Decline in cardiovascular mortality in North Karelia and other parts of Finland

Overview of trends in cardiovascular and diabetes risk factors in Fiji

CONTEXT

Fiji has undergone an epidemiological transition, characterised by declining infectious disease and childhood mortality, that has been offset by rising cardiovascular disease mortality. Other Pacific Island states are in a comparable situation.

OBJECTIVE

With a focus on Fiji, this study reviews and contextualises research performed by the authors and others that examines cardiovascular disease (CVD) and type 2 diabetes (T2DM) and their risk factors in Pacific Island states.

METHODS

This overview covers evidence for the causes and consequences of CVD risk factors and the epidemiological transition and reflects on biological and evolutionary hypotheses. It is based on studies the authors carried out that synthesised disparate population-based CVD risk factor surveys conducted in Fiji over 1980-2012.

RESULTS

Prevalences of obesity, T2DM and hypertension continue to increase in the Fiji population. Tobacco smoking prevalence has decreased, but remains relatively high in men compared to many developed countries. T2DM and hypertension trends, and CVD consequences related to diet, exercise and tobacco smoking, have placed the Fiji population in a variant of the epidemiological transition manifesting as a plateau in life expectancy similar to that of numerous developed countries during the mid-20th century.

CONCLUSION

There is evidence that risk factors and consequent CVD mortality can be reduced in populations. Obesity and T2DM reductions have been observed only in populations surviving in dire circumstances. Interventions to lower the prevalence of CVD and T2DM risk factors in the Fiji population require multi-faceted approaches, with continual monitoring and evaluation for their impact on these risk factors and morbidity and mortality outcomes.

Community-Based Approaches to Health Promotion: Guidelines for Community Mobilization

This article examines the processes of community mobilization for health promotion. First, five community-based health promotion interventions designed to reduce the risk of cardiovascular disease (CVD) are reviewed, with particular attention paid to the processes of community mobilization in these programs. Second, several guidelines for community mobilization for effective health promotion are distilled from the experiences of these programs. The guildelines that are outlined provide a working model for future community-based health promotion interventions. Finally, the limitations of CVD prevention programs are briefly discussed.

Community-wide cardiovascular disease prevention programs and health outcomes in a rural county, 1970-2010

IMPORTANCE

Few comprehensive cardiovascular risk reduction programs, particularly those in rural, low-income communities, have sustained community-wide interventions for more than 10 years and demonstrated the effect of risk factor improvements on reductions in morbidity and mortality.

OBJECTIVE

To document health outcomes associated with an integrated, comprehensive cardiovascular risk reduction program in Franklin County, Maine, a low-income rural community.

DESIGN, SETTING, AND PARTICIPANTS

Forty-year observational study involving residents of Franklin County, Maine, a rural, low-income population of 22,444 in 1970, that used the preceding decade as a baseline and compared Franklin County with other Maine counties and state averages.

INTERVENTIONS

Community-wide programs targeting hypertension, cholesterol, and smoking, as well as diet and physical activity, sponsored by multiple community organizations, including the local hospital and clinicians.

MAIN OUTCOMES AND MEASURES

Resident participation; hypertension and hyperlipidemia detection, treatment, and control; smoking quit rates; hospitalization rates from 1994 through 2006, adjusted for median household income; and mortality rates from 1970 through 2010, adjusted for household income and age.

RESULTS

More than 150,000 individual county resident contacts occurred over 40 years. Over time, as cardiovascular risk factor programs were added, relevant health indicators improved. Hypertension control had an absolute increase of 24.7% (95% CI, 21.6%-27.7%) from 18.3% to 43.0%, from 1975 to 1978; later, elevated cholesterol control had an absolute increase of 28.5% (95% CI, 25.3%-31.6%) from 0.4% to 28.9%, from 1986 to 2010. Smoking quit rates improved from 48.5% to 69.5%, better than state averages (observed - expected [O - E], 11.3%; 95% CI, 5.5%-17.7%; P < .001), 1996-2000; these differences later disappeared when Maine's overall quit rate increased. Franklin County hospitalizations per capita were less than expected for the measured period, 1994-2006 (O - E, -17 discharges/1000 residents; 95% CI -20.1 to -13.9; P < .001). Franklin was the only Maine county with consistently lower adjusted mortality than predicted over the time periods 1970-1989 and 1990-2010 (O - E, -60.4 deaths/100,000; 95% CI, -97.9 to -22.8; P < .001, and -41.6/100,000; 95% CI, -77.3 to -5.8; P = .005, respectively).

CONCLUSIONS AND RELEVANCE

Sustained, community-wide programs targeting cardiovascular risk factors and behavior changes to improve a Maine county's population health were associated with reductions in hospitalization and mortality rates over 40 years, compared with the rest of the state. Further studies are needed to assess the generalizability of such programs to other US county populations, especially rural ones, and to other parts of the world.

Improving allergy management in the primary care network--a holistic approach

The incidence, prevalence and costs of allergy have increased substantially in recent decades in many parts of Europe. The dominant model of allergy care within Europe is at the moment specialist-based. This model will become unsustainable and undeliverable with increasing disease prevalence. One solution to increase provision of allergy services is to diversify the providers. A new model for the provision of allergy care in the community with the general practitioner at the forefront is proposed. Pre- and postgraduate allergy education and training, implementation of pathways of care, allergy specialization and political will to generate resources and support are essential to achieve this new model. In parallel the holistic view of allergic diseases should be maintained, including assessment of severity and risk, psychological factors and health-care related costs in the context of the patient-centered decision making process.

Prehypertension: epidemiology, consequences and treatment

The term prehypertension was coined in 1939 in the context of early studies that linked high blood pressure recorded during physical examination for life insurance purposes to subsequent morbidity and mortality. These studies demonstrated that individuals with blood pressure >120/80 mmHg, but <140/90 mmHg--the accepted value for the lower limit of the hypertensive range--had an increased risk of hypertension, cardiovascular disease and early death from cardiovascular causes. The prehypertension classification of blood pressure was later used by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure to define a group of individuals at increased risk of cardiovascular events because of elevated blood pressure, an increased burden of other risk factors such as obesity, diabetes mellitus, dyslipidemia, and inflammatory markers, and evidence of organ damage for example, microalbuminuria, retinal arteriolar narrowing, increased carotid arterial intima-media thickness, left ventricular hypertrophy and coronary artery disease. Nonpharmacological treatment with lifestyle modifications such as weight loss, dietary modification and increased physical activity is recommended for all patients with prehypertension as these approaches effectively reduce risk of cardiovascular events. Pharmacological therapy is indicated for some patients with prehypertension who have specific comorbidities, including diabetes mellitus, chronic kidney disease and coronary artery disease.

