Geneva Health Forum Archive

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The Asthma Drug Facility: A Practical Solution for one of the Major Non-Communicable Diseases

Author(s): Cecile Mace1, Nils Billo1, Christophe Perrin1
Affiliation(s): 1The International Union Against Tuberculosis and Lung Diseases, Pantin, France
1st country of focus: Not applicable
Additional countries of focus: Low- and Middle-Income Countries
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): The Asthma Drug Facility, a project of the International Union Against Tuberculosis and Lung Disease (The Union) is one of the practical solutions to support low- and middle-income countries to offer standardised asthma management to patients using essential medicines. However, the ADF services have only been used by a very limited number of countries. Having a procurement system in place for asthma medicines at global level is only part of the solution to improve asthma management in low- and middle-income countries. To change the situation, countries also need the political will to invest in asthma management and funds to support all important activities.
Background (max 200 words): The Union established the Asthma Drug Facility (ADF) to provide affordable access to quality-assured, essential asthma medicines for low- and middle-income countries and to promote a quality improvement package for the diagnosis, treatment and management of asthma.
Objectives (max 100 words): This presentation will help participants to understand the ADF procurement system and services and how it will help to overcome one of the major barriers to asthma management in low- and middle-income countries: the lack of access to inhaled corticosteroids. It will also look at the additional barriers for countries to improve asthma management.
Methodology (max 400 words): The ADF is now fully operational since 2009 and has performed two rounds of qualification followed by restricted tenders to establish contracts with manufacturers. Countries, organisations and programmes can now use the ADF services to implement asthma programmes or integrated approaches to respiratory health.
Results (max 400 words): The ADF has already supplied essential asthma medicines to Benin, El Salvador, Kenya, Sudan, Burundi and Vietnam. New orders are also in progress for Guinea Conakry and Burkina Faso and new contacts have also started with other countries. Through the ADF, these countries have seen the cost of inhalers fall by as much as 50%, making one year of treatment with Beclometasone and Salbutamol for a patient with severe asthma cost less than 40 USD. However, the ADF services have only been used by a very limited number of countries. Millions of people with asthma in low- and middle-income countries currently have no treatment, or inappropriate treatment.
Conclusion (max 400 words): Having a procurement system in place for asthma medicines at global level is only part of the solution to improve asthma management in low- and middle-income countries. To change the situation countries need also political will to invest in asthma management and funds to support their activities. The financing options used by the first ADF clients can be an incentive for other countries to move forward to implement asthma management. It is also hoped that further actions following the High-Level Meeting on Non-Communicable Diseases in September 2011 will recognise and promote practical solutions such as the ADF.

Community Based Intervention through 1 Stop Centre for Health: A Community Empowerment Approach in Malaysia

