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

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.

Medical and exercise consultation use for low back and knee pain among cardiovascular mass screening population: A cross-sectional study

Low back and knee pain, as major symptoms and early signs of osteoarthritis, have restricted healthy life expectancy, and numerous guidelines have recommended therapeutic exercise as the first-line treatment for chronic pain. Proportions of medical and exercise consultation use for those pain have been unclear, and these may change in the future. We performed a cross-sectional study of 2,954 persons aged over 30 years in 2017 as a part of the Circulatory Risk in Communities Study. A generalized linear model with logit link and 11-year age-group moving averages were used to estimate sex- and age-specific average proportions of lifetime pain, chronic pain, and dysfunctional chronic pain of the low back and knee, and history of medical and exercise consultation use. The medical consultation use increased in the order of lifetime pain, chronic pain, and dysfunctional chronic pain, reaching 69.1 % [65.2, 72.8] in women and 74.9 % [70.3, 79.0] in men for chronic low back pain, and 70.3 % [66.1, 74.2] in women and 55.6 % [49.3, 61.7] in men for chronic knee pain. On the other hand, the exercise consultation use accounted for 36.5 % [32.6, 40.6] in women and 28.8 % [24.4, 33.5] in men for chronic low back pain, and 40.8 % [36.5, 45.2] in women and 20.6 % [16.0, 26.0] in men for chronic knee pain. This survey revealed the differences in the multilayer proportions of medical and exercise consultation use for low back and knee pain in the cardiovascular mass screening, suggesting exercise consultation was less often provided compared to medical consultation.

Impact of the Essential Public Health Service program on financial protection and health outcomes among hypertensive patients: A quasi-experimental study in China

BACKGROUND

The Chinese government launched the Essential Public Health Service (EPHS) program nationwide in 2009. However, prior studies have not provided clear and integrated evidence on whether the EPHS program improves health outcomes and prevents financial risks among individuals. Because hypertension is the chronic disease with the highest prevalence, this study evaluated the impact of the EPHS program among hypertensive patients to provide evidence for the progress of the program.

METHODS

A cohort of hypertensive patients was identified from the 2011-2018 China Health and Retirement Longitudinal Study (CHARLS). The outcomes assessed included hospitalization expenditure, outpatient expenditure and cardiovascular disease (heart attack and stroke). The key independent variable was whether an individual received EPHS-covered blood pressure measurements in 2013-2015. Based on the International Health Partnership+ (IHP+) common monitoring and evaluation (M&E) framework, a difference-in-differences (DID) method with propensity score matching (PSM) was used to examine the impact of the EPHS program on hypertensive patients.

RESULTS

The results showed that among hypertensive patients covered by the EPHS program, outpatient total costs/OOP costs were reduced by 29.8% and 30.8%, respectively, and hospitalization total costs/OOP costs were reduced by 34.9% and 35.6%, respectively. The EPHS program reduced the probability of heart attack and stroke among hypertensive patients by 3.5% and 2.7%, respectively. Mechanistic tests showed that the EPHS program improved health outcomes by reducing alcohol consumption and increasing physical activity, thereby further reducing health expenditure among hypertensive patients. The impacts of the EPHS program on hypertensive patients varied by age, educational attainment, residential region, and alcohol consumption status.

CONCLUSION

The EPHS program in China significantly improved health outcomes and prevented financial risks for hypertensive patients. This evidence provides a valuable reference for low- and middle-income countries with their essential public health service programs.

Prevention of cardiovascular disease, a major non-communicable disease, in a super-aging society: Health success and unsolved issues in Japan

As far as non-communicable disease is concerned, Japan is unique in showing a substantial decline in stroke mortality and the lowest and declining mortality from ischemic heart disease during the past half century, which contributed to the elongation of a 4-year average life expectancy, leading to top longevity in the world. However, several issues have remained in the prevention of cardiovascular disease with super-aging: i) how to manage the screening and lifestyle modification for both individuals with metabolic syndrome and those with non-overweight/ obesity plus metabolic risk factors, and ii) how to enhance the referral of very high-risk individuals screened at health checks to physicians for seeking treatment and examine whether an early clinical visit was associated with a lower risk of cardiovascular disease and total mortality. Health counseling is needed for both persons with metabolic syndrome and high-risk individuals with non-obese/overweight because the population attributable risk fraction of ischemic cardiovascular disease was similar for both high-risk individuals. Standardized counseling for very high-risk individuals accelerated clinical visits and reduced levels of risk factors. In health counseling, public health nurses were more effective in increasing clinic visits. Furthermore, the earlier clinic visit after the counseling suggested a lower risk of hospitalization for stroke, coronary heart disease, heart failure, and all-cause mortality. This article reviews these epidemiological findings for health practitioners and policymakers to perform further prevention and control for cardiovascular disease in Japan and other Asian and African countries with emerging cardiovascular burden and aging.

Effect of a Community-Based Program to Accelerate Referral to Physicians for Individuals at High-Risk of Lifestyle-Related Diseases: A Cluster Randomized Trial

AIM

A cluster randomized trial was conducted within 43 Japanese municipalities (21 intervention and 22 usual care) to examine whether the standardized health counseling for individuals at high cardiovascular risk screened at community sites accelerates clinic visits to strengthen the primary health care system.

METHODS

Among high-risk individuals aged 40-74 years screened by health checkups, 8,977 and 6,733 were allocated to the intervention and usual care groups, respectively, who were not under medical treatment but had high levels of blood pressure (systolic/diastolic ≥ 160/100 mmHg), hemoglobin A1c or glucose (≥ 7.0% or corresponding glucose levels), LDL-cholesterol (≥ 180 mg/dL for men), and/or proteinuria of ≥ 2+. The intervention was performed from May 2014 to March 2016 under a standardized health counseling program based on the health belief model primarily by public health nurses. The usual care group was provided with local counseling protocols.

