Author's Accepted Manuscript
Cardiovascular health in low- and middle-income countries Mark D. Huffman MD, MPH
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S0146-2806(14)00039-5 http://dx.doi.org/10.1016/j.cpcardiol.2014.05.005 YMCD278
To appear in:
Curr Probl Cardiol
Cite this article as: Mark D. Huffman MD, MPH, Cardiovascular health in low- and middle-income countries, Curr Probl Cardiol, http://dx.doi.org/10.1016/j.cpcardiol.2014.05.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1. TITLE PAGE. Cardiovascular Health in Low- and Middle-Income Countries Mark D. Huffman, MD, MPH
Contact address: Mark D. Huffman, MPH, MPH Departments of Preventive Medicine and Medicine-Cardiology Northwestern University Feinberg School of Medicine 680 N. Lake Shore Drive, Suite 1400 Chicago, IL 60611 T: 312-503-5513 [email protected] Word count: 4,972 (exclusive of references) Tables/Figures: 3 tables; 1 figure Disclosure statement: I receive salary support from grants from the National Heart, Lung, and Blood Institute and the World Heart Federation, the latter of which is for the World Heart Federation’s Emerging Leaders program, which is supported by an unrestricted educational grant from Astra Zeneca and Boehringer Ingelheim.
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2. TABLE OF CONTENTS. I. Defining cardiovascular health. II. Measuring and monitoring cardiovascular health in low- and middle-income countries. III. Recent trends in cardiovascular health metrics in low- and middle-income countries. IV. Strategies to improve cardiovascular health in low- and middle-income countries. 3. BIOGRAPHY. I am an assistant professor of preventive medicine and medicine-cardiology at Northwestern University's Feinberg School of Medicine. I am a practicing cardiologist and researcher with an interest in global cardiovascular epidemiology, prevention, and outcomes research. I lead an acute coronary syndrome quality improvement clinical trial in Kerala, India; am the coordinating editor of the Cochrane Heart Group US satellite; and serve as the senior program advisor to the World Heart Federation for its Emerging Leaders presidential initiative, which aims to develop a cadre of researchers from around the world to help achieve the World Health Organization's goal of reducing premature mortality from chronic diseases, including cardiovascular diseases, by 25% by 2025. I live in Chicago with my wife, Katie, and our two year-old daughter, Virginia. 4. NON-STRUCTURED ABSTRACT (150 words) The American Heart Association has defined cardiovascular health through seven metrics, including three health behaviors (tobacco use, diet, physical activity) and four health factors (body weight, blood pressure, blood cholesterol, and blood glucose). While the American Heart Association has championed the measurement, monitoring, and messaging of cardiovascular health through its goal to improve the cardiovascular health of all Americans by 20% by 2020, the current state of cardiovascular health in low- and middle-income countries (LMICs) has not been well documented. In this review, I will discuss 1) definition of cardiovascular health; 2) methods of measuring and monitoring cardiovascular health in LMICs; 3) recent trends in cardiovascular health metrics in LMICs; and 4) strategies to improve cardiovascular health in LMICs. 5. TEXT I. Defining cardiovascular health. In 2010, the American Heart Association released its 2020 Strategic Impact Goals and announced its call to not only reduce age-adjusted mortality from cardiovascular diseases (CVDs) by 20% but also to improve the cardiovascular health (CVH) of all Americans by 20% by 2020.(1) This new emphasis on CVH required the committee to define metrics to measure CVH as well as methods to monitor CVH in the US population. The committee incorporated several criteria for the defining CVH (Table 1), which directly influenced the metrics ultimately selected. Key considerations included: encompassing more than the absence of CVDs; being data-driven yet simple and accessible to practitioners and individuals; having face validity; being actionable; and being monitoring in all age, sex, and race/ethnic subgroups on a national, representative level. Based on these criteria, the committee developed seven metrics to define CVH, including three health behaviors (tobacco use, diet, physical activity) and four health factors (body weight, blood pressure, blood cholesterol, blood glucose).