Author(s): Noraryana Hassan1
Affiliation(s): 1Ministry of Health, Melaka, Malaysia
1st country of focus: Malaysia
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): This paper presents the outcome results of a 6 months structured intervention program  among 107 subjects in a  community in Pantai Peringgit, Melaka, Malaysia which aimed to reduce  Non Communicable diseases (NCD) risk factors and improve walking stamina.
Background (max 200 words): Obesity is an epidemic in Malaysia and Melaka has one of the highest prevalence of people with obesity in the country. Experts propose that the possible reasons are sedentary lifestyles and over eating which contribute to the fast growth of obesity and is responsible for deaths caused by Non Communicable diseases (for example  ischemic heart diseases, diabetes, and hypertension).  A structured intervention program through community empowerment was found to be effective in making changes in sedentary lifestyle and unhealthy eating.
Objectives (max 100 words): The objective of this study was to reduce the NCD risk factors among the community in Pantai Peringgit Melaka through a structured 6 months community based intervention program.
Methodology (max 400 words): This is a cross sectional study with structured community based intervention.  A total of 107 people in the Pantai Peringgit Community were recruited in the study.  Study subjects were chosen from those who conducted self screening of NCD risk factors and agreed to the intervention. All screening and intervention programs were conducted in the community centre called 1 Stop Centre For Health. Screening and intervention activities were conducted by 10 volunteers in this community lead by the Pantai Peringgit community leaders. Community leader and the volunteers were trained by the Melaka State Health Department in the two main parts components of the intervention screening and intervention. The intervention began in March 2011.  The 107 participants were divided into 8 groups. The intervention programs were easily monitored by the volunteers and community leader in these smaller groups. In order to reduce dropout rate, competitions were held among the groups. Examples of physical activities include aerobic, brisk walking and football games which were carried out twice a week. The diet intervention was carried out by 4 series of health education talks, 4 cooking demonstrations and cooking competitions. Screenings of pre and post intervention included individual BMI, random blood sugar and blood pressure. All data were monitored by the individual through a web system which was then monitored by the Melaka State Health Department. To see the improvement of walking stamina of the intervention groups, every individual in each group had to walk for 5 km and the mean time for each group was recorded.
Results (max 400 words): A total of  number 34 (31.8 % ) men and 73  (68.2 %) women agreed to participate in the intervention program. The mean age was 46.8±17.1. In the pre assessment screening 20.6%  were in the group of normal weight , 35.5 % overweight and 43.0 % obese. After the 6 months intervention the percentage of overweight increased to 38.3%,  however the obesity group reduced to 41.1%.  Percentage of normal BMI remains the same. The mean sugar level was 7.4±7.1 in the pre assessment screening reduced to 5.3 ±1.2 after 6 months intervention (p<0.001). The mean for systolic blood pressure reduced from 134.3±25.1 to 120.2±20.3 (p<0.001) and mean for diastolic reduced from 82.8 ±18.2 to 72.4 ±9.2 (p<0.001). For random blood sugar level the mean reduced from 7.4 ±7.1 to 5.3 ± 1.2. 2 (p<0.001). The mean time to complete 5 km walk between the groups improved from 65 minutes before the intervention to 43.9 after 3 months and to 40 minutes after 6 months.
Conclusion (max 400 words): Structured Community based intervention with the concept of community empowerment has reduced the NCD risk factors of Pantai Peringgit community. The percentage of people in the obese group reduced after the 6 month intervention. Mean systolic blood pressure, mean diastolic blood pressure and mean fasting sugar level showed significant reduction.  Walking stamina among the group has also improved.

Estimation of Salt Intake Using 24-Hour Urine Collection: Switzerland

Author(s): Aline Chappuis1, Fred Paccaud1, Murielle Bochud1, Michel Burnier2
Affiliation(s): 1Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland, 2 Division of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
1st country of focus: Switzerland
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): We submit this abstract on behalf of the Swiss Survey on Salt Group. Within the framework of a nationwide strategy on dietary salt reduction launched by the Swiss Federal Office of Public Health, we conducted a national population-based survey aiming at estimating dietary salt intake in the population aged 15 years and over, using 24-hour urine collection. Mean urinary salt excretion was 10.6 g/24h in men and 7.8 g/24h in women; a large proportion of participants had a urinary salt excretion above the recommended thresholds, which is similar to what is found in other Western countries.
Background (max 200 words): The Swiss Federal Office of Public Health has launched a nationwide strategy on dietary salt reduction for 2008-2012. The aim of this strategy is to reduce salt intake to less than 8g/day in the population. The long term goal is to stabilize salt intake to the WHO-recommendation of less than 5g/day. Data on dietary salt intake are lacking at a national level in Switzerland.
Objectives (max 100 words): We conducted a national survey in 2010-2011 to estimate dietary salt intake in the population living in Switzerland aged 15 years and over.
Methodology (max 400 words): The population-based survey included eleven study centers, covering nine cantons and the three main linguistic regions of Switzerland (German, French and Italian). Participants aged 15 years and over were recruited within eight predefined sex- and age-strata, using a 2-level sampling strategy similar to the one used in the Swiss Health Interview Surveys. Participants collected 24-hour urine; collections <300ml were excluded from the following analysis (n=3). Urinary sodium was measured centrally in the Laboratoire de Chimie Clinique, CHUV, Lausanne, Switzerland using indirect potentiometry.
Results (max 400 words): Data from 704 men and 740 women were available for the analysis. The mean (SD) urinary salt excretion was 10.6 (4.2) g NaCl/24h in men and 7.8 (3.3) g NaCl/24h in women (p<0.001). In the 15-29, 30-44, 45-59 and ≥60 year-old groups, salt excretion was 9.8, 11.1, 11.3 and 10.2 g NaCl/24h in men and 7.8, 8.2, 8.2 and 7.0 g NaCl/24h in women. The age-, sex- and body mass index-adjusted mean urinary salt excretion in the German-speaking region (9.3 g/24h) was higher than in the French- (8.7 g/24h) but similar to the Italian- (9.2 g/24h) speaking region. Cantons of Luzern and St.Gallen had significantly higher salt excretion (9.8 g/24h) than Zürich and Basel (mean 9.0 g/24h), which highlights heterogeneity within the German-speaking region. A large proportion of men and women had a urinary salt excretion above the WHO recommendation of 5 g/day (94.2% and 78.7% respectively, p<0.001); furthermore, 71.2% of men and 41.5% of women (p<0.001) were also above the national short-term objective of 8 g/day.
Conclusion (max 400 words): Similar to what is found in other Western countries, 24-hour urinary salt excretion, which reflects dietary salt intake, is above the recommended thresholds in a large part of the population of Switzerland, especially in men and middle-aged people. The observed small regional differences do not justify different strategies to reduce salt intake in the Swiss population.