RESULTS

The cumulative proportions of clinic visits for 12 months after health checkups were 58.1% (95% confidence interval, 57.0%, 59.3%) versus 44.5% (43.2%, 45.8%), with the probability ratio of clinic visits between the groups being 1.46 (1.24, 1.72). The between-group differences between the baseline and 1-year surveys were -1.50 (-2.59, -0.41) mmHg for diastolic blood pressure in the hypertension category, -0.30% (-0.53%, -0.07%) for HbA1c in the diabetes category, -0.37 (-0.48, -0.27) mmol/L for LDL-cholesterol in the dyslipidemia category, and none for proteinuria.

CONCLUSION

Standardized health counseling for high-risk individuals accelerated clinic visits, with larger reductions in blood pressure, HbA1c, and LDL-cholesterol levels. The nationwide use of counseling after health checkups for high-risk individuals could help in controlling risk factors and in preventing lifestyle-related diseases.

Trends in stroke, cardiovascular disease, and medical expenditure under a community-based long-term stroke prevention program

BACKGROUND

Evidence on the effects of preventive measures for noncommunicable disease is urgently needed for low-income and middle-income countries suffering from stroke epidemics along with population aging.

OBJECTIVES

We sought to examine the impact of a community-based stroke prevention program on incidences of stroke and ischemic heart disease, mortality from cardiovascular disease, and medical expenditure.

METHODS

Trends in the incidences of stroke and ischemic heart disease were documented in a Japanese rural community, Kyowa, from 1981 through 2015. Trends in mortality from cardiovascular disease and in medical expenditures were compared between Kyowa and its surrounding municipalities from 1981 through 2004.

RESULTS

In Kyowa, the age-and-sex-adjusted incidences of stroke and of ischemic heart disease decreased by half (from 4.1 to 1.9 and from 1.5 to 0.7 per year/1000 persons, respectively) over the past 35 years. A similar decreasing trend was observed for the age-and-sex-adjusted mortality from cardiovascular disease, and this decreasing trend occurred earlier than that in the surrounding municipalities. The medical expenditures for cardiovascular disease became lower in Kyowa than in the surrounding municipalities over time.

CONCLUSION

Our study's findings suggest that a community-based stroke prevention program augmented the decline in the incidences of stroke and ischemic heart disease, mortality from cardiovascular disease, and attenuated the increase in medical expenditures for cardiovascular disease.

The impact of increasing expenditure on National Essential Public Health Services on the medical costs of hypertension in China: A difference-in-difference analysis

BACKGROUND

The prevention and control of hypertension should be an effective way to reduce deaths and it has been a high priority in China. In 2013, the Chinese government increased the subsidy standard for the National Essential Public Health Services Package (NEPHSP) from RMB 15 to RMB 30 per person, which was expected to cover 70 million hypertensions. This study explored the influence of increasing NEPHSP subsidy on outpatient and inpatient expenditure among patients with hypertension.

METHODS

Data were mined from the 2011-2015 Harmonized China Health and Retirement Longitudinal Study. The study sample included 3192 hypertensive patients who were not lost to follow-up from 2011 to 2015. Hypertensive patients who covered by NEPHSP from 2011 to 2015 were defined as the treatment group, otherwise defined as the comparison group. The policy intervention was the increase of NEPHSP subsidy in 2013, and the years before and after 2013 were respectively considered as pre- (2011) and post-intervention (2015). The primary outcomes variables were the outpatient and inpatient expenditure of patients with hypertension, based on direct spending of outpatients and inpatients separately reported by patients with hypertension. Using propensity score matching (PSM) to match the individual characteristics of hypertension in the treatment group and the comparison group, difference-in-differences (DID) were used to analyze the outcomes.

RESULTS

The patients with hypertension' outpatient and inpatient expenditure patterns in the treatment and control group show an increasing trend from 2011 to 2015. After PSM, of the 1 956 hypertensive participants, 369 covered by the NEPHSP before and after 2013. A DID estimate of the increased NEPHSP subsidy was associated with a significant decrease of 1 251.35 RMB (t = 2.13, P = 0.034) in hypertension related inpatient expenditure, no significant change (t = 0.61, P = 0.544) among outpatient expenditure.

CONCLUSIONS

The NEPHSP may reduce inpatient expenditure among hypertension. Further strengthening of the NEPHSP may reduce their burden.

The incidence and mortality rates due to stroke and myocardial infarction following implementing the package of essential non-communicable diseases; A historical cohort study

Introduction: The package of essential non-communicable diseases (PEN) has been implemented in 2016 in Iran. The present study aimed to evaluate the incidence rate of myocardial infarction (MI) and stroke, and the mortality rate due to these diseases, following the lunch of the PEN project. Methods: This is a historical cohort study that was performed in 2020. Data were gathered through the hospital information system in the exposed and the control counties hospitals in the Isfahan province. The data about over 30-year-old patients who were hospitalized as definite cases of MI and/or stroke were collected via census sampling. The incidence rates of MI, stroke, and mortality due to those diseases were compared in 2015 (one year before the launch of the PEN project) and 2019 (4 years after the project initiation). Results: Following the implementation of the PEN project, the incidence and mortality rates due to MI among the over 30-year-old population in the exposed county, were reduced by 0.31 per 1000 and 9 per 100 000 respectively. Furthermore, the incidence rate due to stroke in the exposed county further slowed down, and the mortality rate due to stroke was reduced by 33 per 100,000 more than 30 years old population significantly. Conclusion: Following the implementation of the PEN project, the incidence rate due to MI and mortality rates due to MI and stroke decreased significantly. In addition, the incidence rate due to stroke further slowed down in the exposed county in comparison with the control county.

Systematic Review of the Effectiveness of Community Intervention and Health Promotion Programs for the Prevention of Non-Communicable Diseases in Japan and Other East and Southeast Asian Countries

Background: Non-communicable diseases (NCDs) are the leading cause of death worldwide. However, current evidence regarding the efficacy and cost-effectiveness of community intervention and health promotion programs for NCDs, specifically hypertension, obesity, diabetes, and dyslipidemia, in East and Southeast Asia has not yet been systematically reviewed. We systematically reviewed the literature from East and Southeast Asian countries to answer 2 clinical questions: (1) do health promotion programs for hypertension, obesity, diabetes, and dyslipidemia reduce cardiovascular events and mortality; and (2) are these programs cost-effective?

