampsia on the future cardiovascular risk in Finnish women DESIGN: A registry-based nationwide controlled cohort study.

SETTING

Women hospitalised for pre-eclampsia in 1969-1993 and control women with a history of normotensive pregnancies followed from the pre-eclampsia diagnosis until 2019 for cardiovascular outcomes.

PARTICIPANTS

31 688 women with and 91 726 control women without a history of pre-eclampsia.

PRIMARY OUTCOME MEASURES

Incidences of and deaths from ischaemic heart disease (IHD), myocardial infarction (MI) and stroke.

RESULTS

In total, 25 813 (81.5%) women had pre-eclampsia without severe features, 4867 (15.4%) had pre-eclampsia with severe features and 1006 (3.2%) women developed eclampsia. Women with a history of pre-eclampsia showed elevated risks for IHD (HR 1.52, 95% CI 1.44 to 1.59), MI (HR 1.66, 95% CI 1.52 to 1.81) and stroke (HR 1.40, 95% CI 1.32 to 1.48). The risks for death from IHD (HR 1.50, 95% CI 1.28 to 1.75), MI (1.63, 95% CI 1.30 to 2.05) and stroke (1.44, 95% CI 1.03 to 2.01) were also elevated. Pre-eclampsia with severe features or eclampsia was accompanied with 15% higher IHD risk, 19% higher MI risk and 26% higher stroke risk than pre-eclampsia without severe features. The highest risk elevations of 30% for IHD, 32% for MI and 30% for stroke were observed in women with recurrent pre-eclampsia (n=4180).

CONCLUSION

Pre-eclampsia-related significant elevations in CVD risks of Finnish women with inherently high risk for these diseases were of the same magnitude as reported previously from other countries. Thus, women with a history of pre-eclampsia should be screened and treated early for modifiable cardiovascular risk factors.

The feasibility and outcome of a community-based primary prevention program for cardiovascular disease in the 21st century

OBJECTIVE

There is no evidence that systematic screening and risk factor modification in an unselected, asymptomatic population will reduce cardiovascular disease (CVD) mortality. This study aimed to evaluate the effectiveness of a primary care CVD prevention program on mortality during a 13-year follow-up.

DESIGN

A risk factor survey was sent, followed by a nurse-led lifestyle counselling to respondents with at least one CVD risk factor, and a general practitioner's (GP) appointment for high-risk persons. Screening and interventions were performed during 2005-2006.

SETTING

A public health care centre in the town of Harjavalta, Finland.

SUBJECTS

All home-dwelling 45-70-year old inhabitants without manifested CVD or diabetes.

MAIN OUTCOME MEASURES

All-cause and CVD mortality.

RESULTS

Altogether 74% (2121/2856) inhabitants responded to the invitation. The intervention was received by 1465 individuals (52% of the invited population): 398 risk persons had an appointment with a nurse, followed by an appointment with a GP for 1067 high-risk persons. During the follow-up, 370 persons died. Mortality among the non-respondents was twofold compared to the participants'. In subjects who received the intervention, the age- and gender-adjusted hazard ratio for all-cause mortality was 0.44 (95% CI: 0.36 to 0.54) compared to the subjects who did not receive the intervention.

CONCLUSIONS

Reducing mortality is possible in a primary care setting by raising health awareness in the community with screening, by targeted lifestyle counselling and evidence-based preventive medication for persons at high risk for CVD. Subjects not willing to participate in health surveys have the worst prognosis.Key PointsPreviously, there is no evidence that systematic screening and risk factor modification in an unselected, asymptomatic population will reduce cardiovascular disease (CVD) mortality.With a stepwise screening program it is possible to scale the magnitude of CVD prevention in the community.Reducing mortality in a community is possible by screening, targeted lifestyle counselling, and by evidence-based preventive medication for high-risk persons.Subjects not willing to participate in health surveys have the worst prognosis.