Use of leisure time in cardiovascular patients in Gorgan (south east of Caspian Sea)

The aim of this study was to compare activity patterns and leisure time between matched groups of patients with cardiovascular disease and individuals without a heart disease. The study included 100 patients recruited from those referred to cardiology department of 5th Azar General Hospital of Golestan University of Medical Sciences in Gorgan (South East of Caspian Sea) and 100 matched control subjects during the period 2007-2008. Odds ratios (OR), together with 95% confidence intervals (95% CI), were calculated using logistic regression, as estimates of relative risks. Listening to music OR = 8.800 (95% CI: 2.717-28.499, p<0.05), meditation OR = 6.111 (95% CI; 2.616-14.274, p<0.05) were independent risk factors. Subjects who performed 2 h per week and 2-4 h per week physical activity, the odds ratios were 0.038 (95% CI: 0.012-0.124, p<0.05) and 0.079, (95% CI: 0.024-0.260, p<0.05), respectively. Low physical activity and use of long time relaxation are associated with cardiovascular disease in these patients. Regular participation in physical activity such as walking 2 h per week and 2-4 h per week, are associated with reduced risk of cardiovascular disease. This study suggests the importance of both leisure-time physical activity and sedentary behaviors in the prevention of CVD.

Cardiovascular Health in the Developing World: Community Perceptions from Carriacou, Grenada

BACKGROUND: As developing countries shift to increasing prevalence of cardiovascular risk factors and diseases (CVD), prevention efforts, both primary and secondary, become a public health priority. Designing effective methods requires a clear understanding of local beliefs and practices regarding health risks and behaviors. METHODS: A mixed gender and age team deployed a Rapid Assessment Protocol (participant observation; interviews) over three days. Interviews from 25 residents of Carriacou, Grenada included leaders and community members representing a range of demographic characteristics (gender, age, employment). RESULTS: Residents expressed general uncertainty about their actual health. While acknowledging that certain conditions (e.g. diabetes, hypertension) were prevalent, heredity was viewed as being more strongly associated with CVD. Not being able to work or carry out one's daily activities often drove health care seeking behavior (evaluation, care or initiating lifestyle changes). Health improvement activities when practiced were fragmented, not an overall lifestyle change. Physical activity was implicitly valued but not universally practiced; it declined with age and increasing work and other commitments. CONCLUSIONS: While public health programs benefit from understanding community attitudes and beliefs, research to inform program development is often not undertaken or if undertaken not effectively utilized to make needed program modifications. Key to our conclusions was their perspective on health as illness oriented and reactive, strongly associated with heredity rather than preventive and associated with behavior change. A preventive focus informed by local practices is fundamental to designing effective and sustainable primary and secondary prevention programs and particularly useful in developing countries.

Evaluating the impact of repeated community-wide health surveys on cardiovascular morbidity and mortality in the Busselton population

OBJECTIVE

To evaluate the impact of repeated community-wide mass health examinations on cardiovascular mortality and hospital morbidity trends in Busselton.

METHOD

Population census, hospital admission and death data were used to calculate and compare cardiovascular mortality rates from 1965 to 1998 and hospital morbidity rates from 1971 to 1998 in Busselton residents aged 40 to 84 years with the remainder of the south-west region of Western Australia.

RESULTS

Among men aged 40-69 years, the calendar year trends in standardised cardiovascular mortality and morbidity ratios were relatively flat and non-significant. Among women aged 40-69 years, the mortality ratio declined significantly up to 1989 (p = 0.03) but not over the whole period (p = 0.12), and the downward trend in the morbidity ratio did not reach statistical significance (p = 0.21). Among men aged 70-84 years, both the mortality and morbidity ratios rose significantly over time, whereas among women aged 70-84 years the mortality ratios showed a flat trend and the morbidity ratios a rising trend. These increasing trends were opposite to what was expected if the surveys had a beneficial impact.

CONCLUSION

This analysis of trends, while failing to demonstrate a clear benefit of repeated mass health screenings on cardiovascular event rates, also highlights the difficulties in evaluating the longer-term impact on event rates of such programs and suggests that negative conclusions should be made with caution.

The challenge of preventing cardiovascular disease in Tunisia

Chronic disease, and particularly cardiovascular disease (CVD), is the major cause of death in most developed countries, despite the downward trend observed during the last three decades. Although CVD is emerging in developing countries, little is known there about comprehensive preventive measures for controlling its expansion. The health care system in Tunisia faces the challenge of increasing rates of CVD risk factors. Epidemiologic studies show high levels of CVD risk factors among Tunisian adults and children. Evidence shows that several risk factors and conditions are commonly associated with major chronic diseases. Integrated actions against selected risk factors (i.e., smoking, physical inactivity, and unhealthy diet), implemented within the social context, can lead to the reduction of major chronic diseases. These interventions should take place early in childhood. In Tunisia, a much-needed community-based intervention program to control CVD is being planned. This program will promote healthy living, smoke-free air, healthy nutrition, regular physical activity, and supportive living and working environments. Its ultimate goal is to reduce the burden of CVD and its related behaviors. A description of this program and how it will be implemented and assessed in the region of Sousse, Tunisia, is presented.

The renin angiotensin system as a therapeutic target to prevent diabetes and its complications

The role of the RAAS in development and maintenance of blood pressure is well established. In addition, the deleterious effects of angiotensin II on the heart, vasculature, and kidneys have been clearly defined. There seems to be a close relationship between endothelial dysfunction, insulin resistance (a precursor to diabetes and coronary artery disease) and angiotensin II. The signaling pathways for insulin in the vascular wall interacts with the angiotensin signaling, giving rise to potential mechanisms for development of diabetes and resulting harmful effects. A large number of clinical trials using ACE inhibitors or ARBs have shown significant reduction in secondary endpoints in the development of new onset of diabetes. Ongoing prospective studies involving ARBs (eg, the Nateglinide and Valsartan Impaired Glucose Tolerance Outcomes Research trial) and ACE inhibitors (eg, the Diabetes Re-duction Assessment with Ramipril and Rosiglita-zone Medication trial) are testing the ability of certain agents to prevent type 2 diabetes. In the meantime, it is important to recognize insulin resistance and metabolic syndrome as entities that increase the risk for cardiovascular disease. In addition to lifestyle modifications, managing endothelial dysfunction and protecting the vasculature will help prevent diabetes and cardiovascular disease.