͵
Within this CVH framework, the committee created three strata for each metric, termed ideal, intermediate, and poor, based on epidemiologic evidence and clinically meaningful thresholds (Table 2). The ideal CVH phenotype is defined by the following levels of all seven metrics, including: 1) non-smoking status, 2) healthy diet score* of 45, and 3) >150 min/week of moderate intensity physical activity (or >75 minutes/week of vigorous physical activity, 4) normal body weight (4.5 cups per day of fruits/vegetables, >2 servings of fish per week (3.5-oz servings), 150 minutes per week of moderate intensity, > 75 minutes per week of vigorous intensity, or > 150 minutes per week of moderate plus vigorous intensity activity (in which time in vigorous activity is doubled)
Body weight
BMI > 30 kg/m2
BMI = 25-29.9 kg/m2
BMI < 25 kg/m2
Blood glucose
FPG > 126 mg/dl or diagnosed diabetes mellitus with HbA1c >7%
FPG = 100-125 mg/dl or diagnosed diabetes mellitus with HbA1c 200 mg/dl
Total cholesterol = 200-239 mg/dl or treated to total cholesterol
Cardiovascular health in low- and middle-income countries Mark D. Huffman MD, MPH
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S0146-2806(14)00039-5 http://dx.doi.org/10.1016/j.cpcardiol.2014.05.005 YMCD278
To appear in:
Curr Probl Cardiol
Cite this article as: Mark D. Huffman MD, MPH, Cardiovascular health in low- and middle-income countries, Curr Probl Cardiol, http://dx.doi.org/10.1016/j.cpcardiol.2014.05.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1. TITLE PAGE. Cardiovascular Health in Low- and Middle-Income Countries Mark D. Huffman, MD, MPH
Contact address: Mark D. Huffman, MPH, MPH Departments of Preventive Medicine and Medicine-Cardiology Northwestern University Feinberg School of Medicine 680 N. Lake Shore Drive, Suite 1400 Chicago, IL 60611 T: 312-503-5513 [email protected] Word count: 4,972 (exclusive of references) Tables/Figures: 3 tables; 1 figure Disclosure statement: I receive salary support from grants from the National Heart, Lung, and Blood Institute and the World Heart Federation, the latter of which is for the World Heart Federation’s Emerging Leaders program, which is supported by an unrestricted educational grant from Astra Zeneca and Boehringer Ingelheim.
ʹ
2. TABLE OF CONTENTS. I. Defining cardiovascular health. II. Measuring and monitoring cardiovascular health in low- and middle-income countries. III. Recent trends in cardiovascular health metrics in low- and middle-income countries. IV. Strategies to improve cardiovascular health in low- and middle-income countries. 3. BIOGRAPHY. I am an assistant professor of preventive medicine and medicine-cardiology at Northwestern University's Feinberg School of Medicine. I am a practicing cardiologist and researcher with an interest in global cardiovascular epidemiology, prevention, and outcomes research. I lead an acute coronary syndrome quality improvement clinical trial in Kerala, India; am the coordinating editor of the Cochrane Heart Group US satellite; and serve as the senior program advisor to the World Heart Federation for its Emerging Leaders presidential initiative, which aims to develop a cadre of researchers from around the world to help achieve the World Health Organization's goal of reducing premature mortality from chronic diseases, including cardiovascular diseases, by 25% by 2025. I live in Chicago with my wife, Katie, and our two year-old daughter, Virginia. 4. NON-STRUCTURED ABSTRACT (150 words) The American Heart Association has defined cardiovascular health through seven metrics, including three health behaviors (tobacco use, diet, physical activity) and four health factors (body weight, blood pressure, blood cholesterol, and blood glucose). While the American Heart Association has championed the measurement, monitoring, and messaging of cardiovascular health through its goal to improve the cardiovascular health of all Americans by 20% by 2020, the current state of cardiovascular health in low- and middle-income countries (LMICs) has not been well documented. In this review, I will discuss 1) definition of cardiovascular health; 2) methods of measuring and monitoring cardiovascular health in LMICs; 3) recent trends in cardiovascular health metrics in LMICs; and 4) strategies to improve cardiovascular health in LMICs. 5. TEXT I. Defining cardiovascular health. In 2010, the American Heart Association released its 2020 Strategic Impact Goals and announced its call to not only reduce age-adjusted mortality from cardiovascular diseases (CVDs) by 20% but also to improve the cardiovascular health (CVH) of all Americans by 20% by 2020.(1) This new emphasis on CVH required the committee to define metrics to measure CVH as well as methods to monitor CVH in the US population. The committee incorporated several criteria for the defining CVH (Table 1), which directly influenced the metrics ultimately selected. Key considerations included: encompassing more than the absence of CVDs; being data-driven yet simple and accessible to practitioners and individuals; having face validity; being actionable; and being monitoring in all age, sex, and race/ethnic subgroups on a national, representative level. Based on these criteria, the committee developed seven metrics to define CVH, including three health behaviors (tobacco use, diet, physical activity) and four health factors (body weight, blood pressure, blood cholesterol, blood glucose).
͵
Within this CVH framework, the committee created three strata for each metric, termed ideal, intermediate, and poor, based on epidemiologic evidence and clinically meaningful thresholds (Table 2). The ideal CVH phenotype is defined by the following levels of all seven metrics, including: 1) non-smoking status, 2) healthy diet score* of 45, and 3) >150 min/week of moderate intensity physical activity (or >75 minutes/week of vigorous physical activity, 4) normal body weight (4.5 cups per day of fruits/vegetables, >2 servings of fish per week (3.5-oz servings), 150 minutes per week of moderate intensity, > 75 minutes per week of vigorous intensity, or > 150 minutes per week of moderate plus vigorous intensity activity (in which time in vigorous activity is doubled)
Body weight
BMI > 30 kg/m2
BMI = 25-29.9 kg/m2
BMI < 25 kg/m2
Blood glucose
FPG > 126 mg/dl or diagnosed diabetes mellitus with HbA1c >7%
FPG = 100-125 mg/dl or diagnosed diabetes mellitus with HbA1c 200 mg/dl
Total cholesterol = 200-239 mg/dl or treated to total cholesterol