Ancel Keys: The legacy of a giant in physiology, nutrition, and public health

Ancel Keys, whose life spanned over 100 years (1904-2004), made a wealth of seminal scientific and public health contributions. As a physiologist, nutritionist, and public health scientist, he has left his mark on the 20th century by exploring different areas of physiology and nutrition, as well as by contributing to the understanding of basic public health issues. Among his major achievements one can mention in chronological order: studying adaptation to very high altitude, developing the K ration to enable the US military to survive with light but dense food, dissecting the physiology of starvation and nutritional rehabilitation to optimize recovery of functions, uncovering the link between serum cholesterol and heart disease, coordinating the first multi-country epidemiological longitudinal study in nutrition and health, coining the word "body mass index" (BMI), which he showed to be the best body weight index to predict body fat, and promoting the Mediterranean diet for a healthy life style. This review examines the historical events and scientific intrigues that have surrounded Ancel Keys's major classical studies that have ensured him a central place in the history of medical science.

Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update From the GBD 2019 Study

Cardiovascular diseases (CVDs), principally ischemic heart disease (IHD) and stroke, are the leading cause of global mortality and a major contributor to disability. This paper reviews the magnitude of total CVD burden, including 13 underlying causes of cardiovascular death and 9 related risk factors, using estimates from the Global Burden of Disease (GBD) Study 2019. GBD, an ongoing multinational collaboration to provide comparable and consistent estimates of population health over time, used all available population-level data sources on incidence, prevalence, case fatality, mortality, and health risks to produce estimates for 204 countries and territories from 1990 to 2019. Prevalent cases of total CVD nearly doubled from 271 million (95% uncertainty interval [UI]: 257 to 285 million) in 1990 to 523 million (95% UI: 497 to 550 million) in 2019, and the number of CVD deaths steadily increased from 12.1 million (95% UI:11.4 to 12.6 million) in 1990, reaching 18.6 million (95% UI: 17.1 to 19.7 million) in 2019. The global trends for disability-adjusted life years (DALYs) and years of life lost also increased significantly, and years lived with disability doubled from 17.7 million (95% UI: 12.9 to 22.5 million) to 34.4 million (95% UI:24.9 to 43.6 million) over that period. The total number of DALYs due to IHD has risen steadily since 1990, reaching 182 million (95% UI: 170 to 194 million) DALYs, 9.14 million (95% UI: 8.40 to 9.74 million) deaths in the year 2019, and 197 million (95% UI: 178 to 220 million) prevalent cases of IHD in 2019. The total number of DALYs due to stroke has risen steadily since 1990, reaching 143 million (95% UI: 133 to 153 million) DALYs, 6.55 million (95% UI: 6.00 to 7.02 million) deaths in the year 2019, and 101 million (95% UI: 93.2 to 111 million) prevalent cases of stroke in 2019. Cardiovascular diseases remain the leading cause of disease burden in the world. CVD burden continues its decades-long rise for almost all countries outside high-income countries, and alarmingly, the age-standardized rate of CVD has begun to rise in some locations where it was previously declining in high-income countries. There is an urgent need to focus on implementing existing cost-effective policies and interventions if the world is to meet the targets for Sustainable Development Goal 3 and achieve a 30% reduction in premature mortality due to noncommunicable diseases.

Preventable premature deaths (PYLL) in Northern Dimension partnership countries 2003-13

BACKGROUND

Objective was to measure preventable premature loss of life in countries from same geographical area but with considerable differences in social and economic development. By comparing inter-country differences and similarities in premature mortality, acceleration of health-in-all-policies is enhanced.

METHODS

Preventable premature deaths were described by Potential Years of Life Lost (PYLL). Data consisted of death registers for 2003, 2009 and 2013. PYLL-rates were age-standardized by using standard OECD population from 1980 and expressed as sum of lost life years per 100 000 citizens.

RESULTS

In Northern Dimension area, PYLL-rates had declined from 2003 to 2013. In 2013, worst PYLL-rate was in Belarus 9851 and best in Sweden 2511. PYLL-rates among men were twice as high as among women. Most premature losses (1023) were due to external causes. Malignant neoplasms came second (921) and vascular diseases third (816). Alcohol was also an important cause (270) and country differences were over 10-fold.

