Public Health Approach to Cardiovascular Disease Prevention & Management Cardiovascular diseases (CVDs) are the number one cause of death and disability globally, being the most important public health problem that needs to be tackled as more people die annually from CVDs than from any other cause. Over three-quarters of CVD deaths take place in low- and middle-income countries. This book on cardiovascular diseases provides an overview of the global and regional challenges associated with CVDs. Coupled with case studies and theoretical concepts, it helps the reader to contextualize CVDs in the broader public health system and the administrative aspects of practicing CVD control approaches for improved population health in their local setting. Key features: 1. Covers existing and emerging issues in cardovascular disease epidemiology and prevention. 2. Has a multidisciplinary approach in content and audience. 3. Connects with health systems and relevant sustainable development goals. 4. Provides case studies enabling readers to understand and apply evidence-based solutions to key public health issues. 5. Has inputs from globally renowned public health experts. The book is a master piece. There are very few books that integrate public health aspects of CVD prevention and management. The book is unique in that it addresses all the known risk factors along with introducing emerging risk factors such as air pollution while emphasizing their role across the life span. In terms of solutions it discusses a range of responses from health promotion at one end of the spectrum to universal health coverage at the other end. This book will be useful not only to clinicians but also to public health experts all over the world. Dr V. Mohan President & Chief of Diabetes Research, Madras Diabetes Research Foundation Chairman & Chief Diabetologist, Dr Mohan’s Diabetes Specialities Centre Jorge Luis Borges (1899–1986) quoted “Of the various instruments invented by man, the most amazing is the book; all the others are extensions of the body of it…Only the book is an extension of the imagination and memory”. We celebrate the Publication of Public Health Approaches to Cardiovascular Disease Prevention & Management by Prof. Prabhakaran Dorairaj, K. Srinath Reddy, and Shuchi Anand, and invite everyone interested in cardiovascular health to the fruitful reading of it. The book synthesizes the most modern concepts of the prevention and management of cardiovascular diseases, particularly from the perspective of the implementation science and Public Health. Prof Daniel Pineiro Full Professor of Medicine, Universidad de Buenos Aires, Argentina President-Elect, World Heart Federation, 2021–2022 Trustee, Board of Trustees, American College of Cardiology, 2018–2021 This book provides a comprehensive overview focused on one of the most pressing public health challenges of our times. Uniquely presenting a truly global health perspective, the authors carefully dissect the complex evidence relating to the promotion of optimal cardiovascular health across the life course. For anyone engaged in the research or practice of public health relating to cardiovascular conditions, especially in low- and middle-income countries, here is an ideal “one-stop-shop” for the current state of the evidence and its practical applications. Prof Anushka Patel Vice-Principal Director & Chief Scientist The George Institute for Global Health Australia Public Health Approach to Cardiovascular Disease Prevention and Management” flls in a needed gap in the feld of cardiovascular literature by providing a more holistic approach to cardiovascular health, focusing not only on management of disease but also on promotion of cardiovascular health from a public health perspective. This very well written book will certainly be an excellent companion to all of those interested in cardiovascular health and will be another piece contributing to achieve our common goal of “cardiovascular health for everyone”. Prof Fausto J Pinto Director, Serviço de Cardiologia e Departamento Coração e Vasos do CHULN / Head of Department Professor Catedrático de Medicina/Cardiologia, FMUL—Full Professor President, Centro Cardiovascular da Universidade de Lisboa (CCUL) President, World Heart Federation (WHF) (2021–2022) Past-President, European Society of Cardiology (ESC) Despite cardiovascular diseases being the leading causes of premature mortality and disability particularly in low middle income countries, policy and prevention are often neglected and this book is a timely publication to help implement evidence based recommendations to improve population level and patient outcomes. Prof Kamlesh Khunti Professor of Primary Care Diabetes and Vascular Medicine University of Leicester, UK Public Health Approach to Cardiovascular Disease Prevention & Management Edited By Dorairaj Prabhakaran Public Health Foundation of India and Centre for Chronic Disease Control Shuchi Anand Stanford University K. Srinath Reddy Public Health Foundation of India Boca Raton London New York CRC Press is an imprint of the Taylor & Francis Group, an informa business First edition published 2023 by CRC Press 6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742 and by CRC Press 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN CRC Press is an imprint of Taylor & Francis Group, LLC © 2023 Taylor & Francis Group, LLC This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily refect the views/opinions of the publishers. 