Methods and Results: Electronic literature searches were performed across Medline, Cochrane Library, and Ichushi using key words and relevant subject headings related to randomized controlled trials, comparative studies, quasi-experimental studies, or propensity score matching that met eligibility criteria that were defined for each question. In all, 3,389 records were identified, of which 12 full-text articles were reviewed. Three papers were from Japan, 7 were from China/Hong Kong Special Administrative Region, and 2 were from South Korea. None were from Southeast Asia. Four papers examined the effect of community intervention or health promotion on the incidence of cardiovascular events or mortality. Eight studies examined the cost-effectiveness of interventions.

Conclusions: The literature review revealed that community intervention and health promotion programs for the control of NCDs are a cost-effective means of reducing cardiovascular events and mortality in East Asian countries.

Cardiovascular disease, a major global burden: Epidemiology of stroke and ischemic heart disease in Japan

Japan ranks the highest globally, in terms of longevity. The average life expectancy was 81.4 years for men and 87.5 years for women in 2019. Such success in health is attributable to the substantial reduction in age-standardized mortality from cardiovascular diseases, especially stroke (136 per 10⁵ in 1980 and 24 per 10⁵ in 2015), when stroke mortality was the highest in the world between the 1960s and the 1990s. On the other hand, ischemic heart disease mortality was the lowest in the world between the 1960s and the 1980s and has continued to decline (40 per 10⁵ in 1980 and 17 per 10⁵ in 2015). Such a disease profile (larger burden of stroke compared to ischemic heart disease) was observed not only in Japan but also in some countries in central Asia and Africa, where small vessel disease (arteriolosclerosis) is assumed to be more common than large vessel disease (atherosclerosis). Between 1970 and 2015, a large decline in the population with high blood pressure levels was observed for both men and women. Meanwhile, there was a moderate decline in the smoking rate among men, and an increasing trend in serum cholesterol levels in both men and women. The sharp and extensive socioeconomic development between the 1960s and 1990s contributed to these health outcomes, while preventive measures and improved emergency medical care also contributed to the reduction of risk factors, disease incidence, case-fatality, and mortality. However, there is a threat of increasing incidence of ischemic heart disease in urban male employees and middle-aged male residents. Japan, with a super-aging society, needs to develop a new model for the prevention and control of cardiovascular disease and related health issues, with emphasis on efforts towards the early (primordial) prevention of cardiovascular disease as well as the attenuation of their progress towards chronic heart failure, chronic kidney disease, and vascular dementia.

Salt taste perception and blood pressure levels in population-based samples: the Circulatory Risk in Communities Study (CIRCS)

To examine the associations of salt perception with salt intake and blood pressure levels in general populations, we performed a cross-sectional study in two communities where salt intake level is different, Akita and Osaka in Japan. Taste perception (detection for certain taste and recognition for salt taste) was determined using a Na-impregnated test strip for 1024 Akita and 1199 Osaka adults aged 30-74 years. The proportions of detection for 0·1 % salt were 61, 62, 79, and 79 % in Akita men, Osaka men, Akita women and Osaka women, respectively. The corresponding proportions of not recognising of 1·6 % salt taste (>1·6 %) were 34, 30, 16 and 21 %. Detection threshold was higher in Akita than in Osaka for women aged 60-74 years, and recognition threshold was lower in Akita than in Osaka for women aged 30-59 and 60-74 years. The high detection (≥0·4 %) and recognition (>1·6 %) thresholds of salt taste were associated with higher salt intake scores for Akita men aged 30-59 years, whose detection and recognition thresholds tended be positively associated with systolic and diastolic blood pressures (SBP and DBP) after adjustment for potential confounders. Among Akita elderly men, detection threshold tended to be positively associated with SBP and DBP, while among Akita middle-aged women, recognition threshold was associated with SBP. In conclusion, the high thresholds of salt perception were inversely associated with salt intake for Akita middle-aged men and with blood pressure levels for Akita middle-aged and elderly men and middle-aged women.

The Circulatory Risk in Communities Study (CIRCS): A Long-Term Epidemiological Study for Lifestyle-Related Disease Among Japanese Men and Women Living in Communities

The Circulatory Risk in Communities Study (CIRCS) is an ongoing community-based epidemiological study of lifestyle-related disease involving dynamic prospective cohorts of approximately 12,000 adults from five communities of Japan: Ikawa, Ishizawa and Kita-Utetsu (Akita Prefecture), Minami-Takayasu (Osaka Prefecture), Noichi (Kochi Prefecture), and Kyowa (Ibaraki Prefecture). One of the most notable features of CIRCS is that it is not only an observational cohort study to identify risk factors for cardiovascular diseases (CVD), such as stroke, coronary heart disease, and sudden cardiac death, but it also involves prevention programs for CVD. Using basic, clinical, epidemiological, and statistical techniques, CIRCS has clarified characteristics of CVD and the related risk factors to develop specific methodologies towards CVD prevention in Japanese middle-aged or older adults for more than half a century.