CONCLUSIONS

In ND-area, the overall development of public health has been good during 2003-13. Nevertheless, for all countries foci for public health improvement and learning from each other could be identified. Examining the health of populations in countries from relatively similar geographical area with different social history and cultures can provide them with evidence-based tools for health-in-all-policies to advocate health promotion and disease prevention. Gender differences due to preventable premature deaths are striking. The higher the national PYLL-rate, the bigger the PYLL-rate difference between men and women and the loss of human capital.

A Swedish primary healthcare prevention programme focusing on promotion of physical activity and a healthy lifestyle reduced cardiovascular events and mortality: 22-year follow-up of 5761 study participants and a reference group

Objective

To evaluate long-term risk of first cardiovascular (CV) events, CV deaths and all-cause deaths in community-dwelling participants of a cardiovascular disease (CVD) prevention programme delivered in a primary care setting.

Methods

Individuals who visited a primary healthcare service in Sollentuna (Sweden) and agreed to participate in the programme between 1988 and 1993 were followed. They had at least one CV risk factor but no prior myocardial infarction and received support to increase physical activity using the programme Physical Activity on Prescription and to adopt health-promoting behaviours including cooking classes, weight reduction, smoking cessation and stress management. Participants (n=5761) were compared with a randomly selected, propensity score-matched reference group from the general population in Stockholm County (n=34 556). All individuals were followed in Swedish registers until December 2011.

Results

In the intervention group and the reference group there were 698 (12.1%) and 4647 (13.4%) first CV events, 308 (5.3%) and 2261 (6.5%) CV deaths, and 919 (16.5%) and 6405 (18.5%) all-cause deaths, respectively, during a mean follow-up of 22 years. The HR (95% CI) in the intervention group compared with the reference group was 0.88 (0.81 to 0.95) for first CV events, 0.79 (0.70 to 0.89) for CV deaths and 0.83 (0.78 to 0.89) for all-cause deaths.

Conclusions

Participation in a CVD prevention programme in primary healthcare focusing on promotion of physical activity and healthy lifestyle was associated with lower risk of CV events (12%), CV deaths (21%) and all-cause deaths (17%) after two decades. Promoting physical activity and healthy living in the primary healthcare setting may prevent CVD.

National trends in total cholesterol obscure heterogeneous changes in HDL and non-HDL cholesterol and total-to-HDL cholesterol ratio: a pooled analysis of 458 population-based studies in Asian and Western countries

BACKGROUND

Although high-density lipoprotein (HDL) and non-HDL cholesterol have opposite associations with coronary heart disease, multi-country reports of lipid trends only use total cholesterol (TC). Our aim was to compare trends in total, HDL and non-HDL cholesterol and the total-to-HDL cholesterol ratio in Asian and Western countries.

METHODS

We pooled 458 population-based studies with 82.1 million participants in 23 Asian and Western countries. We estimated changes in mean total, HDL and non-HDL cholesterol and mean total-to-HDL cholesterol ratio by country, sex and age group.

RESULTS

Since ∼1980, mean TC increased in Asian countries. In Japan and South Korea, the TC rise was due to rising HDL cholesterol, which increased by up to 0.17 mmol/L per decade in Japanese women; in China, it was due to rising non-HDL cholesterol. TC declined in Western countries, except in Polish men. The decline was largest in Finland and Norway, at ∼0.4 mmol/L per decade. The decline in TC in most Western countries was the net effect of an increase in HDL cholesterol and a decline in non-HDL cholesterol, with the HDL cholesterol increase largest in New Zealand and Switzerland. Mean total-to-HDL cholesterol ratio declined in Japan, South Korea and most Western countries, by as much as ∼0.7 per decade in Swiss men (equivalent to ∼26% decline in coronary heart disease risk per decade). The ratio increased in China.

CONCLUSIONS

HDL cholesterol has risen and the total-to-HDL cholesterol ratio has declined in many Western countries, Japan and South Korea, with only a weak correlation with changes in TC or non-HDL cholesterol.

From monitoring to action: utilising health survey data in national policy development and implementation in Finland

Background

Health interview and examination surveys provide valuable information for policy, practice and research purposes. Appropriate use of high-quality, representative and timely population data can indirectly help the citizens to live healthier and longer lives. The aim of this study was to review how health survey data have supported health policy making, health research and everyday health care in Finland.