The Gait and Balance of Patients with Diabetes Can Be Improved: A Randomised Controlled Trial in Switzerland

Author(s): Lara Allet1, R. A. de Bie1, S. Armand2, A. Golay1
Affiliation(s): 1Geneva University Hospital and University of Geneva, Maastricht University and  Caphri Research School, Maastricht, the Netherlands
1st country of focus: Switzerland
Relevant to the conference theme: Communicable chronic diseases
Summary (max 100 words): This randomised controlled trial evaluates the effect of a specific training programme on gait and balance of diabetic patients. A group of 71 diabetic patients was recruited and randomly assigned to an intervention (n=35) or a control group (n=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function orientated strengthening (twice weekly over 12 weeks). The control group received no treatment. The authors conclude that specific training can improve gait speed, balance, muscle strength and joint mobility in diabetic patients.
Background (max 200 words): Type 2 diabetes mellitus and its common complication, peripheral neuropathy, affect a large population. Peripheral neuropathy leads to sensory and motor deficits, which often results in mobility-related dysfunction, alterations in gait characteristics and balance impairments. Diabetic patients with peripheral neuropathy have lower gait velocity, decreased cadence, shorter stride length, increased stance time and higher step to step variability compared with healthy controls. These gait alterations increase on irregular surfaces. In addition, diabetic patients are known to suffer from increased risk of injurious falls. Fall-related injuries are often assumed to trigger a vicious circle because of their potentially detrimental influence on the physical activity levels of affected patients. Public Health guidelines for diabetes management recommend that patients perform at least 30 min of physical activity a day six times a week, requiring adequate gait security and balance. However, little is known about treatment strategies that could improve patients’ gait and balance, thereby also reducing the risk of falls.
Objectives (max 100 words): This study evaluates the effect of specific training programme on gait and balance of diabetic patients.
Methodology (max 400 words): This was a randomised controlled trial (n=71) with an intervention (n=35) and control group (n=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function orientated strengthening (twice weekly over 12 weeks). Controls received no treatment. Individuals were allocated to the groups in a central office. Gait, balance, fear of falls, muscle strength and joint mobility were measured at baseline, after intervention and at 6-month follow-up.
Results (max 400 words): After training, the intervention group increased habitual walking speed by 0.149 m/s (p<0.001) compared with the control group. Patients in the intervention group also significantly improved their balance (time to walk over a beam, balance index recorded on Biodex balance system), their performance-oriented mobility, their degree of concern about falling, their hip and ankle plantar flexor strength, and their hip flexion mobility compared with the control group. After 6 months, all these variables remained significant except for the Biodex sway index and ankle plantar flexor strength.
Conclusion (max 400 words): Although our study showed positive results, clinicians should be aware of possible adverse events. Two patients developed pain in their Achilles tendon, obliging us to slow down the progression for ‘toe walking’ and ‘one leg stance’exercises. More moderate progression and a longer warm up could possibly avoid such incidents. To the best of our knowledge, this is one of the first randomised controlled trials to describe an effective physiotherapy training programme geared to concurrently improve the balance and gait of diabetic patients. Future studies should examine the effect of exercise regimens on patient groups differentiated by neuropathy status (patients without, with mild or with severe peripheral neuropathy, identified by a more complex instrument for peripheral neuropathy screening). In addition, outcomes such as functional capacity, the number of falls or physical activity level should be considered in order to draw meaningful conclusions about exercise efficacy among patients with diabetes, thereby facilitating medical and clinical decision-making. Overall we can conclude that specific training can improve gait speed, balance, muscle strength and joint mobility in diabetic patients.