Tracking of systolic blood pressure during childhood: a 15-year follow-up population-based family study in eastern Finland

OBJECTIVES

To investigate the tracking of systolic arterial blood pressure (SBP) during childhood.

DESIGN AND SETTING

All children born during 1981-82 in a rural community of eastern Finland were followed at the ages of 6 months, 7 and 15 years (SBP-6m, SBP-7y, SBP-15y). One hundred and thirty-eight out of 205 children completed the full follow-up period, of which 100 (45 girls) were included in the analysis with complete data.

MAIN OUTCOME MEASURES

SBP (mmHg).

RESULTS

SBP-6m was associated with SBP-7y (r = 0.715; P < 0.001) and with SBP-15y (r = 0.238; P = 0.017) and SBP-7y was associated with SBP-15y (r = 0.348; P < 0.001). Adjustment for confounders did not change these results. Children at the highest tertile of SBP-6m had a higher probability of being at the highest tertile of SBP-7y [relative risk (RR) = 4.3; 95% confidence interval (CI), (2.4-7.6)] and SBP-15y [RR = 1.9; 95% CI, (1.1-3.3)]. Children at the highest tertile of SBP-7y had a higher probability of being at the highest tertile of SBP-15y [RR = 2.6 (1.5-4.6)]. The regression analysis showed a significant main effect on SBP-15y for birth weight (negative association), male gender, current body mass index (BMI), change of BMI between the ages of 7 years and 15 years, SBP-6m, SBP-7y and the mean SBP between the ages of 6 months and 7 years (all with positive association). Children with family history of hypertension appear to have a higher SBP during childhood; however, this association did not reach a significant level.

CONCLUSIONS

The study confirmed the tracking of SBP during childhood. Birth weight was inversely associated with SBP-15y. Family history of hypertension was not significantly associated with SBP during childhood.

Review and analysis of evaluation measures used in nutrition education intervention research

The purpose of this review is to provide a summary of the kinds of evaluation measures used in 265 nutrition education intervention studies conducted between 1980 and 1999 and an analysis of psychometric issues arising from such a review. The data are summarized in terms of tables for interventions with each of six key population groups: preschool children, school-aged children, adults, pregnant women and breast-feeding promotion, older adults, and inservice preparation of professionals and paraprofessionals. Measures evaluating knowledge and skills or behavioral capabilities were most widely used in studies with preschool, school-aged, and inservice populations (50%-85%) and less widely used in studies with the other groups, particularly breast-feeding promotion (5%). Measures of potential psychosocial mediators or correlates of behavior such as outcome expectancies, self-efficacy, or behavioral intention were used in 90% of behaviorally focused studies with school-aged children and in about 20% of studies with adults. Dietary intake measures were used in almost all studies, primarily food recalls, records, and quantitative food frequency questionnaires. Short frequency instruments involving only foods targeted in the intervention such as fruits and vegetables are increasingly being used. Measures of specific observable behaviors are also increasingly being used. Physiologic parameters were used in about 33% of behaviorally focused interventions with school-aged children and adults, 20% with older adults, and 65% with pregnant women and/or their infants. Criterion validity of newly developed intake instruments and content validity of instruments measuring mediating variables were reported in the majority (range 50%-90%) of studies. Reliability and stability of measures of mediating variables were reported in 50% to 75% of studies, with reliability coefficients mostly about .6 to .7. Two major conclusions from this review are that evaluation measures should be appropriate to the purpose, duration, and power of the intervention and that measures should have adequate validity and reliability in relation to both the outcomes and characteristics of the target audience. Major implications are that considerable preliminary work needs to be done before any intervention study to develop and test evaluation instruments so that they are appropriate and have adequate psychometric properties, and cognitive testing of published instruments with each new target audience is essential. We will then be better able to make judgments about the effectiveness of nutrition education.

Evaluation of "Live for Life", a health promotion programme in the County of Skaraborg, Sweden

STUDY OBJECTIVE

To evaluate a health promotion programme, combining a population and individual based strategy, in the County of Skaraborg, Sweden, with special attention to outcome.

DESIGN

The evaluation was subdivided into structure, process and outcome. The evaluation procedure as a total is described here, but the results presented refer only to outcome. In order to study the potential effect of the individually based health examination, 35 year old subjects who had participated five years previously were in 1994-1996 compared with 35 year old subjects who had not participated before, and compared with their own values five years earlier. The results during 1995-1996 were compared with those of 1989-1990 for corresponding ages in order to study the effect of, particularly, the population based strategy.

SETTING

The County of Skaraborg in the south western part of Sweden with about 270 000 inhabitants. In addition to population strategy, involving the total county, men and women aged 30 and 35 years were invited to an individually based examination.

MAIN RESULTS

Factors related to body weight increased during the study period, while other factors mostly changed in the direction wanted. As a whole the changes were rather modest. There were favourable changes in lifestyle variables, for example, concerning smoking and dietary habits.

CONCLUSIONS

There were beneficial effects from the health promotion programme, but there is a need for continuous improvement of methods of intervention referred to lifestyle.

What is the "golden standard" for assessing population-based interventions?--problems of dilution bias

OBJECTIVES

To identify different types of dilution bias in population-based interventions and to suggest measures for handling these methodological problems.

DESIGN

Literature review plus analysis of data from a population-based intervention against cardiovascular disease in a Swedish municipality.

MAIN RESULTS

The effects of an intervention on mortality and morbidity were much more diluted by non-intervening factors, dissemination to areas outside the intervention area, social diffusion, population mobility and time than by using intermediate outcome measures.

CONCLUSIONS

Theoretically, changes in scientifically well documented risk factors, for example, intermediate outcome measures, should be preferred to using morbidity or mortality as outcome measures.

Mortality impact of an integrated community cardiovascular health program

BACKGROUND

Preventing cardiovascular disease through community interventions makes theoretical sense but has been difficult to demonstrate. We set out to determine whether a community cardiovascular health program had an impact on mortality.