Methods

Data were collected by focused interviews with ten Finnish senior experts from the Ministry of Social Affairs and Health, political parties, National Institute for Health and Welfare, universities, and health associations.

Results

Most interviewees agreed that health surveys have positively affected the health of the population over the past 50 years - through health strategies, care guidelines, legislation, research, prevention programs, risk calculators, and healthier products on the market. There is also a need for further development: the latest research results should be provided in a nutshell for politicians, and effective tools should be developed more for health care professionals’ use. The coverage of health information on children, adolescents, oldest old, disabled persons, migrants and ethnic minorities should be improved.

Conclusions

Sound health policy and its successful implementation require extensive national cooperation and new communication strategies between policy makers, researchers, health care professionals, health service providers - and citizens. The future health information system in Finland should better cover all population groups. To obtain more comprehensive health information, the possibilities for register linkages should be secured and register data should be further evaluated and developed to serve health monitoring purposes.

Healthy Weight and Obesity Prevention: JACC Health Promotion Series

Overweight and obesity have reached epidemic levels in the United States and worldwide, and this has contributed to substantial cardiovascular and other health risks. However, controversy exists concerning the causes of obesity and effective modalities for its prevention and treatment. There is also controversy related to the concept of metabolically healthy obesity phenotype, the "obesity paradox," and on the importance of fitness to protect individuals who are overweight or obese from cardiovascular diseases. In this state-of-the-art review, the authors focus on "healthy weight" with the emphasis on the pathophysiologic effects of weight gain on the cardiovascular system; mechanistic/triggering factors; and the role of preventive actions through personal, education/environment, and societal/authoritative factors, as well as factors to provide guidance for caregivers of health promotion. Additionally, the authors briefly review metabolically healthy obesity, the obesity paradox, and issues beyond lifestyle consideration for weight loss with medications and bariatric surgery.

The Predicted Impact of Adopting Health-Promoting Behaviors on Disease Burden in a Commercially Insured Population

OBJECTIVE

The aim of this study was to better understand, in a commercially insured population, the potential impact of adopting six health-promoting behaviors relative to treating diseases and conditions.

METHODS

We combined survey and insurance claims data to compare the potential benefit from adopting behaviors relative with the burden from 27 groups of diseases and conditions.

RESULTS

If every member adopted all six behaviors, an 11.6% reduction in disability-adjusted life years (DALYs) might be expected, and a 7.6% reduction in DALYs might be expected if they adopted the one most impactful behavior that they did not currently practice. These amounts are, respectively, greater than the DALYs attributed to all but the two and five most burdensome groups of diseases and conditions in this population.

CONCLUSIONS

The potential impact of adopting health-promoting behaviors is large relative to the burden from most medical conditions.

Cardiovascular Diseases in African Americans: Fostering Community Partnerships to Stem the Tide

In 2002, the Institute of Medicine highlighted community partnerships as important in strategies for ensuring the public's health in the 21st century. Whether defined narrowly as the neighborhood or more broadly as the entire nation, communities represent settings in which health is supported and protected by healthy social connections and environments or risked and damaged by detrimental social, environmental, and policy determinants, as well as adverse behavioral and lifestyle choices. In this article, cardiovascular disease in African Americans is used as an example to highlight the successes achieved during the last half-century in reducing mortality rates, the persisting challenge of suboptimal adoption of evidence-based practices to promote community health and prevent disease, and the still widespread and pervasive health disparities. The article concludes with a call for the scientific community to embrace implementation research in strategic partnership with community stakeholders to stem the tide of cardiovascular disease and reduce related cardiovascular health disparities.

Non-Communicable Chronic Diseases Among Residents of a Remote Settlement in the Transbaikal Region of the Russian Federation

INTRODUCTION

Over a quarter of the population of the Russian Federation resides in rural communities. However, the data on chronic disease rates in these communities are limited, which makes screening for chronic diseases extremely important. The aim of this study was to measure the prevalence of chronic noncommunicable diseases among residents of a remote settlement in the Transbaikal region, Russian Federation.

