Community control of hypertension— experiences from Finland

Evaluation of Tear Evaporation Rate in Subjects with a High Body Mass Index

Aim This study evaluated the tear evaporation rate (TER) in subjects with a high body mass index (BMI) and tested the correlation between BMI and dry eye.

Methods Thirty male subjects aged 18 – 38 years (26.4 ± 4.0 years) with a high BMI (26.4 – 47.0 kg/m2) were enrolled in the study. In addition, a control group of 30 males aged 20 – 36 years (24.0 ± 3.6 years) with a normal BMI (< 25 kg/m2) participated in the study for comparison. Each subject completed the ocular surface disease index (OSDI), followed by the TER measurement using a handheld VapoMeter.

Results Significant differences (Wilcoxon test; p = 0.002 and 0.001) were found between the median scores of the OSDI (10.3 [3.7] vs. 5.9 [7.2]) and TER (35.5 [13.1] vs. 15.5 [12.8] g/m2 h) in the study and control groups, respectively. The OSDI indicated dry eye in 60.0% of subjects in the study group (n = 18). The TER measurements showed that 76.7% of subjects in the study group (n = 23) had dry eyes. A medium correlation (r = 0.569; p = 0.001) was found between the OSDI scores and TER measurements.

Conclusions The means of the tear evaporation rate and the ocular surface disease index scores are significantly higher in subjects with a high BMI compared with the control group. Therefore, a high BMI is considered a risk factor for dry eye. The measurement of the tear evaporation rate using a handheld VapoMeter is a simple and rapid method to detect dry eyes in combination with other tools.

Assessment of tear film in subjects with a high body mass index

PURPOSE

The aim of the study was to assess the tear film in subjects with a high body mass index (BMI).

METHODS

Twenty male subjects aged 23-42 years (mean ± standard deviation =31.3±5.7 years) with a high BMI [median (interquartile range) =31.8 (5.2) kg/m2] were recruited. An age-matched control group of twenty male subjects aged 22-38 years with a normal BMI [20.5 (2.8) kg/m2] also participated in the study.

RESULTS

There were significant (Kolmogorov-Smirnov test; P<0.05) differences in the BMI, non-invasive tear break-up time (NITBUT), and tear ferning (TF) scores between the study and control groups. There were some differences in the ocular surface disease index (OSDI), tear meniscus height (TMH), and phenol red thread (PRT) scores between the study and control groups, but these differences were not significant (Kolmogorov-Smirnov test; P>0.05). For the study group, the NITBUT and TF tests mean scores showed a dry eye condition (8.5±2.8 s and 2.0±1.1, respectively). However, these two tests showed a normal eye condition within the control group (14.7±2.8 s and 0.7±0.6, respectively). The TMH score had strong correlations with the NITBUT (r=0.711; P=0.001) and PRT scores (r=0.566; P=0.009) and strong negative correlations with age (r=-0.503; P=0.024) and the OSDI scores (r=-0.520; P=0.018). The TF score had a strong correlation with age (r=0.579; P=0.007) and strong negtive correlations with the scores from the NITBUT (r=-0.525; P=0.018), TMH (r=-0.575; P=0.008), and PRT (r=-0.773; P=0.001) tests.

CONCLUSION

The acquired data suggest a high BMI has an effect on the quality of tears. The quality of tears seems to be lower in subjects with a high BMI compared with normal subjects. On the other hand, the tear volume in subjects with a high BMI was just as high and adequate as for normal eye subjects.

Is the Rule of Halves framework relevant for diabetes care in Copenhagen today? A register-based cross-sectional study

OBJECTIVE

The study aimed at analysing whether the 'Rule of Halves' framework applies for diabetes care in the Danish healthcare system with high levels of accessibility and equity. The Rule of Halves states that only one-half of people with a particular chronic condition are diagnosed; one-half of those diagnosed get treatment, and one-half of treated achieve desired therapeutic goals.

DESIGN

The analysis is cross sectional based on available surveys, register data and clinical databases covering the adult population in Copenhagen. We analysed five levels of prevention and care including behavioural risk factors and biomarkers, prevalence of diagnosed and undiagnosed diabetes as well as how many received care according to guidelines and achieved relevant outcomes.

SETTING

The study population is Copenhagen City with a population of 550 000 with 21 500 prevalent cases of diabetes. While the registers used cover the whole population, the surveys include 750 cases and the biobank data 365 cases.