DESIGN

Program evaluation plus ecologic observational analysis of program encounters and mortality rates with external comparisons.

SETTING

Franklin County and two comparison counties in rural Maine.

PARTICIPANTS

Program encountered >50% of regional adults, broadly distributed by site, gender, and age.

INTERVENTIONS

From 1974 to 1994, a community program, integrated with primary medical care and staffed by professional nurses, provided education, screening, counseling, referral, tracking, and follow-up for cardiovascular risk factors.

MAIN OUTCOME MEASURES

Age-adjusted mortality rates (total, heart, coronary, cerebrovascular, cancer) for three counties and Maine, plus annual program encounters.

RESULTS

Relative to Maine, the Franklin heart disease death rate was 0.97 at baseline (1960-1969; 95% confidence interval, 0.91 to 1.03), 0.91 during the program (0.85 to 0.97), 0.83 during the 11 years of program growth (0.78 to 0.88), but 1.0 during the 10 years of decreasing encounters. Franklin's total death rate was 1.01 at baseline, 0.95 during the program (0.92 to 0.98), and 0.90 during program growth (0.86 to 0. 94). Results were similar for coronary disease, stroke, and cancer. Relative death rates did not fall in either comparison county. Nurse-client encounters totaled 120,280 over 21 years. Relative to Maine, heart disease death rates correlated inversely with program encounters (r = -0.53) but not with unemployment or physician supply.

CONCLUSIONS

Integrated with primary medical care, a comprehensive, nurse-mediated community cardiovascular health program in rural Maine has been associated with significant time-dependent and dose-dependent reductions in cardiovascular and total mortality.

Public health burden of coronary heart disease risk factors among middle-aged and elderly men

BACKGROUND

An epidemiological evidence shows that smoking, high total cholesterol, hypertension, overweight, and a low level of physical activity are significant risk factors for coronary heart disease mortality. Therefore, by turning these risk factors in a healthier direction, presumably a substantial proportion of the deaths would be preventable.

METHODS

The avoidable proportion of coronary heart disease deaths associated with smoking, a high level of total cholesterol, systolic hypertension, overweight, and a low level of leisure-time physical activity was assessed with the use of the population attributable risks for initially 30- to 63-year-old Finnish men (six studies with 1,340-7,928 subjects) who were followed up from 7 to 30 years.

RESULTS

The theoretical estimates of population at tributable risks derived from published studies were as follows: smoking 10 to 33%; high total cholesterol 9 to 21%; hypertension 6 to 15%; overweight 3 to 6%; and low level of leisure-time physical activity 22 to 39%.

CONCLUSIONS

These estimations, based on observed mortality rates and risk factor prevalences, suggest that, even if modest estimates are used, the burden from coronary heart disease deaths can be substantially reduced by converting the risk factors to more healthful levels. The results also suggest that efforts to increase physical activity deserve as much consideration as those aimed at influencing more traditional risk factors.

The validity of the routine mortality statistics on coronary heart disease in Finland: comparison with the FINMONICA MI register data for the years 1983-1992. Finnish multinational MONItoring of trends and determinants in CArdiovascular disease

We compared the diagnoses obtained from the routine mortality statistics with the standardized World Health Organization (WHO) MONICA (multinational MONItoring of trends and determinants in CArdiovascular disease) classification in suspect coronary heart disease (CHD) deaths registered in the FINMONICA myocardial infarction (MI) register during 1983-1992. All CHD deaths from routine mortality statistics (International Classification of Diseases codes 410-414) were registered in the MI register. Of the CHD deaths in routine mortality statistics 1.7% in men and 4.8% in women did not fulfill the MONICA criteria for CHD death (P<0.001 for the difference between the sexes). In men 4.7% and in women 7.3% (P=0.004) of the deaths registered in the MI Register and classified as CHD deaths by MONICA criteria had another underlying cause of death than CHD in routine mortality statistics; this proportion increased over time in both sexes (P=0.002 in men and P=0.77 in women). The CHD mortality trends obtained separately from the routine mortality statistics and from the FINMONICA MI Register were very similar. In conclusion, the high CHD mortality in Finland reported by the routine mortality statistics is real. It is possible that some CHD deaths have escaped registration, but the decline seen in the CHD mortality is also real.

Effects of a long-term hypertension control program on stroke incidence and prevalence in a rural community in northeastern Japan

BACKGROUND AND PURPOSE

Although randomized clinical trials have demonstrated the benefit of antihypertensive treatment in preventing stroke, the effectiveness of community-based programs is largely unknown. We investigated long-term community-based prevention activities.

METHODS

In rural northeastern Japan, people aged > or = 30 years numbered 3219 in the full intervention community and 1468 in the minimal intervention community in 1965. Systematic blood pressure screening and health education began in 1963. Stroke was registered through 1987.

RESULTS

More than 80% of people aged 40 to 69 years were screened in both communities in the 1960s. One community charged for screening services after 1968, whereas the other community intensified intervention; subsequently, screening rates and the follow-up of hypertensive individuals declined in the minimal intervention community, especially in men. In men, stroke incidence declined more (P < 0.001) in the full intervention (42% in the period 1970 to 1975, 53% in the period 1976 to 1981, and 75% in the period 1982 to 1987) than in the minimal intervention community (5% increase, 20% decrease, and 29% decrease, respectively); in women, the stroke incidence declined about 45% to 65% in both communities. Changes in stroke prevalence paralleled those in stroke incidence. Trends in systolic blood pressure levels tend to explain the differential stroke rates in men.

CONCLUSIONS

Delivery of hypertension control services through intensive, free, community-wide screening and health education was effective in prevention of stroke for men in a community.

Position of the American Dietetic Association: nutrition education for the public

In keeping with the ADA's mission, which is to be "the advocate of the dietetics professional serving the public through the promotion of optimal nutrition, health and well-being," ADA supports nutrition education delivered by qualified dietetics professionals as essential for the public to achieve and maintain optimal nutritional health. Nutrition education serves as a foundation for achieving notable advances in the nutritional status of the public. To be effective in creating actual behavior change, nutrition education programs must be developed on the basis of the needs, behaviors, motivations, and desires of target audiences. A wide variety of strategies have been identified as effective in helping to increase awareness, enhance motivation, and foster and sustain behavior change. A multiple reinforcing strategy, by which consumers are repeatedly reached with consistent messages, may support individual nutrition education efforts best. It is clear that more research is necessary to identify the needs, behaviors, motivations, and desires of target audiences. Developing and testing cost-effective methods for evaluating the effectiveness of nutrition education programs along with comparative models to investigate the effectiveness of alternative educational interventions are also needed. Practitioner involvement in nutrition education research is vital to gain maximum benefit.