Prevalence of hypertension and hypertension control rates among elderly adults during the cold season in rural Northeast China: a cross-sectional study

Objective: The burden of noncommunicable diseases (NCDs) is increasing in China, together with economic development and social changes. The prevalence of risk factors for NCDs, such as overweight/obesity, hypertension, diabetes, and dyslipidemia, is reported to be high even among poor residents of rural areas. We aimed to investigate the prevalence of hypertension among elderly adults in rural Northeast China and the proportion with controlled hypertension among those on antihypertensive medication (hypertension control rate). We also aimed to examine the association of hypertension control with health facilities that provide treatment. Methods: We conducted a community-based cross-sectional study in six rural villages of Northeast China from February to early March, 2012. We interviewed 1593 adults aged 50-69 years and measured their blood pressure. We examined the differences in mean blood pressure between participants who obtained antihypertensive medication from village clinics and those who obtained medication from other sources, using analysis of covariance adjusted for several covariates. Results: The prevalence of hypertension among participants was as high as 63.3%, but the hypertension control rate was only 8.4%. Most villagers (98.1%) were not registered in the chronic disease treatment scheme of the public rural health insurance. The mean systolic blood pressure, adjusted for the covariates, of participants who obtained antihypertensive medication from village clinics was significantly lower than that of participants who obtained medication from township hospitals (by 16.5 mmHg) or from private pharmacies (by 7.3 mmHg). Conclusion: The prevalence of hypertension was high and the hypertension control rate low among elderly villagers during the cold season. As treatment at village clinics, which villagers can access during the cold season seems to be more effective than self-medication or treatment at distant hospitals, improving the quality of treatment in village clinics is urgently needed.

Rationale and Descriptive Analysis of Specific Health Guidance: the Nationwide Lifestyle Intervention Program Targeting Metabolic Syndrome in Japan

AIM

All health insurers in Japan are mandated to provide Specific Health Checkups and Specific Health Guidance (SHG) focusing on metabolic syndrome (MetS) in middle-aged adults, beginning in 2008; intensive HG for individuals who have abdominal obesity and two or more additional MetS risk factors, and motivational HG for individuals with one risk factor. The aim of this study is to describe medium-term changes in health indexes for intensive and motivational HG groups using the National Database.

METHODS

We compared changes of risk factors and initiation of pharmacological therapy over 3 yr between participants (n=31,790) and nonparticipants (n=189,726) who were eligible for SHG in 2008.

RESULTS

Body weight reduction in intensive HG was 1.98 kg (participants) vs 0.42 kg (nonparticipants) in men (p＜0.01) and 2.25 vs 0.68 kg in women (p＜0.01) after 1 yr. In motivational HG, the respective reduction was 1.40 vs 0.30 kg in men (p＜0.01) and 1.53 vs 0.42 kg in women (p＜0.01). Waist circumference reduction was also greatest among participants in intensive HG (2.34 cm in men and 2.98 cm in women). These reductions were fairly unchanged over 3 yr and accompanied greater improvements in MetS risk factors in participants. We also detected significantly smaller percentages of SHG participants who initiated pharmacological therapy compared with nonparticipants.

CONCLUSION

Participants in SHG showed greater improvements in MetS profiles with proportionally smaller pharmacological treatment initiations than did nonparticipants for 3 yr. Although selection bias may be present, this study suggests SHG would be a feasible strategy to prevent MetS and its sequelae.

Impact of the National Essential Public Health Services Policy on Hypertension Control in China

BACKGROUND

Hypertension remains a severe challenge to population health worldwide. This study assessed the impact of a nationwide program in China-Essential Public Health Services (EPHS) on improvement of hypertension treatment and control.

METHODS

A cohort of hypertensive patients was identified from the 2011-2013 China Health and Retirement Longitudinal Study. Hypertension was defined based on: (i) an average systolic blood pressure of ≥140 mm Hg, and/or an average diastolic blood pressure of ≥90 mm Hg; and/or (ii) currently taking antihypertensive medications. Outcomes assessed included the rate of hypertension control, medication use, and blood pressure monitoring at a doctor's office. The key independent variable was defined as whether one received services from the EPHS-covered physical examination by 2013. Probit regression models with a difference-in-difference approach were performed for each of the 3 outcomes. Data were analyzed in 2017.

RESULTS

Among the 4,958 hypertensive patients, 404 (8.1%) received the EPHS-covered service by 2013. Coverage by the EPHS program was associated with an increase of 7.9% in hypertension control rate (SE = 2.9%, P = 0.020), an increase of 10.3% in the rate of medication use (SE = 2.5%, P < 0.001), and an increase of 10.5% in the rate of blood pressure monitoring (SE = 2.5%, P < 0.001). Results also showed that the EPHS program helped mitigate the geographic disparities in access to health services such as blood pressure monitoring.

CONCLUSIONS

The National EPHS program improved the treatment and control among hypertension patients. Expanding its program reach could further benefit the cardiovascular health of the population.

Prevalence of non-communicable disease risk factors among poor shantytown residents in Dhaka, Bangladesh: a community-based cross-sectional survey

OBJECTIVES

This study aims to describe the prevalence of non-communicable disease (NCD) risk factors among the urban poor in Bangladesh.

DESIGN

We conducted a community-based cross-sectional epidemiological study.

SETTING

The study was conducted in a shantytown in the city of Dhaka. There were 8604 households with 34 170 residents in the community. Those households were categorised into two wealth strata based on the housing structure.

PARTICIPANTS

The study targeted residents aged 18-64 years. A total of 2986 eligible households with one eligible individual were selected by simple random sampling stratified by household wealth status. A total of 2551 residents completed the questionnaire survey, and 2009 participated in the subsequent physical and biochemical measurements.

OUTCOME MEASURES

A modified WHO survey instrument was used for assessing behavioural risk factors and physical and biochemical measurements, including glycated haemoglobin (HbA1c). The prevalence of NCD risk factors, such as tobacco use, fruit and vegetable intake, overweight/obesity, hypertension, diabetes (HbA1c ≥6.5%) and dyslipidaemia, was described according to household wealth status and gender differences.

RESULTS

The prevalence of current tobacco use was 60.4% in men and 23.5% in women. Most of them (90.8%) consumed more than 1 serving of fruits and vegetables per day; however, only 2.1% consumed more than 5 servings. Overweight/obesity was more common in women (39.2%) than in men (18.9%), while underweight was more common in men (21.0%) than in women (7.1%). The prevalence of hypertension was 18.6% in men and 20.7% in women. The prevalence of diabetes was 15.6% in men and 22.5% in women, which was much higher than the estimated national prevalence (7%). The prevalence of raised total cholesterol (≥190 mg/dL) was 25.7% in men and 34.0% in women.