OUTCOME MEASURES

Outcome measures are for each level of analysis: the prevalence of high-risk individuals, prevalence of undiagnosed and diagnosed diabetes, proportion receiving treatment and proportion achieving quality and treatment targets.

RESULTS

We found that the 'Rule of Halves' framework raises relevant questions on how diabetes care works in a specific population, but the actual proportions found in Copenhagen are far from halves. Our analyses showed that 74% are diagnosed and among those who are 90% are receiving care. 40%-60% have achieved target levels of treatment in terms of HbA1c level and lipid levels. 80% have received eye and foot examinations in the last 2 years. 11% have retinopathy and 25% have macrovascular complications.

CONCLUSION

Copenhagen is doing much better than halves, when it comes to diagnosis and providing treatment, whereas the Rule of Halves still prevails when it comes to treatment targets. There is thus still room for improvement.

Blood Pressure, Sodium Intake, and Hypertension Control: Lessons From the North Karelia Project

From the very beginning of the North Karelia Project, prevention, detection, and control of hypertension were included as key aims in the project. An intensive hypertension prevention and control program was established in North Karelia in 1972 that included community-based activities to reduce blood pressure levels in the entire population, detect people with hypertension, improve their treatment, establish standard diagnostic and therapeutic methods, and to monitor blood pressure levels, control of hypertension, and the performance of the health care. After the first 5 years of the project, most of these activities were also implemented on the national level. In late 1970s, work to reduce the salt intake was started, and substantial reductions have taken place in salt intake in the Finnish population. Remarkable improvements have been seen both in blood pressure levels and in treatment and control of hypertension in North Karelia and in the whole of Finland. Between 1972 and 2012 in North Karelia, the mean systolic blood pressure among 30- to 59-year-old men has decreased from 149 mm Hg to 135 mm Hg and among women from 153 mm Hg to 129 mm Hg. The decreases in mean diastolic blood pressure have been from 92 mm Hg to 84 mm Hg among men and from 92 mm Hg to 79 mm Hg among women.

Stages of Behavioral Change for Reducing Sodium Intake in Korean Consumers: Comparison of Characteristics Based on Social Cognitive Theory

High sodium intake increases the risk of cardiovascular disease. Given the importance of behavioral changes to reducing sodium intake, this study aims to investigate the stages of change and the differences in cognitive and behavioral characteristics by stage in Korean consumers. Adult participants (N = 3892) completed a questionnaire on the stages of behavioral change, recognition of social efforts, outcome expectancy, barriers to practice, nutrition knowledge and dietary behaviors, and self-efficiency related to reduced sodium intake. The numbers of participants in each stage of behavioral change for reducing sodium intake was 29.5% in the maintenance stage, 19.5% in the action stage, and 51.0% in the preaction stage that included the precontemplation, contemplation, and preparation stages. Multiple logistic regression showed that the factors differentiating the three stages were recognizing a supportive social environment, perceived barriers to the practice of reducing sodium intake, and self-efficacy to be conscious of sodium content and to request less salt when eating out. Purchasing experience of sodium-reduced products for salty foods, knowledge of the recommended intake of salt and the difference between sodium and salt, and improving dietary habits of eating salted fish, processed food, and salty snacks were factors for being in the action stage versus the preaction stage. These findings suggest that tailored intervention according to the characteristics of each stage is helpful in reducing sodium intake.

Hypertension in Russia: Changes Observed After 4 Years of a Comprehensive Health System Improvement Program in the Yaroslavl Region

Rates of cardiovascular mortality and morbidity in Russia have been among the highest in Europe. A comprehensive health system improvement program targeting better diagnosis and control of hypertension was undertaken in the Yaroslavl Region of Russia. This initiative was a joint program between clinicians, the Department of Health and Pharmacy of the Yaroslavl Region, and Novartis Pharma LLC. From 2011 to 2014, the blood pressure control rate improved substantially (94% relative improvement), the percentage of patients with a systolic blood pressure ≥180 mm Hg decreased (from 10% to 5%), and there was a reduction in stroke incidence rate from 4.6 to 3.7 per 1000 population. During this same period, significant changes were made to the way hypertension was diagnosed and treated across all regional government polyclinics, and the use of antihypertensive therapies increased.