Coeur en santé St-Henri--a heart health promotion programme in a low income, low education neighbourhood in Montreal, Canada: theoretical model and early field experience

STUDY OBJECTIVE

Coeur en santé St-Henri is a five year, community based, multifactorial, heart health promotion programme in a low income, low education neighbourhood in Montreal, Canada. The objectives of this programme are to improve heart-healthy behaviours among adults of St-Henri. This paper describes the theoretical model underlying programme development as well as our early field experience implementing interventions.

DESIGN

The design of the intervention programme is based on a behaviour change model adapted from social learning theory, the reasoned action model, and the precede-proceed model. The Ottawa charter for health promotion provided the framework for the development of specific interventions. Each intervention is submitted to formative, implementation, and impact evaluations using simple and inexpensive methods.

PARTICIPANTS

The target population consists of adults living in St-Henri, a neighbourhood of 23,360 residents. Because of costs constraints, the intervention strategy targets women more specifically. The community is one of the poorest in Canada with 46% of the population living below the poverty line and 20% being very poor. The age-sex adjusted ischaemic heart disease mortality in 1985-87 was 317 per 100,000 compared with 126 per 100,000 in an affluent adjacent neighbourhood.

RESULTS

Thirty nine distinct interventions have been developed and tested in the community, eight related to tobacco, 10 to diet, seven to physical activity, and 14 which are multifactorial. The interventions include smoking cessation and healthy recipes contests, a menu labelling and healthy food discount programme in restaurants, a point of choice nutrition education campaign, healthy eating and smoking cessation workshops, a walking club, educational material, print and electronic media campaigns, heart health fairs, and community events.

CONCLUSION

An integrated heart health promotion programme is feasible in low income urban neighbourhoods but not all interventions are successful. Such a programme requires substantial energy and resources as well as long term commitment from public health departments.

Declining trends in incidence, case-fatality and mortality of stroke in three geographic areas of Finland during 1983-1989. Results from the FINMONICA stroke register

Stroke mortality has decreased during the last decade in many industrialized countries, but there has been no clear evidence for a decline in the incidence of stroke. The present study analyzes the trends in the incidence, mortality and case-fatality of stroke in Finland from 1983 to 1989. We used data from the FINMONICA stroke register, a community based register collecting information on all suspected stroke cases aged 25-74 in three geographical areas of Finland. Annual attack rate, incidence, mortality and case-fatality rates were calculated for all strokes and for different subcategories of stroke. A linear regression model was applied to calculate the yearly trends of these rates. In men, the attack rate of stroke was 336/100,000 in 1983 and 310/100,000 in 1989 (-8% during the observation period); incidence declined from 269/100,000 in 1983 to 236/100,000 in 1989 (-12%); mortality declined from 82/100,000 to 64/100,000 (-22%), and case-fatality declined from 25% to 21% (-18%). Also among women similar declining trends were observed (-11%, -13%, -16%, and -10% respectively), but they were not statistically significant. In both incidence and mortality of stroke, the decline was seen in all age groups. Incidence and mortality of cerebral infarction declined similarly to all strokes. A large fall in the incidence (-24% in both men and women) and mortality (-38% in men and -27% in women) of subarachnoid haemorrhage was also observed. An increasing trend, although not significant, was instead observed for cerebral haemorrhage. First stroke and especially first cerebral infarction contributed most to the decline in case-fatality. The availability of computerized brain tomography improved from 18% in 1983 to 60% in 1989. We observed a fall in the incidence, mortality, and case-fatality of stroke during 1983-1989. Among the subtypes of stroke, cerebral infarction contributed most to the decline, but the data suggested also a declining trend in the incidence and mortality of subarachnoid haemorrhage, observed now for the first time in Finland since the 1960s. The fall in the incidence of stroke was not as steep during the 1980s as it was during the 1970s; Finland is anyhow the only European country which has reported a decreasing trend in stroke incidence during the 1980s. We need now to investigate how much the decline in the classical risk factors for stroke observed in Finland during the last two decades predicts the observed trends.

Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland

OBJECTIVES

To estimate the extent to which changes in the main coronary risk factors (serum cholesterol concentration, blood pressure, and smoking) explain the decline in mortality from ischaemic heart disease and to evaluate the relative importance of change in each of these risk factors.

DESIGN

Predicted changes in ischaemic heart disease mortality were calculated by a logistic regression model using the risk factor levels assessed by cross sectional population surveys, in 1972, 1977, 1982, 1987, and 1992. These predicted changes were compared with observed changes in mortality statistics.

SETTING

North Karelia and Kuopio provinces, Finland.

SUBJECTS

14,257 men and 14,786 women aged 30-59 randomly selected from the national population register.

MAIN OUTCOME MEASURES

Levels of the risk factors and predicted and observed changes in mortality from ischaemic heart disease.

RESULTS

The observed changes in the risk factors in the population from 1972 to 1992 predicted a decline in mortality from ischaemic heart disease of 44% (95% confidence interval 37% to 50%) in men and 49% (37% to 59%) in women. The observed decline was 55% (51% to 58%) and 68% (61 to 74) respectively.

CONCLUSION

An assessment of the data on the risk factors for ischaemic heart disease and mortality suggests that most of the decline in mortality from ischaemic heart disease can be explained by changes in the three main coronary risk factors.

Stroke mortality and case-fatality rates in three geographic areas of Finland from 1983 to 1986

BACKGROUND AND PURPOSE

Our aim was to describe the mortality and early case-fatality rates of stroke in three geographic areas of Finland during 1983 to 1986 by means of a community-based stroke register and to estimate the accuracy of registration of stroke deaths in the official statistics compared with the FINMONICA stroke register.

METHODS

Annual and average mortality and case-fatality rates of stroke were derived from data collected in the FINMONICA stroke register during 1983 to 1986. Age-specific and age-standardized rates were calculated for the three areas, and the results were compared with the official mortality statistics and with the case-fatality figures published previously in the literature for Finland and elsewhere.