METHODS

A sample of residents from the Transbaikal region settlement was screened in August 2017. The screening included a survey to determine the frequency of self-reported chronic diseases as well as sociodemographic and behavioral risk factors. Additionally, vascular stiffness was measured by volumetric sphygmography using the VaSera-1500 device. Descriptive statistics have been used for data analysis.

RESULTS

126 residents were screened for this study. The prevalence of chronic non-communicable diseases and their risk factors were: hypertension (56.3%), gastrointestinal diseases (33.3%), chronic obstructive pulmonary disease (13.5%), smoking (35.7%), obesity (19.1%), and diabetes mellitus (6.3%). Pathological vascular changes typical of atherosclerosis were found by volumetric sphygmography in 17.5% of cases, with 5.5% of those cases corresponding to significant forms of severe peripheral atherosclerosis (ABI<0.9). An analysis of mortality causes for this settlement for 2016-2017 found that cardiovascular diseases accounted for over 50% of the total number of deaths.

CONCLUSION

This study showed a high prevalence of detectable chronic non-communicable diseases and their associated risk factors. Cardiovascular diseases were the main cause of mortality. Active prevention programs and screenings are required to reduce the burden of chronic diseases in this region.

Heart failure in Finland: clinical characteristics, mortality, and healthcare resource use

Aims

The aims of this study were to describe patient characteristics of the adult chronic heart failure (HF) population and to estimate the prevalence, incidence, healthcare resource utilization (HCRU), and mortality associated with HF in Southwest Finland.

Methods and results

This was a retrospective biobank and clinical registry study. Adult patients with an HF diagnosis (International Statistical Classification of Diseases and Related Health Problems (ICD) code I50) during 2004–2013 in secondary care were included in the study and compared with age‐matched and gender‐matched control patients without an I50 diagnosis. HF patients were stratified in groups by left ventricular ejection fraction (LVEF) as follows: LVEF < 40% [HF with reduced ejection fraction (HFrEF)]; LVEF ≥ 40% [HF with preserved ejection fraction (HFpEF)]; or unknown (LVEF unknown). HCRU was stratified by inpatient, outpatient, and emergency room visits. In 2013, the incidence of HF was 3.2/1000, and the prevalence was 13.9/1000 inhabitants (n = 15 594). In the stratified analysis of HF patients (n = 8833, average ± SD age 77.1 ± 11.2), 1115 (12.6%) patients had HFrEF (female 31.3%), 1449 (16.4%) had HFpEF (female 50.9%), and 6269 (71%) had unknown LVEF (female 52.1%). The most common co‐morbidities were essential hypertension (58%), chronic elevated serum creatinine (57.3%), atrial fibrillation and flutter (55.1%), and chronic ischaemic heart disease (46.4%). Patients with HF diagnosis had higher HCRU compared with that of age‐matched and gender‐matched controls (3.7 more days per year at the hospital for HF patients compared with the controls). The total 5 year mortality was 62.6% for HF patients and 28.3% for controls, with higher age being the strongest predictor of mortality. Moreover, multivariable Cox regression analysis showed that patients with HFrEF had a 13% (95% confidence interval 2.7–25%) increased risk of mortality compared with HFpEF patients.

Conclusions

The high mortality rate and HCRU among the studied HF patients highlight the severity of the disease and the economic and social burden on both patients and society. This calls for improved methods of care for this large patient population.

Prevalence and Prognostic Significance of Negative U-waves in a 12-lead Electrocardiogram in the General Population

Negative U-waves are a relatively rare finding in an electrocardiogram (ECG), but are often associated with cardiac disease. The prognostic significance of negative U-waves in the general population is unknown. We evaluated 12-lead ECGs of 6,518 adults (45% male, mean age 50.9 ± 13.8 years) for the presence of U-waves, and followed the subjects for 24.5 ± 10.3 years. Primary end points were all-cause mortality, cardiac mortality, and sudden cardiac death; secondary end point was hospitalization due to cardiac causes. Negative U-waves (amplitude ≥0.05 mV) were present in 231 subjects (3.5%), minor negative (amplitude <0.05 mV) or discordant U-waves in 1,004 subjects (15.4%), normal positive U-waves in 3,950 (60.6%) subjects, and no U-waves were observed in 603 subjects (9.3%). In 730 subjects (11.2%), U-waves were unassessable. When adjusted for age and gender, negative U-waves were associated with all end points (p <0.01). In an analysis adjusted for multiple demographic and clinical factors, in men, negative U-waves were associated with increased risk of all-cause mortality (hazard ratio [HR] 1.60; 95% confidence interval [CI] 1.26 to 2.03; p <0.001), cardiac mortality (HR 1.74; 95% CI 1.26 to 2.39; p = 0.001), and cardiac hospitalization (HR 1.67; 95% CI 1.27 to 2.18; p <0.001), but not with sudden cardiac death, whereas women did not show a significant association to any of the end points (p >0.30). In conclusion, negative U-waves are associated with adverse events in the general population. In men, this association is independent of cardiovascular risk factors.