Sex Differences in the Association between Serum Uric Acid and Adiposity Markers in the Population-Based CoLaus Study

Author(s): Tanica Lyngdoh1, Pascal Bovet1, Pedro Marques-Vidal1, Gerard Waeber1, Peter Vollenweider1, Murielle Bochud1
Affiliation(s): Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
1st country of focus: Switzerland
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Women and men differ in their serum uric acid (SUA) levels and fat distribution. As very few large scale population-based studies have systematically assessed sex differences in the relationship between SUA and markers of adiposity, we explored these associations in the CoLaus study. Our study supports previous findings that an elevated serum uric acid is closely associated with measures of adiposity. We present additional information on the differential effects of sex on the relationship. Our findings seem to suggest that the observed sex-differences are, in large part, explained by leptin.
Background (max 200 words): High serum uric acid (SUA) is known to co-exist with the different components of metabolic syndrome including obesity. Epidemiological and clinical studies have established positive associations between SUA and different adiposity markers including waist circumference, body mass index, waist-hip ratio, visceral fat, subcutaneous fat and total body fat. Sex is an important determinant underlying the relationship between SUA and metabolic syndrome. This is evident by the finding that the association is stronger in females than in males. Furthermore, recent findings suggest the role of leptin as a plausible explanation for the sex differences observed in the metabolic pathways involved in metabolic syndrome. Although SUA concentrations, serum leptin, and body fat distribution show obvious sex differences, very few studies have tried to systematically assess sex-differences in the relationship between serum uric acid and the different markers of adiposity.
Objectives (max 100 words): The objective of the current study was to explore sex differences in the relationship of serum uric acid with markers of adiposity and to assess if leptin could be a factor underlying the relationship between serum uric acid and adiposity.
Methodology (max 400 words): In 6184 participants aged 35 to 75 years randomly selected from the general population in Lausanne, we measured SUA, leptin and anthropometric variables including weight, height, body mass index (BMI),  waist circumference (WC), and fat and lean mass (using bioimpedance), and assessed lifestyle behaviors using a questionnaire. Fasting venous blood were collected after an overnight fasting.  Uric acid was measured by uricase-PAP and leptin by ELISA. Multiple median regressions were used to test the association of SUA with the different adiposity markers (as dependent variable) one at a time. We tested the interaction of SUA with sex by adding a multiplicative interaction term in the model.
Results (max 400 words): Mean SUA was higher in men (361.1 ± 75.7 µmol/L) than in women (270.6 ± 67.2 µmol/L). Men had higher mean weight, height, BMI and WC, while women had higher fat mass (p values <0.0001 for all). Positive correlations of SUA with weight, BMI, WC, and fat mass were stronger in women than in men (Spearman r:  0.35, 0.37, 0.40, and 0.41 in women, and 0.26, 0.30, 0.31, and 0.30 in men, respectively, p<0.0001 for all). In univariate analysis, SUA was strongly associated with weight, BMI, WC and fat mass in both men and women and the regression coefficients were almost twice as large in women than in men (p<0.001 for all associations). The associations remained significant upon adjustment for age, alcohol intake, smoking, Modification of the diet in Renal Disease (MDRD), diabetes, hypertension and the use of diuretics (regression coefficients ±SE for weight, BMI, WC and fat mass was 3.35 ±0.38; 1.25±0.10; 3.43±0.30; 2.00±0.15 in men and 5.61±0.38; 2.18±0.13; 6.21±0.32; 4.13±0.22 in women respectively, p<0.001 for all). In models including men and women together, there was a statistically significantly interaction by sex for all the associations between SUA and adiposity markers (p<0.001 for all). The interaction by sex was unaltered upon adjustment for insulin but was no longer significant upon adjustment for leptin.
Conclusion (max 400 words): In this population-based study of Caucasians aged 35 to 75 years, we found a strong association between SUA and markers of adiposity, with women showing stronger associations than men. We observe the sex difference to be largely explained by leptin, consistent with a leptin resistance in maintaining higher fat mass in women.

Effects of Particulate Matters on Inflammatory Markers in the General Adult Population