RESULTS

Mortality from stroke in the three FINMONICA areas was between 73 and 90 per 100,000 per year among men aged 25 to 74 years and between 42 and 55 per 100,000 per year among women in the same age group. Average case-fatality was similar in the three areas and globally high: 20% to 27% in men and 24% to 28% in women. Approximately half of the fatal strokes occurred within less than 2 days from the onset of the attack, and a further 25% within the first week. Hemorrhagic strokes accounted for 54% to 81% of all fatal strokes occurring in less than 2 days among men, while among women the corresponding proportions varied in the three areas between 35% and 74%. Of cerebral infarctions, approximately 28% to 37% among men and 19% to 20% among women were fatal within less than 2 days. Although the number of fatal strokes was similar in both the FINMONICA register and official mortality statistics, only 82% to 85% of the stroke cases were common in both registers; a further 13% to 14% of the cases classified as stroke deaths in the FINMONICA register could also be found in the official mortality statistics, but the underlying cause of death was something other than stroke.

CONCLUSIONS

The reliability of the Finnish official mortality statistics with regard to stroke deaths is reasonably good in aggregate numbers, but at the individual level considerable discrepancies seem to occur. Mortality from stroke in Finland has not declined further after 1979 and remains high internationally. Early case-fatality of stroke also seems higher in Finland than in most other countries. We believe that both the high incidence of stroke and the severity of the attacks are contributing to mortality and case-fatality rates of stroke in Finland.

The prevalence of macrovascular disease and lipid abnormalities amongst diabetic patients in Sri Lanka

The prevalence of macrovascular disease and hyperlipidaemia was examined in 500 patients with non-insulin-dependent diabetes mellitus attending a diabetic clinic in a Sri Lankan teaching hospital and 250 controls matched for age and gender. Macrovascular disease was assessed using a modified World Health Organisation questionnaire and modified Minnesota coding of electrocardiogram recordings. Twenty-one per cent of diabetic patients and 14.3% of controls had hypercholesterolaemia (P < 0.05). Macrovascular disease was present in 13.4% of diabetic patients and 8.2% of controls. Significant differences were seen in the prevalence of hypertension (15.6% vs 4.8%, P < 0.05), obesity (16.2% vs 9.7%, P < 0.05), peripheral vascular disease (5.6% vs 2%, P < 0.05) and electrocardiographic abnormalities (12% vs 6%, P < 0.05) in diabetic patients when compared to controls. Hyperlipidaemia and macrovascular disease is common in non-insulin-dependent diabetic patients in Sri Lanka and accounts for significant morbidity.

The epidemic cycle of Chlamydia pneumoniae infection in eastern Finland, 1972-1987

The epidemic cycle of Chlamydia pneumoniae infection was examined in two areas in eastern Finland over a period of 15 years, 1972-87. The C. pneumoniae IgG antibody prevalence was determined with 5-year intervals in a random sample of the population aged 25-59 years. The total number of sera studied using immunofluorescence was 2387. In 1972 the antibody prevalence was 57% and it increased to 66% in 1977. Over the next 5 years the prevalence decreased to 44% in 1982, but by 1987 it had again increased to 59%. The temporal variation in prevalence was statistically significant (P < 0.001) and similar for both genders. Throughout the observation period the overall prevalence was 7-11% higher in men than in women (P < 0.01). The antibody prevalence increased with age, being the highest among the oldest study subjects of both genders. The periods of high and low prevalence alternated in an epidemic cycle (P < 0.001) of about 10 years.

Multiple cardiovascular disease risk factors in Canadian adults. Canadian Heart Health Surveys Research Group

OBJECTIVE

To estimate the prevalence and distribution of the coexistence of major cardiovascular disease (CVD) risk factors among Canadian adults.

DESIGN

Population-based cross-sectional surveys.

SETTING

Nine Canadian provinces, from 1986 to 1990.

PARTICIPANTS

A probability sample of 26,293 men and women, aged 18 to 74 years, was selected from provincial health insurance registries. For 20,582 of these participants, at least two blood pressure (BP) measurements were taken using a standardized technique. At a subsequent visit to a clinic, two additional BP readings, anthropometric measurements and a blood specimen for plasma lipid analysis were obtained.

OUTCOME MEASURES

The percentage distribution of subjects by number of major risk factors (smoking, high BP and elevated blood cholesterol level) and by concomitant factors (body mass index [BMI], ratio of waist to hip circumference [WHR], physical activity, diabetes, awareness of CVD risk factors and education).

MAIN RESULTS

Sixty-four percent of men and 63% of women had one or more of the major risk factors. Prevalence increased with age to reach 80% in men and 89% in women aged 65 to 74 years. Prevalence of two or three risk factors was highest among men in the 45-54 age group (34%) and in women in the 65-74 age group (37%). The most common associations were between smoking and high blood cholesterol level (10%) and between high BP and high blood cholesterol level (8%). Prevalence of high BP and elevated blood cholesterol, alone or in combination, increased with BMI and WHR. Smoking, elevated blood cholesterol, BMI and prevalence of one or more risk factors increased with lower level of education. Less than 48% of participants mentioned any single major risk factor as a cause of heart disease. Awareness was lowest in the group with fewest years of education.

CONCLUSION

The findings of this study call for an approach to reduce CVD that stresses collaboration of the different health sectors to reach both the population as a whole and the individuals at high risk.

Mortality from ischemic heart disease in Iceland, 1951-1985

The objective of this study was to evaluate mortality rates from ischemic heart disease among Icelanders during the period of 1951 to 1985. In some developed countries, the number of deaths from ischemic heart disease declined markedly in this time period, and it is interesting to study whether the same has occurred in Iceland. The study was based on information obtained from the Statistical Bureau of Iceland, which keeps records of deaths based on death certificates as well as other population records. Nonparametric tests were used to correlate death rates and calendar years. Rates per 100,000 were calculated and plotted. The results indicated that the mortality rates from ischemic heart disease among Icelanders have not yet peaked.