CONCLUSION

The study identified that tobacco use, both overweight and underweight, diabetes, hypertension and dyslipidaemia were prevalent among the urban poor in Bangladesh.

Fifty-year Time Trends in Blood Pressures, Body Mass Index and their Relations in a Japanese Community: The Circulatory Risk in Communities Study (CIRCS)

Aim: Data for long-term trends in blood pressures, body mass index (BMI), and their relations are needed to set future intervention priorities for prevention of cardiovascular disease. The objective of this study was to investigate these trends revealed by repeated cross-sectional surveys conducted from 1963 to 2013 in a Japanese community.

Methods: Men and women aged 40–79 years who participated in annual cardiovascular checkups were enrolled, and the number of participants ranged between 1,776 and 2,366 with consistently high participation rates for both sexes aged 60–69 years. Sex- and age-specific mean systolic and diastolic blood pressures were calculated using mixed effects modeling for repeated measurement, and the prevalence of hypertension with and without obesity (BMI ≥ 25 kg/m²) were also calculated.

Results: Sex- and age-specific mean systolic and diastolic blood pressures declined irrespective of antihypertensive medication use in both men and women from 1963–1966 to 2009–2013, while mean BMI increased among men of all ages and women of ages 60–69 and 70–79 years. For both sexes aged 60–69 years, the prevalence of hypertension with obesity increased, but the prevalence of hypertension without obesity was still higher that with obesity.

Conclusions: Despite the transition to increased BMI levels, targeting non to obese hypertension remains important in addition to targeting obese hypertension for cardiovascular disease prevention.

Global Strategies for the Prevention and Control of Infectious Diseases and Non-Communicable Diseases

This article on global health reviews the environment surrounding health strategies and plans, as well as lessons learned from the first 15 years of the 21st century, followed by a discussion on the quest for a new paradigm for disease control efforts and challenges and opportunities for Japan.

Stroke Is the Leading Cause of Death in Rural Gadchiroli, India: A Prospective Community-Based Study

BACKGROUND AND PURPOSE

Stroke is an important cause of death and disability worldwide. However, information on stroke deaths in rural India is scarce. To measure the mortality burden of stroke, we conducted a community-based study in a rural area of Gadchiroli, one of the most backward districts of India.

METHODS

We prospectively collected information on all deaths from April 2011 to March 2013 and assigned causes of death using a well-validated verbal autopsy tool in a rural population of 94 154 individuals residing in 86 villages. Two trained physicians independently assigned the cause of death, and the disagreements were resolved by a third physician.

RESULTS

Of 1599 deaths during the study period, 229 (14.3%) deaths were caused by stroke. Stroke was the most frequent cause of death. For those who died because of stroke, the mean age was 67.47±11.8 years and 48.47% were women. Crude stroke mortality rate was 121.6 (95% confidence interval, 106.4-138.4), and age-standardized stroke mortality rate was 191.9 (95% confidence interval, 165.8-221.1) per 100,000 population. Of total stroke deaths, 87.3% stroke deaths occurred at home and 46.3% occurred within the first month from the onset of symptoms.

CONCLUSIONS

Stroke is the leading cause of death and accounted for 1 in 7 deaths in this rural community in Gadchiroli. There was high early mortality, and the mortality rate because of stroke was higher than that reported from previous studies from India. Stroke is emerging as a public health priority in rural India.

Activation of the ACE2/Ang-(1-7)/Mas pathway reduces oxygen-glucose deprivation-induced tissue swelling, ROS production, and cell death in mouse brain with angiotensin II overproduction

We previously demonstrated that mice which overexpress human renin and angiotensinogen (R+A+) show enhanced cerebral damage in both in vivo and in vitro experimental ischemia models. Angiotensin-converting enzyme 2 (ACE2) counteracts the effects of angiotensin (Ang-II) by transforming it into Ang-(1-7), thus reducing the ligand for the AT1 receptor and increasing stimulation of the Mas receptor. Triple transgenic mice, SARA, which specifically overexpress ACE2 in neurons of R+A+ mice were used to study the role of ACE2 in ischemic stroke using oxygen and glucose deprivation (OGD) of brain slices as an in vitro model. We examined tissue swelling, the production of reactive oxygen species (ROS), and cell death in the cerebral cortex (CX) and the hippocampal CA1 region during OGD. Expression levels of NADPH oxidase (Nox) isoforms, Nox2 and Nox4 were measured using western blots. Results show that SARA mice and R+A+ mice treated with the Mas receptor agonist Ang-(1-7) had less swelling, cell death, and ROS production in CX and CA1 areas compared to those in R+A+ animals. Treatment of slices from SARA mice with the Mas antagonist A779 eliminated this protection. Finally, western blots revealed less Nox2 and Nox4 expression in SARA mice compared with R+A+ mice both before and after OGD. We suggest that reduced brain swelling and cell death observed in SARA animals exposed to OGD result from diminished ROS production coupled with lower expression of Nox isoforms. Thus, the ACE2/Ang-(1-7)/Mas receptor pathway plays a protective role in brain ischemic damage by counteracting the detrimental effects of Ang-II-induced ROS production.

A trend analysis of the prevalence, awareness, treatment, and control of hypertension by age group

Objectives

We examined the trends in prevalence, awareness, treatment, and control of hypertension in Korea as a basis for improving hypertension control programs.

Methods

12 598 participants of the Korean National Health and Nutrition Examination Survey were included in this study. Weighted linear regression to test time trends from 2007 to 2011 was performed.

Results

The prevalence of hypertension was 20.7% in 2007, 29.4% in 2009, and 26.2% in 2011. Awareness of hypertension was 64.8% in 2007 and 61.1% in 2011. Awareness in those aged 65 and over was greater than in younger groups (age 19 to 44 and 45 to 64; p<0.001). The treatment rates were 58.4% in 2007 and 56.8% in 2011. The treatment rate was greater for those 65 and over than for younger age groups (p<0.001). The percentage of controlled hypertension was 37.6% in 2011. The percentage of controlled hypertension in those 65 and over was higher than in younger age groups (p<0.001). The treatment-control rates were 65.9% in 2007 and 67.7% in 2011. The prevalence of hypertension was higher in the males (p<0.001), while the awareness (p<0.001), treatment (p<0.001), and control (p<0.001) rates were higher in the females.