Author(s): Dai-Hua Tsai1,2, Nadia Amyai3, Pedro Marques-Vidal1, Jia-Lin Wang2, Michael Riediker4, Vincent Mooser5, Fred Paccaud1, Gerard Waeber3, Peter Vollenweider3, Murielle Bochud1
Affiliation(s): 1Institute of Social and Preventive Medicine, Lausanne University Hospital, Epalinges, Switzerland, 2Department of Chemistry, National Central University, Taoyuan County, Taiwan,  3Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland, 4 Institute for Work and
Health (IST), Lausanne, Switzerland, 5 Department of Genetics, GlaxoSmithKline, Philadelphia, PA, USA
1st country of focus: Switzerland
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Particulate air pollution is associated with increased cardiovascular risk. The induction of systemic inflammation following particle inhalation represents a plausible mechanistic pathway. The purpose of this study was to assess the associations of short-term exposure to ambient particulate matters of aerodynamic diameter less than 10 μm (PM10) with circulating inflammatory markers in 6183 adults in Lausanne, Switzerland. The results show that short-term exposure to PM10 was associated with higher levels of circulating IL-6 and TNF-α. The positive association of PM10 with markers of systemic inflammation materializes the link between air pollution and cardiovascular risk.
Background (max 200 words): Variations in short-term exposure to particulate matters (PM) have been repeatedly associated with daily all-cause mortality. Particle-induced inflammation has been postulated to be one of the important mechanisms for increased cardiovascular risk. Experimental in-vitro, in-vivo and controlled human studies suggest that interleukin 6 (IL-6) and tumor-necrosis-factor alpha (TNF-α) could represent key mediators of the inflammatory response to PM. The associations of short-term exposure to ambient PM with circulating inflammatory markers have been inconsistent in studies including specific subgroups so far. The epidemiological evidence linking short-term exposure to ambient PM and systemic inflammation in the general population is scarce. So far, large-scale population-based studies have not explored important inflammatory markers such as IL-6, IL-1β or TNF-α. We therefore analyzed the associations between short-term exposure to ambient PM10 and circulating levels of high-sensitive CRP (hs-CRP), IL-6, IL-1β and TNF-α in the population-based CoLaus study.
Objectives (max 100 words): To assess the associations of short-term exposure to ambient particulate matters of aerodynamic diameter less than 10 μm (PM10) with circulating inflammatory markers, including hs-CRP, IL-6, IL-1β and TNF-α, in adults aged 35 to 75 years from the general population.
Methodology (max 400 words): All study subjects were participants to the CoLaus study (www.colaus.ch) and the baseline examination was carried out from 2003 to 2006. Overall, 6184 participants were included. For the present analysis, 6183 participants had data on at least one of the four measured circulating inflammatory markers.  The monitoring data was obtained from the website of Swiss National Air Pollution Monitoring Network (NABEL). We analyzed data on PM10 as well as outside air temperature, pressure and humidity. Hourly concentrations of PM10 were collected from 1 January 2003 to 31 December 2006.   Robust linear regression (PROC ROBUSTREG) was used to evaluate the relationship between cytokine inflammatory and PM10. We adjusted all analyses for age, sex, body mass index, smoking status, alcohol consumption, diabetes status, hypertension status, education levels, zip code, and statin intake. All data were adjusted for the effects of weather by including temperature, barometric pressure, and season as covariates in the adjusted models. We performed simple and multiple logistic regression analyses. Descriptive statistical analysis used the Wilcoxon rank sum test (for medians). All data analyses were performed using SAS software (version 9.2; SAS Institute Inc., Cary, NC, USA), and a two-sided significance level of 5% was used.
Results (max 400 words): PM10 levels averaged over 24 hours were significantly and positively associated with continuous IL-6 and TNF-α levels, in the whole study population both in unadjusted and adjusted analyses. For each cytokine, there was a similar seasonal pattern, with wider confidence intervals in summer than during the other seasons, which might partly be due to the smaller number of participants examined in summer. The associations of PM10 with IL-6 and TNF-α were also found after having dichotomized these cytokines into high versus low levels, which suggests that the associations of PM10 with the continuous cytokine levels are very robust to any distributional assumption and to potential outlier values. In contrast with what we observed for continuous IL-1β levels, high PM10 levels were significantly associated with high IL-1β. PM10 was significantly associated with IL-6 and TNF-α in men, but with TNF-α only in women. However, there was no significant statistical interaction between PM10 and sex. For IL-6 and TNF-α, the associations tended to be stronger in younger people, with a significant interaction between PM10 and age groups for IL-6. PM10 was significantly associated with IL-6 and TNF-α in the healthy group and also in the “non-healthy” group, although the statistical interaction between healthy status and PM10 was not significant.
Conclusion (max 400 words): In summary, we found significant independent positive associations of short-term exposure to PM10 with circulating levels of IL-6 and TNF-α in the adult population of Lausanne. Our findings strongly support the idea that short-term exposure to PM10 is sufficient to induce systemic inflammation on a broad scale in the general population. From a public health perspective, the reported association of elevated inflammatory cytokines with short-term exposure to PM10 in a city with relatively clean air such as Lausanne supports the importance of limiting urban air pollution levels.