The role of cold in ischaemic heart disease: a review

A review of the literature suggests that the geographical and social class distribution of ischaemic heart disease (IHD) could be partly explained by variations in degrees of cold exposure, which includes wind and rain as well as temperature, with frequent exposure to cold being more harmful than steady exposure. Blood pressure (BP) and serum cholesterol are raised in response to acute and chronic exposure to cold. Smoking and cold produce similar physiological changes which increase the risk of IHD, while regular exercise blunts the physiological effects of cold and other stresses. There are many acute responses to cold which could trigger a myocardial infarction (MI) and therefore cold is probably a major precipitating factor in many cases of MI. Public health measures to improve domestic housing and the working environment may produce a significant impact on the incidence of IHD.

The Minnesota Heart Health Program. Education for youth and parents

Within the Minnesota Heart Health Program, all schools have participated in these programs and most have been incorporated as part of the regular school curriculum. The involvement of parents in youth programs has been challenging, but we view it as essential to making significant changes. Further, a program with appropriate underlying behavioral theory and community involvement can be successful. Such efforts seem critical to primary prevention of cardiovascular disease risk and subsequent disease in a culture where these diseases are common.

Cholesterol: should we screen all children or change the diet of all children

Hypercholesterolaemia is a major risk factor for coronary heart disease and may present during childhood. Dietary measures can reduce plasma cholesterol and may thus delay or prevent the development of the atherosclerotic process. Although plasma cholesterol concentrations measured during childhood track into adult life with a correlation coefficient of about 0.6 this in itself is insufficient to justify total population screening of children especially as the mechanisms for management and follow-up and their social, psychological and economic implications have not been adequately evaluated. Targeted screening of children in families with the genetic disorder of familial hypercholesterolaemia, where the risk of premature coronary heart disease is very high, should, however, be undertaken even though such screening may only identify half of all affected children. Dietary change designed to lower plasma cholesterol can be applied to the whole population including children over the age of 2 years, does not require pre-determination of plasma cholesterol, and is to be recommended. The effects of such change on the growth and health of children should be monitored.

The Kilkenny Health Project: a community research and demonstration cardiovascular health programme

Ireland has one of the highest death rates in the world from coronary heart disease (CHD) and has not shared in the rapid decline in mortality which has occurred in other countries. The Kilkenny Health Project was established as a community-based research and demonstration programme for cardiovascular disease prevention in County Kilkenny and as a pilot project for future national initiatives. The first phase of the health promotion programme in Kilkenny is being carried out between 1985 and 1990. Changes in behaviour and in factors associated with CHD will be estimated by the difference in changes over time between Kilkenny and the reference area, as measured by independent random sample surveys of men and women aged 35 to 64 years. CHD and stroke events, fatal and non-fatal, will be registered in both areas from 1987-1992. The Project has studied attitudes to CHD and its prevention. Health behaviours have been studied in adults and in post-primary school pupils. Risk factors for CHD have been measured in adults in accordance with the methods of the international MONICA Project. It has been demonstrated that health and education professionals can incorporate preventive activities and health education into everyday practice.

Evaluating South Carolina's community cardiovascular disease prevention project

A community cardiovascular disease prevention program was undertaken as a cooperative effort of the South Carolina Department of Health and Environmental Control and the Centers for Disease Control of the Public Health Service. As part of the evaluation of the project, a large scale community health survey was conducted by the State and Federal agencies. The successful design and implementation of the survey, which included telephone and in-home interviews as well as clinical assessments of participants, is described. Interview response rates were adequate, although physical assessments were completed on only 61 percent of those interviewed. Households without telephones were difficult and costly to identify, and young adults were difficult to locate for survey participation. The survey produced baseline data for program planning and for measuring the success of ongoing intervention efforts. Survey data also have been used to estimate the prevalence of selected cardiovascular disease risk factors.

Mortality, cardiovascular risk factors, and diet in China, Finland, and the United States

Mortality, cardiovascular risk factors, and diet were compared in Tianjin province, People's Republic of China; in North Karelia Province, Finland; and in the United States as a whole. People in Tianjin received 7 percent of their energy intake from saturated fats, whereas people in the United States received 13 percent and those in North Karelia received 20. The mean blood cholesterol levels for men were 158 milligrams per deciliter (mg per dl) for Tianjin, 216 mg per dl for the United States, and 241 mg per dl for North Karelia. The smoking prevalence among men was highest in Tianjin (66 percent), followed by the United States (42 percent) and Finland (36 percent). The differences among mortality rates for the three locales were less pronounced among women than among men. Age-standardized total mortality for women was highest for Tianjin and lowest in North Karelia. The reverse was true for men. Age-standardized total mortality for men was lowest in Tianjin and highest in North Karelia. Age-standardized ischemic heart disease mortality for men was lowest in Tianjin (99 per 100,000) and highest in North Karelia (730 per 100,000). For women, the corresponding figures were 83 per 100,000 in Tianjin and 164 per 100,000 in North Karelia. Although salt intake was higher in Tianjin than in North Karelia, the blood pressure was on average lower in persons from Tianjin than in those from North Karelia. The stroke mortality rate in Tianjin, however, was much higher than in either Finland or the United States. The strong discrepancy in stroke mortality relative to prevalence of hypertension and salt intake raises the issue of the etiology of stroke in Tianjin. Recently it has been reported that hemorrhagic stroke may be more common among people whose blood cholesterol level is very low and blood pressure level high. This joint condition may be relatively common in Tianjin and calls for longitudinal and case-control studies to clarify the relationships among these factors in Tianjin.

Survival following stroke. A prospective population-based study of 438 hospitalized cases with prediction according to subtype, severity and age

In a prospective population-based study analyses were performed to estimate the survival prognosis following stroke, in relation to age of the patient as well as to subtype, severity and occurrence of the stroke diagnosis. The statistical technique of stepwise regression analysis was used to discriminate the isolated importance of these factors on survival outcome. A total of 438 patients, consecutively admitted to the Department of Neurology during the period Feb. 1st 1986-September 30th 1987 were followed 15 days, 3, 6, and 12 months after the acute stroke. The one-year survival rate was 75% compared with 93% for a control group matched for age, sex, residence and calendar year. Mortality after stroke occurred predominantly within the first 3 months, after 3 months survival prognosis was no different from that of the general population. Statistical analysis identified 2 factors that gave significant isolated prediction on survival outcome. These factors were in order of importance age and severity of stroke diagnosis, whereas sex, subtype and occurrence of stroke were of no discriminative value.

Relation between leisure time exercise and cardiovascular risk factors among 15-year-olds in eastern Finland

STUDY OBJECTIVE

To examine the associations between frequency of leisure time exercise and cardiovascular risk factors in adolescents.