Coronary heart disease risk factor levels in eastern and western Finland from 1980 to 2011 in the cardiovascular risk in Young Finns study

BACKGROUND AND AIMS

In the 1960s and 1970s, Finland, mortality due to coronary heart disease (CHD) was over 30% higher among Finns residing in the east of the country compared with those residing in the west. Today, CHD mortality remains 20% higher among eastern Finns. The higher incidence of CHD mortality among eastern Finns has largely been explained by higher risk factor levels. Using a unique longitudinal cohort, we aimed to determine if participants who resided in eastern Finland during childhood had higher CHD risk factors in adulthood and from childhood to adulthood.

METHODS

The study population included 2063 participants of the Cardiovascular Risk in Young Finns Study, born during the period 1962-1977, with risk factor data available from baseline (1980) when participants were aged 3-18 years, and had risk factor data collected again in adulthood (2011) when aged 34-49 years.

RESULTS

Adult CHD risk factor profile was similar for those who resided in eastern or western Finland in childhood. Over life-course from 1980 to 2011, those subjects with childhood residency in eastern Finland had, on average, higher systolic (p = 0.006) and diastolic (p = 0.0009) blood pressures, total (p = 0.01) and LDL-cholesterol (p = 0.01), triglycerides (p = 0.04), apoB (p = 0.02), and serum glucose (p < 0.0001) than those who resided in western Finland in childhood.

CONCLUSIONS

Our sample of adult Finns aged 34-49 years had a similar CHD risk factor profile irrespective of whether they resided in eastern or western Finland during their childhood. However, when considering participants risk factor profiles over a 31-year period, those who resided in eastern Finland in childhood were associated with a less favorable CHD risk factor profile than those who resided in western Finland in childhood. The observed differences suggest that future CHD mortality might remain higher in eastern Finland compared with western Finland.

Cardiovascular disease in diabetes type 2: current concepts

Type 2 diabetes is a major and accelerating public health challenge. Between 1980 and 2014, a period of just 35 years, the number of adults with diabetes globally is estimated to have increased from 108 to 422 million, due not only to sharply rising obesity rates, but also to increasing population size, longer life expectancy, and rising prevalence of diabetes worldwide. Overall, worldwide age-standardized adult diabetes prevalence doubled from 4.3% to 9.0% in men and from 5.0% to 7.9% in women. The largest increases in diabetes type 2 have been demonstrated in low- and middle-income countries, whilst rises in high-income countries have been less marked, or even flat. Diabetes type 2 rates in low- and middle-income countries now in many instances surpass those in high-income countries, in response to changes in lifestyle. One factor of particular concern are the large relative increases in type 2 diabetes amongst young individuals observed in many countries, their higher overall risk factor burden, long exposure to hyperglycaemia and greater risk of complications over the life course. Type 2 diabetes is increasingly found to be a heterogeneous condition, where risk of cardiovascular disease that traditionally has been estimated at 2-4 times that of the nondiabetic population varies substantially with diabetes phenotype and accordingly diabetes does not confer the same increase in relative or absolute risk in all people. New research shows that excess risk varies substantially with type of outcome, age, glycaemic control, the presence of renal complications and other factors. Heart failure, previously less recognized that other cardiovascular conditions, is increasingly coming into focus, because of strong links with poor glycaemic control and obesity. The knowledge about risk of cardiovascular disease in diabetes is almost entirely derived from high-income countries, whereas there is comparatively very little data from low- and middle income countries, where the majority of persons with type 2 diabetes live, and where management in many cases is far from optimal. The reductions in cardiovascular disease incidence and mortality now observed in high-income countries are encouraging, because this reinforces the fact that improvement is possible and that a near-normal, or even normal life-expectancy can be achieved in subtypes of type 2 diabetes.