Cardiovascular Disease Mortality Trends in a Rapidly Developing Country in the African Region

Author(s): Silvia Stringhini1, Flavie Sinon2, Joaquim Didon2, Jude Gedeon2, Fred Paccaud1 Pascal Bovet1,2,
Affiliation(s): 1Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland, 2Ministry of Health, Victoria, Republic of Seychelles
1st country of focus: Seychelles
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Cardiovascular diseases (CVD) mortality is declining in high income countries. In low and middle income countries (LMIC), the total CVD burden is expected to increase due to demographic transition, but few reliable data allow assessing trends in age-adjusted cause-specific CVD rates. The Republic of Seychelles, a middle-income small island state located east to Kenya, is one of the few countries in the African region where vital statistics are obtained for the whole population. We examined trends in all-cause, CVD, stroke and myocardial infarction (MI) mortality between 1989-91 and 2008-10. Despite the increasing and aging population between 1989 and 2010, the total number of stroke deaths did not change over time and the number of MI deaths decreased. The age-adjusted mortality rates decreased by (men/women) 26%/25% for stroke and 39%/43% for MI between 1889 and 2010. Decreasing age-adjusted CVD mortality rates underlie reduced incidence (improved risk factors levels in the population) and/or improve case-fatality (improved case management). However, while MI mortality rates are low, stroke mortality rates remain high which is consistent with the high prevalence of hypertension in Seychelles. This emphasizes the need to further strengthen CVD prevention and control.
Background (max 200 words): CVD mortality has decreased markedly over the past three decades in high income countries. In contrast, the total CVD burden (i.e. the total number of CVD deaths) is expected to increase in LMICs due to increasing and aging populations (demographic transition). However, few reliable data are available on age-adjusted mortality rates in LMICs, because of the paucity of vital statistics or otherwise reliable population-based information systems in these countries, in particular in the African region. The Republic of Seychelles, a rapidly developing country, represents a unique opportunity to examine trends in cause-specific mortality in the African region, as all deaths are medically certified along vital statistics (numerator), the age- and sex-distribution of the population is known (denominator), and barriers to health care access are limited due to free health care. Assessing age-adjusted trends is important in order to monitor the epidemiological situation and to inform prevention and treatment strategies.
Objectives (max 100 words): The objective of this study was to examine trends in crude and age-adjusted mortality for CVD, stroke and MI in the Seychelles between 1989 and 2010. The emphasis is on stroke and MI, which are diagnoses that rely on minimal investigations and are likely to have been reported fairly reliably during the 22-year investigation period.
Methodology (max 400 words): All deaths recorded in the vital statistics between 1989 and 2010 were reviewed and manually coded. We considered stroke and MI as the cause of death if these diagnoses were reported in any of the 4 fields for underlying and concomitant causes of death. This approach (vs. considering only the first underlying cause of death) limits misclassification since the sequences of the underlying causes of death were recorded without formal validation. This approach also limits biases related to changing coding practices over time. However, the ascertainment of causes of death based on diagnoses appearing in any of 4 fields slightly overestimates the true MI and stroke mortality rates. The estimation of changes over time is unbiased. The yearly distribution of the population was available from census data, regularly updated by civil status authorities. Mortality rates for each year were directly standardized to the WHO 2001 standard population. In view of the small size of the country, and the relatively small number of deaths, we pooled events within 3-year groups. Trends in mortality were based on yearly analysis and examined using Poisson regression.
Results (max 400 words): Between 1989-91 and 2008-10, the population increased by 27% (from 204’854 to 261’033 people) and the proportion aged ≥70 years increased from 4% to 6%. A total of 13’163 deaths (7560 men and 5603 women) occurred in 22 years. The mortality rates (crude/age-adjusted, per 100’000) were 947/1625 for men and 684/704 for women in 1989-91 and 1083/1456 for men and 519/657 for women in 2008-10. CVD mortality represented 46% of all deaths in 1989-91 (762 cases) and 42% in 2008-10 (846 cases). Stroke and MI were reported as a cause of death in 17% and 7% of all death certificates in 1989-91 and in 14% and 5% in 2008-10. The total number of CVD deaths increased by 11% in 2008-10 compared to 1989-91; the number of stroke deaths was virtually unchanged (285 cases in 1989-91 and 290 in 2007-10); and the total number of MI deaths decreased (116 cases in 1989-91 and 97 in 2008-10). Comparing 1989-91 to 2008-10, age-standardized mortality rates (men/women, per 100,000) decreased from 764/343 to 565/310 for CVD; from 255/144 to 190/108 (a decrease of 26%/25%) for stroke; and from 119/52 to 79/30 (a decrease of 39%/43%) for MI. Based on yearly analysis, the decline in CVD, stroke and MI mortality was monotonous (an annual decrease (men/women) of 3.3%/2.7% for stroke and 3.0%/3.8% for MI, all p<0.001).
Conclusion (max 400 words): The total numbers of stroke and MI deaths in Seychelles did not increase over time despite the rapidly aging and growing population, and age-adjusted mortality rates decreased by approximately 25% for stroke and approximately 40% for MI between 1989 and 2010. This marked decline in CVD, which is consistent with the situation in high income countries and in some middle-income countries (e.g. Argentina or Brazil) underlie reduced incidence and/or improved case-fatality (e.g. decreasing prevalence of smoking, improved treatment for hypertension, better case management of acute cases, etc). While mortality rates of MI are fairly low by international standards, mortality rates for stroke remain high and are consistent with the high prevalence of several major risk factors in Seychelles, particularly hypertension.  This emphasizes the need to strengthen primary and secondary CVD prevention.