Conclusions

The prevalence of hypertension was increasing and the hypertension awareness, treatment, and control rates were low in younger age groups and males.

Cost-effectiveness and budget impact analyses of a long-term hypertension detection and control program for stroke prevention

OBJECTIVES

The nation-wide, community-based intensive hypertension detection and control program, as well as universal health insurance coverage, may well be contributing factors for helping Japan rank near the top among countries with the longest life expectancy. We sought to examine the cost-effectiveness of such a community-based intervention program, as no evidence has been available for this issue.

METHODS

The hypertension detection and control program was initiated in 1963 in full intervention and minimal intervention communities in Akita, Japan. We performed comparative cost-effectiveness and budget-impact analyses for the period 1964-1987 of the costs of public health services and treatment of patients with hypertension and stroke on the one hand, and incidence of stroke on the other in the full intervention and minimal intervention communities.

RESULTS

The program provided in the full intervention community was found to be cost saving 13 years after the beginning of program in addition to the fact of effectiveness that; the prevalence and incidence of stroke were consistently lower in the full intervention community than in the minimal intervention community throughout the same period. The incremental cost was minus 28,358 yen per capita over 24 years.

CONCLUSION

The community-based intensive hypertension detection and control program was found to be both effective and cost saving. The national government's policy to support this program may have contributed in part to the substantial decline in stroke incidence and mortality, which was largely responsible for the increase in Japanese life expectancy.

Methodological issues for a large-scale intervention trial of lifestyle modification: Interim assessment of the high-risk and population strategy for occupational health promotion (HIPOP-OHP) study

OBJECTIVE

To clarify the methodological issues for the High-risk and population Strategy for Occupational Health Promotion Study (HIPOP-OHP study), which is a 4-year non-randomized control trial, an interim assessment of male participants was performed 3 years after the baseline survey.

METHODS

We had approximately 2,500 and 4,000 participants in the intervention and control groups, respectively. The population measures and prevalence of risk factors at each year, and between the baseline and 4th examinations were compared between the two groups. The personal trends of returning participants who were in the study at the 1(st) and 4(th) examinations were also evaluated.

RESULTS

During the 3 years, an increase in serum HDL cholesterol (2.7 mg/dl), and a reduction in the prevalence of hypertriglycemia detected with fasting blood samples (3.6%) and current smokers (5.4%) were observed in the intervention group. The mean HDL cholesterol level was significantly higher in the intervention group than in the control group at the 4th examination, reversed from the baseline survey. The serum non-HDL cholesterol level was significantly increased only in the control group. There was also a significant increase in the prevalence of hypertriglycemia nad high plasma glucose detected with fasting blood samples in the control group. The return participation rate after 3 years was 72.2% for the intervention group and 74.9% for the control group. The above-mentioned changes for risk factors were mainly due to returning participants at each examination.

CONCLUSION

These interventional methods may be effective in improving overall cardiovascular risk factors in the population. However, the low return participation rate will dilute the effect of the intervention.

Breakfast habits among adolescents and their association with daily energy and fish, vegetable, and fruit intake: a community-based cross-sectional study

OBJECTIVES

To investigate breakfast eating habits on daily energy and fish, vegetable, and fruit intake in Japanese adolescents.

METHODS

This study was completed as part of the Shunan Child Health Cohort Study. Two types of questionnaires, one on lifestyle habits and the other a brief-type, self-administered questionnaire on diet history, were administered to second-year junior high school students (1,876 boys and 1,759 girls) in Shunan City, Yamaguchi, Japan. The different breakfast habits were compared using the general linear model and the estimated means and P value for trend were calculated, with energy-adjusted food intake as the dependent variable and body mass index, gender, age, residential areas, and living status as covariates.

RESULTS

In both males and females, the proportion of those who ate breakfast irregularly was about 10%. The daily intake of fish, vegetables, and fruit was significantly higher in those who ate breakfast with their guardians than in those who ate breakfast alone (P for trend <0.01). The daily intake of fish, seafood, and vegetables was significantly higher in those who less frequently ate cooked foods for breakfast (P for trend <0.01). Those who ate rice more frequently than bread at breakfast had a higher daily intake of fish, seafood, and vegetables (P for trend <0.01).

CONCLUSIONS

Eating breakfast with the family, reducing the intake of cooked foods at breakfast, and eating breakfast with rice as a main staple food are suggested to contribute to an improved quality of diet in adolescents.

What has made the population of Japan healthy?

People in Japan have the longest life expectancy at birth in the world. Here, we compile the best available evidence about population health in Japan to investigate what has made the Japanese people healthy in the past 50 years. The Japanese population achieved longevity in a fairly short time through a rapid reduction in mortality rates for communicable diseases from the 1950s to the early 1960s, followed by a large reduction in stroke mortality rates. Japan had moderate mortality rates for non-communicable diseases, with the exception of stroke, in the 1950s. The improvement in population health continued after the mid-1960s through the implementation of primary and secondary preventive community public health measures for adult mortality from non-communicable diseases and an increased use of advanced medical technologies through the universal insurance scheme. Reduction in health inequalities with improved average population health was partly attributable to equal educational opportunities and financial access to care. With the achievement of success during the health transition since World War 2, Japan now needs to tackle major health challenges that are emanating from a rapidly ageing population, causes that are not amenable to health technologies, and the effects of increasing social disparities to sustain the improvement in population health.

[An occupational physician-pharmacist cooperative management for hypertension by the use of educational letters and posters]

OBJECTIVES

To provide an occupational physician-pharmacist cooperative management for hypertension, we aimed to improve blood pressure (BP) control for workers with high-normal BP or hypertension.