Effects of macrophage migration inhibitory factor on cardiac reperfusion injury in mice with depression induced by constant-darkness

RATIONALE

Depression is associated with coronary artery disease and increases adverse outcomes and mortality in patients with acute myocardial infarction, but the underlying pathophysiological mechanisms remain unclear.

OBJECTIVE

To evaluate the effect of macrophage migration inhibitory factor (MIF) on cardiac ischemia-reperfusion (I/R) injury in mice with constant darkness-induced depression.

METHODS AND RESULTS

Twenty C57BL/6 mice (8 weeks old, male) were randomly divided into 2 groups: one group was housed in a 12h light/dark cycle environment (LD) and the other in a constant darkness environment (DD). After 3 weeks, constant darkness-exposed (DD) mice displayed depression-like behavior as indicated by increased immobility in the forced swim test (FST) and lower sucrose preference rate. Western blotting revealed cardiac MIF expression was significantly lower in the DD mice than that in the LD mice. Next, 84 mice were randomly divided into 4 groups: LD sham group, LD I/R group, DD sham group, and DD I/R group. Following ischemia and reperfusion, mice in the DD I/R group had a larger infarct area and lower heart function index than mice in the LD I/R group (P < 0.05 for both). The cardiac pAMPK and pACC expression levels of the DD I/R group were also lower in the DD I/R group (P < 0.05).

CONCLUSION

DD-induced depression might cause decreased expression of MIF in the heart, resulting in downregulation of MIF-AMPK signaling and a subsequent adverse outcome after a cardiac I/R injury.

An analysis on intersectional collaboration on non-communicable chronic disease prevention and control in China: a cross-sectional survey on main officials of community health service institutions

BACKGROUND

Our study aimed to design a tool of evaluating intersectional collaboration on Non-communicable Chronic Disease (NCD) prevention and control, and further to understand the current status of intersectional collaboration in community health service institutions of China.

METHODS

We surveyed 444 main officials of community health service institutions in Beijing, Tianjin, Hubei and Ningxia regions of China in 2014 by using a questionnaire. A model of collaboration measurement, including four relational dimensions of governance, shared goals and vision, formalization and internalization, was used to compare the scores of evaluation scale in NCD management procedures across community healthcare institutions and other ones. Reliability and validity of the evaluation tool on inter-organizational collaboration on NCD prevention and control were verified.

RESULTS

The test on tool evaluating inter-organizational collaboration in community NCD management revealed a good reliability and validity (Cronbach's Alpha = 0.89,split-half reliability = 0.84, the variance contribution rate of an extracted principal component = 49.70%). The results of inter-organizational collaboration of different departments and management segments showed there were statistically significant differences in formalization dimension for physical examination (p = 0.01).There was statistically significant difference in governance dimension, formalization dimension and total score of the collaboration scale for health record sector (p = 0.01,0.00,0.00). Statistical differences were found in the formalization dimension for exercise and nutrition health education segment (p = 0.01). There were no statistically significant difference in formalization dimension of medication guidance for psychological consultation, medical referral service and rehabilitation guidance (all p > 0.05).

CONCLUSION

The multi-department collaboration mechanism of NCD prevention and control has been rudimentarily established. Community management institutions and general hospitals are more active in participating in community NCD management with better collaboration score, whereas the CDC shows relatively poor collaboration in China. Xing-ming Li and Alon Rasooly have the same contribution to the paper. Xing-ming Li and Alon Rasooly listed as the same first author.

Lifestyle Medicine and the Management of Cardiovascular Disease

PURPOSE OF REVIEW

Evidence has clearly demonstrated the importance of lifestyle factors (e.g., diet, physical activity, smoking) in the development of cardiovascular disease (CVD). Interventions targeting these behaviors may improve outcomes for CVD patients. The aim of this review is to summarize the effects of lifestyle interventions in individuals with established CVD.