Predictive Value of Elevated Blood Pressure during Childhood: Seychelles

Author(s): Arnaud Chiolero1, Gilles Paradis2, Georges Madeleine3, Pascal Bovet1
Affiliation(s): 1Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland, 2Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada, 3Ministry of Health and Social Services, Victoria, Seychelles
1st country of focus: Seychelles
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Hypertension has roots in childhood and screening for elevated BP beginning in children is advocated.  However, having elevated blood pressure (BP) in childhood may not be associated with a high probability of elevated BP later in life.  Using data collected in school children of the Seychelles, we showed that having an elevated BP on one occasion in childhood is a weak predictor of sustained elevated BP 3-4 years later.
Background (max 200 words): Screening of elevated blood pressure (BP) in children has been advocated to early identify hypertension. However, identification of children with sustained elevated BP is challenging due to the high BP variability.  The value of an elevated BP measure during childhood and adolescence for the prediction of future elevated BP is not well described.
Objectives (max 100 words): We assessed the positive (PPV) and negative (NPV) predictive value of high BP for sustained elevated BP in cohorts of children of the Seychelles, a rapidly developing island state in the African region.
Methodology (max 400 words): Serial school-based surveys of weight, height, and BP were conducted yearly between 1998-2006 among all students of the country in four school grades (kindergarten [G0, mean age (SD): 5.5 (0.4) yr], G4 [9.2 (0.4) yr], G7 [12.5 (0.4) yr] and G10 (15.6 (0.5) yr].  We constituted three cohorts of children examined twice at 3-4 years interval:  4,557 children examined at G0 and G4, 6,198 at G4 and G7, and 6,094 at G7 and G10.  The same automated BP measurement devices were used throughout the study.  BP was measured twice and averaged at each exam. Obesity and elevated BP were defined using the CDC (BMI 95th sex-, and age-specific percentile) and the NHBPEP criteria (BP 95th sex-, age-, and height specific percentile), respectively.
Results (max 400 words): Prevalence of obesity was 6.1% at G0, 7.1% at G4, 7.5% at G7, and 6.5% at G10.  Prevalence of elevated BP was 10.2% at G0, 9.9% at G4, 7.1% at G7, and 8.7% at G10.  Among children with elevated BP at initial exam, the PPV of keeping elevated BP was low but increased with age: 13% between G0 and G4, 19% between G4 and G7, and 27% between G7 and G10, respectively.   Among obese children with elevated BP, the PPV was higher: 33%, 35% and 39% respectively. Overall, the probability for children with normal BP to remain in that category 3-4 years later (NPV) was 92%, 95%, and 93%, respectively.  By comparison, the PPV for children initially obese to remain obese was much higher at 71%, 71%, and 62% (G7-G10), respectively.  The NPV (i.e. the probability of remaining at normal weight) was 94%, 96%, and 98%, respectively.
Conclusion (max 400 words): During childhood and adolescence, having an elevated BP at one occasion is a weak predictor of sustained elevated BP 3-4 years later.  In obese children, it is a better predictor.