Successful up-scaled population interventions to reduce risk factors for non-communicable disease in adults: results from the International Community Interventions for Health (CIH) Project in China, India and Mexico

BACKGROUND

Non-communicable disease (NCD) is increasing rapidly in low and middle-income countries (LMIC), and is associated with tobacco use, unhealthy diet and physical inactivity. There is little evidence for up-scaled interventions at the population level to reduce risk in LMIC.

METHODS

The Community Interventions for Health (CIH) program was a population-scale community intervention study with comparator population group undertaken in communities in China, India, and Mexico, each with populations between 150,000-250,000. Culturally appropriate interventions were delivered over 18-24 months. Two independent cross-sectional surveys of a stratified sample of adults aged 18-64 years were conducted at baseline and follow-up.

RESULTS

A total of 6,194 adults completed surveys at baseline, and 6,022 at follow-up. The proportion meeting physical activity recommendations decreased significantly in the control group (C) (44.1 to 30.2%), but not in the intervention group (I) (38.0 to 36.1%), p<0.001. Those eating ≥ 5 portions of fruit and vegetables daily decreased significantly in C (19.2 to 17.2%), but did not change in I (20.0 to 19.6%,), p=0.013. The proportion adding salt to food was unchanged in C (24.9 to 25.3%) and decreased in I (25.9 to 19.6%), p<0.001. Prevalence of obesity increased in C (8.3 to 11.2%), with no change in I (8.6 to 9.7%,) p=0.092. Concerning tobacco, for men the difference-in-difference analysis showed that the reduction in use was significantly greater in I compared to C (p=0.014).

CONCLUSIONS

Up-scaling known health promoting interventions designed to reduce the incidence of NCD in whole communities in LMIC is feasible, and has measurable beneficial outcomes on risk factors for NCD, namely tobacco use, diet, and physical inactivity.

Prevention and control of hypertension: developing a global agenda

PURPOSE OF REVIEW

This review demonstrates the need for enhancing strategic approaches to the prevention and control of hypertension, a global health issue.

RECENT FINDINGS

An epidemic of chronic noncommunicable diseases is threatening national healthcare systems' sustainability and the economy of many countries. Increased blood pressure is the leading risk for premature death and disability and accounts for approximately 10% of healthcare spending. Four of nine recent United Nations' targets for reducing chronic noncommunicable diseases relate directly or indirectly to hypertension. The expanded chronic care model provides a comprehensive framework for developing hypertension prevention and control strategies. The model addresses the roles of healthy public policy, healthy living environments, healthy communities, reorientation of health services delivery toward management of chronic illness, support for improving clinical decisions, enhanced skills of people to prevent and self-manage chronic disease, partnerships of stakeholders and information systems to track the impact of interventions and identify care 'gaps'. The authors advocate that hypertension organizations can lead aspects of hypertension strategy development and implementation.

SUMMARY

Prevention and control of hypertension requires a strategic approach that could have a central role for hypertension experts and the hypertension community.

Current levels of salt knowledge: a review of the literature

High salt intake increases the risk of hypertension and cardiovascular diseases. Given the role of knowledge as a determinant of food intake, this paper aims to review the current levels of salt knowledge and the association between salt knowledge and dietary salt intake and salt-related dietary practices in the general population. Twenty two studies were included in the review. In general, the studies showed consumers were able to identify the health risks associated with high salt intake. However, knowledge of recommended daily intakes, understanding of the relationships between salt and sodium and foods that contribute most salt to the diet were poor. Four of the five studies which examined the relationships between salt knowledge and salt-related dietary practices reported significant associations. Two important gaps in the current literature were identified. First, there is a need for a robustly validated tool to examine salt knowledge and its impact on salt intake. Second, a comprehensive salt knowledge assessment should include assessment of procedural, as well as declarative, knowledge.

Prevalence of Risk Factors for Chronic Non-communicable Diseases Using WHO Steps Approach in an Adult Population in Delhi

OBJECTIVE

The burden of non-communicable diseases (NCDs) is increasing worldwide largely due to prevalence of various risk factors, which can be controlled. Therefore, the present study was undertaken to measure the prevalence of major preventable risk factors for chronic non-communicable diseases in an urban resettlement colony of Delhi, using STEPS approach.

MATERIALS AND METHODS

A cross-sectional study, that included a random sample of 200 adults, was conducted. A study tool based on the WHO STEPS questionnaire for assessing non-communicable diseases and their risk factors was used. Fasting venous blood sample was collected to assess the lipid profile and fasting blood sugar. Anthropometric measurements of the participants were also taken. Data was analyzed using SPSS version 17.