RECENT FINDINGS

Most recent trials focused on diet, physical activity, stress reduction, or a combination of these. Findings were mixed, but most interventions improved at least some markers of cardiovascular risk. Few studies measured long-term clinical outcomes, but some suggested a possible benefit of stress reduction and multifaceted interventions on cardiovascular events. The benefits of lifestyle change for CVD patients have been established by decades of evidence. However, further research is needed to determine the optimal intensity, duration, and mode of delivery for interventions. Additional studies with long-term follow-up and measurement of clinical outcomes are also needed.

Saturated fat -a never ending story?

Science has no clear message regarding health effects of saturated fats, it seems. Different RCTs, prospective cohort studies and meta-analysis have led to contrasting conclusions. The aim of the present commentary is to discuss some possible reasons for an apparently never-ending fat controversy. They are of a purely scientific nature, which is important to recognize, but unfortunately hard to overcome. First is the placebo problem. In pharmaceutical science, evidence-based medicine is often synonymous with data on verified medical events from long-lasting double-blind randomized placebo controlled trials. In nutritional science the lack of double-blind design and lack of placebo food generate less conclusive data than those achieved in pharmaceutical science. Some scientists may apply the same type of scientific criteria used to evaluate the effects of drugs for foods. This leaves an impression of insufficient data since in this respect the fundamental criteria for evidence based medicine are not present. The next scientific problem is the energy balance equation. In contrast to pharmaceuticals, nutrients contain energy. An increased intake of one nutrient will lead to a decreased intake of another. The effect of change in only one nutrient is then difficult to isolate. Lastly, in nutritional science, generalizability is difficult compared to pharmaceutical science. Food culture interferes with lifestyle and food habits change over time. In conclusion, all available knowledge, from molecular experiments to population studies, must be taken in to account, to convert scientific data into dietary recommendations.

International Society for the Study of Fatty Acids and Lipids 2016 Debate: For Science-Based Dietary Guidelines on Fats, Meta-Analysis and Systematic Reviews Are Decisive

This paper summarizes a debate on whether meta-analyses and systematic reviews are decisive in formulating guidelines for dietary fat. Held during the 12th congress of the International Society for the Study of Fatty Acids and Lipids in Stellenbosch, South Africa, September 7, 2016, the debate was hosted by the International Union of Nutritional Sciences and the International Expert Movement to Improve Dietary Fat Quality (IEM, www.theiem.org). Clemens von Schacky, Ludwig Maximilians-University, Munich, Germany, supported the statement, describing the types of weaknesses in individual studies and clinical trials. With examples of how to overcome such limitations, he concluded that nutritional guidelines on fat need a proper scientific basis in which randomized controlled trials (RCTs) with clinical endpoints and their meta-analyses are essential and decisive. In contention, Ingeborg Brouwer, Vrije Universiteit, Amsterdam, declared that recommendations on dietary fat intake should always be based on the totality of the evidence, including physiologic and biochemical knowledge and associations from observational epidemiology. RCTs and meta-analyses have their shortcomings, but well-conducted systematic reviews and meta-analyses support a transparent process for developing dietary fat guidelines. Participants agreed that evidence-based decision-making for dietary guidance should consider all the best available evidence using a transparent, systematic review.

Lifestyle as Medicine: The Case for a True Health Initiative

The power of lifestyle as medicine was perceived thousands of years ago. There is now consistent and compelling science to support the important influence of lifestyle on health. Approximately 80% of chronic disease and premature death could be prevented by not smoking, being physically active, and adhering to a healthful dietary pattern. Cardiovascular disease, diabetes, stroke, dementia, and cancer are all influenced by lifestyle choices. Despite the ample evidence about what behaviors promote health, confusion still prevails among the general population. This is particularly true with regard to diet. Confusing nutrition messages from scientists, the media, the food industry, and other sources have made it all but impossible for any single authority to convey persuasively the fundamentals of healthful eating. The case is made here that a global coalition of diverse experts has the power to do what no individual can: clarify and popularize an understanding of the fundamentals of a health-promoting, sustainable pattern of diet and lifestyle, and rally the general public to their consistent support.