Community Empowerment – Intervention of Non Communicable Diseases in Luanti Baru Village District of Ranau, Sabah, Malaysia

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Author(s): Koay TengKhoon1, Rahim Bin Sulong1, Chin Kim Ling2, Saibi Modusin2
Affiliation(s): 1Tuaran Area Health Office, Sahah, Malaysia, 2Ranau Health Office, Ranau, Malaysia
1st country of focus: Malaysia
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): This paper presents the results of ongoing intervention programmes for non-communicable diseases (NCD) through community empowerment in "Luanti Baru" Village, district of Ranau
Background (max 200 words): Non-communicable diseases have increased in Malaysia where we are face an epidemiological transition. There is a need for affordable and effective community based preventive programs. By empowering the community, it is possible to make the prevention of non-communicable diseases more affordable, accessible and effective.
Objectives (max 100 words): The objective of this paper is to describe and evaluate ongoing intervention programmes for non-communicable diseases through community empowerment in “Luanti Baru” Village, Ranau.
Methodology (max 400 words): Pre assessment was completed with a universal sample to evaluate the Body Mass Index (BMI), Blood Pressure (BP) and Blood Glucose for the community aged 13 years and above. We used a self administered questionnaire to collect data about socio-demographic characteristics, eating and physical activities, cigarette smoking and alcohol consumption habits.  The intervention program commenced in November 2010. The intervention program consists of educative sessions on healthy diet, physical activity, cardiovascular diseases, tobacco & alcohol uses and mental health. A total of 14 community members were selected and trained to be NCDs facilitator to facilitate the intervention program. Physical activities session, health counselling clinic, and healthy cooking demonstrations were  also carried out.
Results (max 400 words): The total number of participants was 89. The proportion of males and female was 48.3% and 51.7% respectively. The age group of 13-34 years was 44.9% and 35 years & above was 55.1%. A proportion 62.9% was overweight or obese, 10.8% were found to have borderline blood sugar, 76.4% were found to be either borderline or hypertensive and 72% was smokers. Based on food intake assessment score, 51.3% were excellent, 39.5% were good and 9.2% were fair. Physical activity status for the past 1 week based on MET (Metabolic Equivalent for physical activity) reviewed that 56.6% was inactive.  After 6 months intervention, a total of 29 (64.4%) out of 45 residents participated in the intervention recorded weight reduction, 5 (62.5%) out of 8 borderline blood sugar became normal, 5 (11%) out of 44 participants became normal blood pressure and three residents successfully quit smoking.
Conclusion (max 400 words): Intervention through community empowerment is important and could possibly lead to prevention of non communicable diseases in the community.

Immigrant Diabetes in Spain: IDIME Study

Author(s): Francesc Xavier Cos Claramunt1,2, Josep Franch Nadal2, Albert Goday Arno2, Sara Artola Menendez2
Affiliation(s): 1CAP sant Marti de Provençals en Institut Catala de la Salut, Barcelona, Spain, 2redGDPS (Spanish type 2 diabetes Primary Care Network)
1st country of focus: Spain
Relevant to the conference theme: Non-communicable chronic diseases.
Summary (max 100 words): To analyze the epidemiological characteristics of diabetes mellitus in the immigrant population of Spain.
Methodology (max 400 words): This was a national cross-sectional case-control study (diabetic immigrants versus native diabetic, a proportion of 2 to 1) of  875 patients with diabetes mellitus (307 native, 169 South-Americans, 126 Hindustani, 184 Maghribian and 89 from other countries). Sociodemographic, anthropometric and clinical variables of DM were analyzed. The existence of cardiovascular risk factors, their treatment and the presence of complications related to diabetes was studied by using descriptive and analytical statistics.
Results (max 400 words): The results revealed that diabetic immigrants have a lower average age than Spanish diabetics (50.4 ±11.5 vs 62.7 ±13 years) with less diabetes evolution years (5.8 ±6.4 vs 10.5 ±8.3 years) (p<0.001). South-American diabetics show higher BMI (31 ±5.8 kg/m2) (p<0.001). There is no statistical significance between abdominal perimeter nor waist-to-height ratio. The glycaemic control in diabetic immigrants is worse than in the native diabetic (HbA1c 7.8 ±2.2 vs 7.1 ±1.5%), especially among Hindustani (8.1 ±2.5%) (p<0.001). Considering the treatment of hyperglycemia, there is less use of insulin among diabetic Hindustani (12.8% vs 30.7% other immigrants) (p<0.001). However, the prevalence of complications related to diabetes is lower in diabetic immigrants, especially the macrovascular ones (7.7% vs 24.4%) (p<0.01).
Conclusion (max 400 words): Diabetic immigrants show important epidemiological differences compared to native diabetics. They are younger, with less disease evolution time and have a worse metabolic control even though the prevalence of diabetes related complications is lower (especially the macrovascular), affirming the image of “healthy diabetic immigrant”.