DESIGN

Cross sectional survey carried out over a 3 month period in 1984.

SETTING

All 24 schools in North Karelia province and 16 randomly selected schools in Kuopio province.

PARTICIPANTS

A total of 1142 boys and girls aged 15, randomly selected from 40 schools (16 boys and 16 girls from each), participated out of a possible total sample of 1280. Main reason for non-participation was absence from school but a small number refused to participate.

MEASUREMENTS AND MAIN RESULTS

The investigation comprised a medical examination, including anthropometry, a self administered questionnaire checked by interview, a parental questionnaire, and a blood sample for biochemical estimations. The main findings were: (1) Leisure time exercise was inversely related to daily smoking (Spearman's rho, boys -0.16, p less than 0.01; girls -0.13, p less than 0.01) but was not related to serum lipoproteins or blood pressure. The inverse association between exercise and smoking was independent of socioeconomic family background. (2) Body mass index and sexual maturation were associated with systolic blood pressure, and among boys they were inversely related to high density lipoprotein cholesterol. (3) The lack of linear trends between exercise and biological risk factors may be explained by the high prevalence of leisure time exercise in the sample (72% of boys and 71% of girls exercised at least 2-3 times per week, in addition to physical education classes at school).

CONCLUSIONS

Among 15-year-old eastern Finnish boys and girls, leisure time exercise is favourably associated with the main behavioural cardiovascular risk factor, smoking, but not with serum total cholesterol or blood pressure.

Diabetes mellitus as a risk factor for acute myocardial infarction in Asians and Europeans

Ischaemic heart disease is commoner among immigrants from the Indian subcontinent than among Europeans in the United Kingdom. The excess cannot be accounted for by differences in smoking, blood pressure, or lipid concentrations. There is, however, an increased prevalence of diabetes mellitus in the Asian population. Separate estimates of the relative risk of acute myocardial infarction associated with diabetes from parallel case-control studies were made to compare the importance of diabetes as a risk factor in the two ethnic groups. For Asians the relative risk was 3.3 (95% confidence interval 1.9 to 5.8) and for Europeans 1.3 (1.0 to 1.7). Calculations of population attributable risk indicated that clinical diabetes mellitus accounts for 21% of the incidence of myocardial infarction in Asians but only 3% of the incidence in Europeans. Diabetes mellitus is of sufficient quantitative importance as a risk factor to account for the whole of the observed excess of deaths from ischaemic heart disease among Asians in the United Kingdom.

Epidemiology of coronary arterial disease in the Chinese

The occurrence of coronary arterial disease and, in particular, acute myocardial infarction in three Chinese communities, namely Hong Kong, Taiwan and China, was reviewed by using a multifaceted approach. Both the prevalence and death incidence of coronary arterial disease or acute myocardial infarction were much lower than those in most western countries: in these three places, the prevalence of coronary arterial disease, the incidence of mortality from coronary arterial disease, the incidence of acute myocardial infarction and the mortality from acute myocardial infarction were roughly one-eighth to one-quarter of the average western figures. While the prevalence and mortality figures have been declining in most affluent western countries, they have been increasing in these three large Chinese communities with 1200 million people. The implication of this increasing trend should certainly deserve more consideration in future planning in these regions. While aging is a contributing factor to such a trend, more work is required to delineate and assess the relative significance of the changes in the socioeconomic and coronary risk factors in the process of modernisation.

Coronary risk factor prevalence in a high incidence area: results from the Belfast MONICA Project

Northern Ireland remains at the top of the world mortality league for ischaemic heart disease. The Province is providing a centre for the World Health Organisation's MONICA Project. Registration of coronary heart disease events began in 1983 and the first of three population surveys took place in 1983-4. A total of 2,361 men and women aged 25-64 years was screened. Subjects were shorter and heavier than their fellow citizens in Great Britain. The estimated mean cholesterol levels in the 25-64-year-old population (5.80 mmol/l in males and 5.85 mmol/l in females) were similar to those reported from Great Britain. Although mean systolic blood pressures were lower, mild diastolic hypertension was considerably more common; cigarette smoking levels were similar. The results were consistent with those expected for an area with a high coronary heart disease mortality, with more than 80% of subjects being at increased risk in terms of the three major factors (cigarette smoking, hypertension and raised cholesterol). Public concern about coronary heart disease has grown and recently the Department of Health and Social Services (NI) has launched a 10-year prevention programme which will primarily employ a population approach.

Prevention of cardiovascular disease by psychological methods

It is generally recognised that much cardiovascular disease is the result of voluntary behaviour such as smoking cigarettes, and the pursuit of stress-prone lifestyles. Since these risks are primarily behavioural, it is appropriate to attempt to alter them, and hence reduce the risk of cardiovascular disease, using psychological methods, and such methods can reduce both biological and psychological stress-related factors. Studies of healthy populations, of those at increased risk, and of patients with clear cardiovascular disease have all shown that risk-related behaviour can be altered and, in some cases, the incidence of cardiovascular disease reduced. Future research will have to extend these findings, which were often on atypical populations, and confirm reduction of cardiovascular disease.

Increasing incidence of stroke among Swedish women

The incidence of stroke and transient ischemic attack was studied prospectively in the municipality of Söderhamn, Sweden, during the periods 1975-1978 and 1983-1986. A total of 723 cases of stroke and 111 cases of transient ischemic attack were registered during the two periods. The number of first-ever strokes increased by 28% between the 1970s and the 1980s, while the annual incidence of first-ever stroke rose from 2.90 to 3.53/1,000 (p less than 0.02). Female incidence increased by 38%, from 2.62 to 3.62/1,000 (p less than 0.05) between the study periods. Male incidence, however, changed nonsignificantly from 3.19 in the first period to 3.43 in the second. In 1975-1978, male incidence was four times greater than that of females up to 65 years of age, but the distribution became balanced in 1983-1986, when the increment of female incidence was 47% in the group 25-44 years old and 232% (p less than 0.05) in the group 45-64 years old. The annual incidence of first-ever transient ischemic attack was 0.43/1,000 in men and 0.48/1,000 in women in 1975-1978. The corresponding rates for 1983-1986 were 0.56 and 0.45/1,000, respectively. These changes were not significant. The cause of the increase in the incidence of stroke among women has not been established.