METHOD

Health checkups were performed from May 2005 to May 2008 for male professional grooms and exercise riders aged 20-69 years working at Miho Training Center, the largest racing-horse training facility in Japan. An occupational physician-pharmacist cooperative hypertension management was performed from Jan 2007 to Mar 2008, including the use of posters at the work site and letters to employers and the subjects who were diagnosed as having high-normal BP (office systolic/diastolic BPs 130-139 and/or 85-89 mmHg) or hypertension (≥ 140 and/or 90 mmHg) twice during 2005-2006 examinations. The observational study examined BP measurements before and after the hypertension management.

RESULTS

We analyzed 232 participants in the 2008 Nov examination with had high-normal BP or hypertension in both of 2005 and 2006 Nov examinations. Office systolic and diastolic BP decreased after the hypertension management by the use of educational letters and posters (-3.1 mmHg; p<0.001, -1.5 mmHg; p=0.02). The prevalence of workers with high-normal BP and hypertension also decreased after those activities (-15% and -7%; p<0.001). The subjects who started or continued the antihypertensive medication were more likely to show reductions in office BP and body mass index than those who received no treatment.

CONCLUSIONS

An occupational physician-pharmacist cooperated hypertension management by the use of educational letters and posters may improve BP control for subjects with high-normal BP or hypertension.

A Japanese health success story: trends in cardiovascular diseases, their risk factors, and the contribution of public health and personalized approaches

There has been a substantial decline in mortality from stroke and ischemic heart disease (IHD) in Japan between the 1960s and 2000s, which contributed to placing Japanese at the top of world’s life expectancy rankings. That mortality decline was attributable to reductions of blood pressure and smoking, in spite of increases in dyslipidemia and diabetes mellitus. The combination of public health and personalized treatment activities to enhance sodium reduction, balanced diets, smoking prevention/cessation as well as hypertension detection and treatment have contributed to the reduction of cardiovascular diseases, demonstrated by a community-based stroke prevention program. The health success story, however, contains an underlying concern about future health threats, the plateaued IHD mortality decline and increased IHD incidence among urban middle-aged men, probably due to increased dyslipidemia and diabetes. The IHD incidence and mortality trends need to be monitored because of a potential future problem for predictive, preventive and personalized medicine.

Patient's education in arterial hypertension

Non-compliance is an important factor in lack of appropriate control of blood pressure. Education of hypertensive patients on about consequences of hypertension and benefits of antihypertensive therapy has been reported to improve the results of the management of hypertension. The aim of this article is to present main factors influencing patients' compliance with antihypertensive treatment and the role of educational interventions in the process of therapy.

The taste of salt measured by a simple test and blood pressure in Japanese women and men

Salt intake is an important risk factor for hypertension. Because it has been reported that increased salt intake dulls the taste of salt, measuring the sense of taste might be a good way of identifying individuals who consume excessive salt. Using a recently developed simple salt taste test, we investigated the relationship between the taste of salt and blood pressure. The subjects in this cross-sectional study were 823 Japanese adults (479 women and 344 men) 40 years old or older. Following a taste test with salt-impregnated taste strips, the subjects were divided into two groups: normal (recognition threshold of salt at <1.0% concentration) and taste impaired (>or=1.0%). We determined hypertension from the measured blood pressure. In women, the multi-adjusted odds ratio (95% CI) of hypertension in the impaired group was 2.47 (1.53-3.99) compared with the normal group, whereas no significant difference was observed between the two male groups. When we excluded subjects with moderate and severe hypertension, similar findings were observed. A sub-analysis of couples living alone showed a higher prevalence of hypertension among men whose wives were in the impairment group (58.8%) than in the normal group (36.7%, P=0.10). In conclusion, the taste of salt is associated with blood pressure in Japanese women, but not in men. Because most family meals in Japan are prepared by women, educating women about salt reduction may contribute to the prevention of hypertension, not only among women but also among their husbands and family members.-

Age-Period-Cohort analysis of mortality due to ischemic heart disease in Japan, 1955 to 2000

BACKGROUND

Mortality from ischemic heart disease (IHD) has been showing a marked decline in Japan. The objective of this study was to clarify the effects of age, time period, and cohort on mortality from IHD in Japan from 1955 to 2000.

METHODS AND RESULTS

IHD death data from vital statistics and national population surveys were tabulated for 11 5-year age groups (from 30-34 to 80-84) and 10 quinquennial demographic profiles (from 1955 to 2000), to yield 20 5-year birth cohorts (mid-years from 1873 to 1968). The stratified Age-Period-Cohort model with 7 age classes shows: (1) mainly linear age trends for men with IHD, but effects below the linear age trends for women in middle-aged groups (40-74 years); (2) a decline in the effect of time period on IHD for both men and women from 1970 to 1990, and a sharp increase between 1990 and 1995 along with the change of the International Classification of Diseases Code; and (3) 2 patterns for both sexes for non-linear birth cohort effects, an increase (1873-1928) and a decrease (1928-1968) for men, and an increase (1873-1923) and a decrease (1923-1968) for women, with a stronger effect for women than for men born between 1893 and 1938, but the reverse for men and women born between 1938 and 1968.

CONCLUSION

Declining effects of birth cohort on mortality rates of IHD for young and middle-aged people suggest that mortality rates are likely to continue to decrease in Japan.

Stratified age-period-cohort analysis of stroke mortality in Japan, 1960 to 2000

BACKGROUND

Although stroke mortality has been decreasing in Japan, in 2000 it was still the third leading cause of death among Japanese of either sex. Elucidation of stroke mortality trends among age, calendar year, and birth cohorts should improve stroke prevention efforts. The objective of this study was to clarify the age, period, and cohort effects on stroke mortality in Japan from 1960 to 2000 by using stratified age-period-cohort models with improved goodness of fit.