RESULTS

Out of the 200 participants, 26% (n = 52) were consuming alcohol and 17% (n = 34) were smoking. Majority (77.5%) had a raised waist circumference, and more than two-thirds were either overweight or obese. Fasting blood sugar levels were found to be raised in 18% of the study population. More than third participants had raised systolic and diastolic blood pressures and abnormal lipid profiles. More males were found to be overweight in comparison to females (P < 0.01), but in contrast, obesity (P < 0.05) and raised waist circumference (P < 0.001) were more common in females. Tobacco use was more common in lower class (P < 0.05), whereas obesity was commoner in the upper socio-economic class (P < 0.05).

CONCLUSIONS

Study showed a high burden of risk factors for NCDs in the study population, pointing towards changing disease epidemiology of non-communicable diseases in India.

Prevalence, Awareness, Treatment, and Control of High Blood Pressure: A Population-Based Survey in Thai Nguyen, Vietnam

Background

Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality in Vietnam and hypertension (HTN) is an important and prevalent risk factor for CVD in the adult Vietnamese population. Despite an increasing prevalence of HTN in this country, information about the awareness, treatment, and control of HTN is limited. The objectives of this study were to describe the prevalence, awareness, treatment, and control of HTN, and factors associated with these endpoints, in residents of a mountainous province in Vietnam.

Methods

Data from 2,368 adults (age≥25 years) participating in a population-based survey conducted in 2011 in Thai Nguyen province were analyzed. All eligible participants completed a structured questionnaire and were examined by community health workers using a standardized protocol.

Results

The overall prevalence of HTN in this population was 23%. Older age, male sex, and being overweight were associated with a higher odds of having HTN, while higher educational level was associated with a lower odds of having HTN. Among those with HTN, only 34% were aware of their condition, 43% of those who were aware they had HTN received treatment and, of these, 39% had their HTN controlled.

Conclusions

Nearly one in four adults in Thai Nguyen is hypertensive, but far fewer are aware of this condition and even fewer have their blood pressure adequately controlled. Public health strategies increasing awareness of HTN in the community, as well as improvements in the treatment and control of HTN, remain needed to reduce the prevalence of HTN and related morbidity and mortality.

Economic aspects of chronic diseases in Vietnam

Introduction

There remains a lack of information on economic aspects of chronic diseases. This paper, by gathering available and relevant research findings, aims to report and discuss current evidence on economic aspects of chronic diseases in Vietnam.

Methods

Data used in this paper were obtained from various information sources: international and national journal articles and studies, government documents and publications, web-based statistics and fact sheets.

Results

In Vietnam, chronic diseases were shown to be leading causes of deaths, accounting for 66% of all deaths in 2002. The burdens caused by chronic disease morbidity and risk factors are also substantial. Poorer people in Vietnam are more vulnerable to chronic diseases and their risk factors, other than being overweight. The estimated economic loss caused by chronic diseases for Vietnam in 2005 was about US$20 million (0.033% of annual national GDP). Chronic diseases were also shown to cause economic losses for families and individuals in Vietnam. Both population-wide and high-risk individual interventions against chronic disease were shown to be cost-effective in Vietnam.

Conclusion

Given the evidence from this study, actions to prevent chronic diseases in Vietnam are clearly urgent. Further research findings are required to give greater insights into economic aspects of chronic diseases in Vietnam.

Prevalence, Awareness, Treatment, and Control of Hypertension in China

Background— The present article aims to provide accurate estimates of the prevalence, awareness, treatment, and control of hypertension in adults in China.

Methods and Results— Data were obtained from sphygmomanometer measurements and an administered questionnaire from 141 892 Chinese adults ≥18 years of age who participated in the 2002 China National Nutrition and Health Survey. In 2002, ≈153 million Chinese adults were hypertensive. The prevalence was higher among men than women (20% versus 17%; P <0.001) and was higher in successive age groups. Overall, the prevalence of hypertension was higher in urban compared with rural areas in men (23% versus 18%; P <0.01) and women (18% versus 16%; P <0.001). Of the 24% affected individuals who were aware of their condition, 78% were treated and 19% were adequately controlled. Despite evidence to suggest improved levels of treatment in individuals with hypertension over the past decade, compared with estimates from 1991, the ratio of controlled to treated hypertension has remained largely unchanged at 1:4.

