Cardiovascular disease: reducing the risk

Informal Briefing, INB 5

Geneva, Switzerland
16 October 2002

Chair, Distinguished delegates, Ladies and gentlemen,

The negotiations that we are engaging in at present illustrate a major risk to public health: tobacco.

As you know, tobacco plays an important role in increasing the toll of cardiovascular diseases, such as heart attack and stroke. New analytic tools, used in the preparation of WHR 2002, have led to new evidence about the size, and about potential prevention of major risks in this area.

Today, these new data will be released and I wanted to share this information with you.

A significant new finding is that blood pressure alone causes about 50 per cent of cardiovascular disease worldwide. Cholesterol causes about one-third. Inactive lifestyles, tobacco use and low fruit and vegetable intake account for 20 per cent each. You may notice that this adds up to more than 100 per cent. The reason is, of course, that several of these risks overlap.

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

The global disease burden due to blood pressure is twice as high as previously thought. This reflects recent findings on how strongly blood pressure is linked to heart disease and stroke in many diverse populations around the globe, and the fact that most people have sub-optimal levels.

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

A key message of the Report is that more than 50 per cent of deaths and disability from heart disease and strokes can be avoided by a combination of simple, cost-effective, national efforts and individual actions to reduce the major risk factors such as high blood pressure, high cholesterol, obesity and smoking. Together, heart disease and strokes kill more than 12 million people worldwide each year. So the savings in terms of lives could be enormous.

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

The need to control cardiovascular disease is especially important in poor countries, because it places a double burden on national health systems. These countries already have to deal with infectious diseases. In the new mega-cities of the developing world, we see massive illness, due to under-nutrition, side by side with poor cardiovascular health.

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

The trend towards increased cardiovascular disease in developing countries may be particularly dangerous in poorer countries and communities. In industrialized countries, the incidence of cardiovascular disease has increased among the poor and minorities, while the better off have been able to reduce their incidence over the past decades. If this trend repeats in the developing countries, the very poorest of the world's poor will be the ones most at risk.

These new findings have the potential of saving millions of lives.

Population-wide interventions are the most cost-effective methods of reducing risk. They should be the first to be considered in all settings. Modern-day conditions frequently mean that individuals, particularly the poor in developing world cities, have little control themselves over the major risk factors. For example, urban poor often can only buy high-fat and high-salt processed foods. Many processed foods - breads, soups, meats, etc. - have salt concentrations approaching or even exceeding those found in seawater.

The World Health Report 2002 urges countries to adopt policies and programmes to promote population-wide interventions such as reducing salt in processed foods, cutting dietary fat, encouraging exercise and higher consumption of fruits and vegetables, in addition to lowering smoking. We need policies that make healthier choices the easier choices.

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

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

Our new research finds that many established approaches to cutting cardiovascular disease risk factors are very inexpensive, so that even countries with limited health budgets can implement them and cut their cardiovascular disease rate significantly.

This Report will likely challenge current priorities in many countries:

Few Governments have yet to develop successful collaboration with the food industry to reduce salt and high fat in processed food. WHO is currently discussing the prospects for this.

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

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

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

The WHO CHOICE project has found that several established approaches to cardiovascular disease risk factor management easily meet international standards for cost-effectiveness, even in the poorest countries of the world.

Tobacco tax is one very good example. Countries that raise their tobacco taxes dramatically witness an almost immediate reduction in tobacco use and have corresponding improvements in cardiovascular health very quickly. A seven-dollar pack of cigarettes will go a long way toward persuading smokers to quit and non-smokers not to start.

Governments, industry and civil society can work together to enable the behavioural changes necessary to reduce risk among entire populations. The best approaches will differ from country to country, but the benefits for all will be great.

Thank you.