METHODS

Death and population from the Vital Statistics of Japan and the National Statistics Bureau, respectively, were tabulated among 12 age groups (30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75-79, 80-84, and 85-89) and 9 quinquennials (1960, 1965, 1970, 1975, 1980, 1985, 1990, 1995, and 2000), which yielded 20 birth cohorts (midyears of 1873, 1878, 1883, 1888, 1893, 1898, 1903, 1908, 1913, 1918, 1923, 1928, 1933, 1938, 1943, 1948, 1953, 1958, 1963, and 1968). A stratified model (age-periods-cohort model) with 7 age classes (30-44, 45-54, 55-64, 65-69, 70-74, 75-79, and 80-89 years) was applied under the assumption that the number of deaths has an extra-Poisson variation.

RESULTS

The stratified model showed that: (1) middle-aged groups (40-64 years in men and 40-59 years in women) had higher mortality than their linear age trends; (2) young (30-44 years) and middle-aged (45-64 years) groups showed different patterns than those of the elderly (65-89 years) age groups: the two younger groups had higher nonlinear period effects than their linear trends between 1970 and 1990, and the trend of decreasing began later (in 1975 in men and 1980 in women, respectively) than it did for the elderly (1970); and (3) the nonlinear cohort effects indicated 4 patterns in each sex, and the effects increased in post-1948 cohort in men and in post-1958 cohort in women.

CONCLUSION

Young and middle age (30-59 years) boosted the mortality, suggesting that this age range should be targeted for increased stroke prevention efforts.

The high-risk and population strategy for occupational health promotion (HIPOP-OHP) study: study design and cardiovascular risk factors at the baseline survey

In order to establish the methodology of a population strategy for improving cardiovascular risk factors, we have planned the High-risk and Population Strategy for Occupational Health Promotion Study (HIPOP-OHP study). This study is a nonrandomized control trial in approximately 6500 participants in six intervention and six control companies. Our population strategy is based on three factors, nutrition, physical activity, and smoking. For each factor, a researcher's working team was organized and has been supporting the intervention. A standardized method to obtain comparable data has also been established. In the baseline survey, urinary sodium excretion in male subjects was higher, and urinary potassium excretion was lower in both genders in the intervention group compared to the control group. The prevalence of hypertension for both genders was also higher in the intervention group. Male subjects in the intervention group had higher serum total cholesterol than controls, while high-density lipoprotein cholesterol was lower in both genders in the intervention group compared to the control group. These differences were reflected by our finding that the predicted relative risk of coronary heart disease for male subjects was significantly higher in the intervention group (relative risk, RR: 1.17; 95% confidence interval, 95% CI.: 1.09, 1.25) and significantly lower in the control group (RR: 0.93; 95% CI.: 0.89, 0.98) compared to a model Japanese population. Similar results were observed in the female subjects. Taken together, these findings indicate that it is possible to compare trends of predicted relative risk for coronary heart disease between two groups.

Impact of the high-risk and mass strategies on hypertension control and stroke mortality in primary health care

Stroke has been the second leading cause of death in Taiwan in recent years. Following a 6-month pilot study in Yu-Chi in 1993, a 3.5-year hypertension control programme was performed to examine the effectiveness of combined high-risk and mass strategies in a rural community with limited medical resources. All Yu-Chi residents aged 40 years and older were invited to participate in the programme. The high-risk strategies included hypertension screening, home visits, and follow-up for the hypertensives. The mass strategies included health education and village-based campaigns. Changes over time in the participants' hypertension knowledge, behaviour, and blood pressure control status were evaluated. A comparison of the stroke mortality between the intervention community and a neighbourhood reference community before and after the intervention programme was performed. A total of 4977 residents were screened and 3761 completed the first and second rescreening. The hypertension knowledge and behaviour scores in the hypertensives significantly improved, systolic and diastolic blood pressure and waist-to-hip ratio significantly reduced, and the rates of hypertension treatment and control increased significantly at 1 and 3.5 years after intervention. In contrast, blood pressure levels increased significantly in the normotensives. Between 1994 and 1997, stroke mortality rate decreased by 39.9 and 4.8% in the intervention and reference communities, respectively. The results indicated that the community-based hypertension control programme was effective. The immediate decline in stroke mortality appeared to be mostly related to the high-risk strategies.

Research agenda for understanding Alzheimer disease in diverse populations: work group on cultural diversity, Alzheimer's association

The emerging evidence of ethnic variations in apolipoprotein polymorphism and Alzheimer disease risk shows that one cannot generalize findings based on a single cultural group too broadly ( Tang et al., 2001). Presence of one apolipoprotein E epsilon 4 allele is a stronger risk factor for Alzheimer disease in whites and Asians than in blacks ( Farrer et al., 1997). Environmental or genetic cofactors may modulate the effects of epsilon 4 on beta-amyloid metabolism differently in different subpopulations ( Shadlen, 1998). Recognizing this, the Alzheimer's Association has extended its goals to strengthen the scientific information base on the interactions of population diversity and Alzheimer disease heterogeneity ( NIA, 1998). This new focus is timely since minority elderly are the most rapidly increasing segment of the elderly population ( Lilienfeld and Perl, 1994, Brookmeyer et al., 1998). In this article, the authors highlight recent progress in research on Alzheimer disease among culturally diverse populations with a special emphasis on gaps in the knowledge base. The authors recommend four priorities for future Alzheimer disease research: (1) determine whether genetic causative factors interact differently in different populations; (2) reexamine the nature and role of cerebral ischemia and infarction and variations in symptom severity of Alzheimer disease; (3) explore the interaction of genes and environmental influences that are protective against Alzheimer disease; and (4) recruit and enroll ethnically diverse subjects in Alzheimer disease clinical trials.

Trends of cardiovascular risk factors and diseases in Japan: implications for primordial prevention

We have documented a 70% fall in stroke mortality and a 20% decline in coronary disease (CHD) mortality over the past 30 years in Japan. This parallels a change away from the traditional Japanese eating pattern, with less salt and more meat and dairy products, and decreased rates of smoking. A recent increase in CHD rates among urban Japanese men raises the need for vigorous primordial prevention efforts to avoid elevated blood lipids in modern Japanese populations, while primary prevention efforts must continue for the prevention of hypertension and smoking.