Conclusions— One in 6 Chinese adults is hypertensive, but only one quarter are aware of their condition. Despite increased rates of blood pressure–lowering treatment, few have their hypertension effectively controlled. National hypertension programs must focus on improving awareness in the wider community, as well as treatment and control, to prevent many tens of thousands of cardiovascular-related deaths.

Canada Chair in hypertension prevention and control: a pilot project

A five-year pilot project was initiated in Canada to fund an individual to lead the effort in improving hypertension prevention and control. As the initial recipient of the funding, the author's objectives were to provide leadership to improve the management of hypertension through enhancements to the Canadian Hypertension Education Program, to increase public knowledge of hypertension, to reduce the prevalence of hypertension by reducing dietary sodium additives and to develop a comprehensive hypertension surveillance program. The initiative has received strong support from the hypertension community, the Public Health Agency of Canada, the Heart and Stroke Foundation of Canada, and many Canadian health care professional and scientific organizations. Progress has been made on all objectives. The pilot project was funded by The Canadian Hypertension Society, the Canadian Institutes of Health Research and sanofi-aventis, in partnership with Blood Pressure Canada, and will finish in July 2011.

Public education on hypertension: a new initiative to improve the prevention, treatment and control of hypertension in Canada

High blood pressure is one of the leading risk factors for death. Nevertheless, there is a lack of awareness of hypertension as a risk factor, as well as significant misconceptions about hypertension in the Canadian population. Furthermore, according to the Canadian Heart Health Surveys (1985 to 1992), 42% of hypertensive adult Canadians are unaware of their hypertensive status. A collaboration between Blood Pressure Canada, the Heart and Stroke Foundation of Canada, the Canadian Hypertension Society and the Canadian Hypertension Education Program has been formed to improve public and patient awareness and knowledge of hypertension. The effort will involve the translation of Canadian Hypertension Education Program recommendations for the prevention and management of hypertension to a public level with a broad and evolving dissemination strategy; the training of health professionals to speak to the public and patients on hypertension, coupled with opportunities to speak in forums organized in their local communities; and, media releases and information on hypertension in association with World Hypertension Day and the release of the annually updated public recommendations. Based on higher rates of awareness of hypertension in countries with sustained public education programs on hypertension, it is anticipated that this evolving program will result in improvement in the rates of awareness, treatment and control of hypertension and, ultimately, in lower cardiovascular disease rates in Canada. Public health programs that could reduce the prevalence of hypertension will be integrated into key public recommendations. The program outcomes will be monitored using Statistics Canada national surveys and by specific surveys examining hypertension knowledge in the Canadian population.

Sodium in the Finnish diet: 20-year trends in urinary sodium excretion among the adult population

OBJECTIVE

High sodium intake increases the risk of cardiovascular diseases and may also be associated with higher rates of stomach cancer, asthma disorders and infections. In Finland, cross-sectional population surveys to monitor cardiovascular risk factors have been carried out since the 1970s. The main aim of this paper is to present trends in urinary sodium and potassium excretion from 1979 to 2002.

DESIGN

Cross-sectional population surveys on cardiovascular risk factors.

SETTING

Surveys were carried out in Finland in 1979, 1982, 1987 and 2002 in four geographical areas: North Karelia, the Kuopio area, Southwestern Finland and the Helsinki area.

SUBJECTS

For each survey a random sample stratified by age and sex was drawn from the population register. In this analysis, participants of urine collection subsamples aged 25-64 years (n = 4648) were included.

INTERVENTIONS

A 24-h urinary collection was carried out in subsamples (n = 2218-2487) in connection with population risk factor surveys. Urinary sodium and potassium concentrations were analyzed in the same laboratory throughout, using a flame photometer in 1979, 1982 and 1987 and an ion-selective electrode in 2002.

RESULTS

Between 1979 and 2002 urinary sodium excretion in Finland decreased from over 220 to less than 170 mmol/day among men and from nearly 180 to less than 130 mmol/day among women. Although potassium excretion decreased somewhat as well, the decrease in sodium-potassium molar ratio was also significant.

CONCLUSIONS

The 24-h urinary sodium excretion in Finland has decreased significantly during the last 20 years. However, excretion levels are still considerably higher than recommendations. A further decrease in sodium intake remains a goal for the Finnish food industry and consumers.

SPONSORSHIP

All surveys were funded by the National Public Health Institute in Finland.