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Coupled with case studies and theoretical concepts, it helps the reader to contextualize CVDs in the broader public health system and the administrative aspects of practicing CVD control approaches for improved population health in their local setting”— Provided by publisher. Identifers: LCCN 2022043142 (print) | LCCN 2022043143 (ebook) | ISBN 9781032403571 (hardback) | ISBN 9781138483620 (paperback) | ISBN 9781003352686 (ebook) Subjects: MESH: Cardiovascular Diseases | Public Health Practice | Health Policy Classifcation: LCC RA645.C34 (print) | LCC RA645.C34 (ebook) | NLM WG 120 | DDC 362.1961— dc23/eng/20221103 LC record available at https://lccn.loc.gov/2022043142 LC ebook record available at https://lccn.loc.gov/2022043143 ISBN: 978-1-032-40357-1 (hbk) ISBN: 978-1-138-48362-0 (pbk) ISBN: 978-1-003-35268-6 (ebk) DOI: 10.1201/b23266 Typeset in Palatino by Apex CoVantage, LLC Dedicated to our students, mentees, patients and the population-at-large from whom we have learnt a lot. Contents Preface. ...................................................................... ix Acknowledgments. ........................................................... xi About the Editors. ........................................................... xiii List of Contributors .......................................................... xv 1 Introduction to Cardiovascular Diseases..............................................1 Dorairaj Prabhakaran 2 Cardiovascular Diseases Worldwide..................................................8 Thomas A. Gaziano 3 Concepts of Risk and Risk Factors...................................................19 Rima N. Pai and Shivani A. Patel 4 Concepts in Prevention ............................................................29 Radhika Prakash Asrani and Shivani A. Patel 5 Risk Factors ......................................................................37 5.1 Cardiovascular Disease Risk Factors.................................................38 Dorairaj Prabhakaran 5.2 Tobacco ..........................................................................43 Manu Raj Mathur and Piyu Sharma 5.3 Diet .............................................................................49 Lindsay M. Jaacks, Arun K. Chopra, and Dorairaj Prabhakaran 5.4 Physical Activity..................................................................57 Shifalika Goenka, Prarthna Mukerjee, and Greg Heath 5.5 Cardiovascular Disease, Overweight, and Obesity: Shared Strategies for Prevention and Management.......................................................61 Johanna Ralston, Piyu Sharma, and Panniyammakal Jeemon 5.6 Alcohol..........................................................................67 Monika Arora, Neha Jain, and Sven Andreasson 5.7 Hypertension.....................................................................73 Arun Pulikkottil Jose and Neil R. Poulter 5.8 Diabetes .........................................................................83 Dorothy Lall, Ram Jagannathan, and K.M. Venkat Narayan 5.9 Lipids ...........................................................................94 Samuel S. Gidding and Arun K. Chopra 6 Emerging and Life-Course Factors in CVD..........................................102 Krithiga Shridhar, Vinita Subramanya, and Poornima Prabhakaran 7 Social Determinants of Cardiovascular Diseases..................................... 118 Panniyammakal Jeemon and K. Srinath Reddy vii CONTENTS 8 How Do We Frame Public Health Policies? ..........................................126 Anand Krishnan, Tilahun Haregu, and Brian Oldenburg 9 Public Health Policies for Prevention and Control of Cardiovascular Diseases ...........135 Sailesh Mohan 10 Situational Analysis of Health Policies for Cardiovascular Disease Prevention and Control.....................................................................144 Sugitha Sureshkumar and Sailesh Mohan 11 Role of Surveillance Systems and Health Observatories for an Intelligent Public Health Approach to Cardiovascular Diseases ..............................................157 Anand Krishnan and Lorraine Oldridge 12 Health Systems Interventions for Preventing CVD in Low- and Middle-Income Countries....................................................................... 167 Shreya Rao, Ricardo A. Peña Silva, and Ambarish Pandey 13 Advocacy and Health Promotion...................................................183 Radhika Shrivastav, Aastha Chugh, Prachi Kathuria, and Manjusha Chatterjee 14 Digital Health and Cardiovascular Disease: Current Status and Future Directions........192 Arun Pulikkottil Jose, Devraj Jindal, and Dorairaj Prabhakaran 15 Public Health Approaches to Rheumatic Heart Disease Prevention and Management.....200 R. Krishna Kumar 16 Cost-Effectiveness Analysis: Methods, Innovations, and Applications ...................209 Kaitlin Harold, Shuchi Anand, and Rachel Nugent 17 Universal Health Coverage for Better Cardiovascular Disease Outcomes in LMICs: Focus on Quality, Not Just Coverage ................................................215 Giridhara R. Babu, Yamuna Ana, Min Kyung Kim, Margaret E. Kruk, and Hannah H. Leslie 18 Monitoring and Evaluation of Cardiovascular Disease Prevention Programs. . . . . . . . . . . . .228 Rajmohan Panda and Abdul Ghaffar Index ...................................................................... 239 viii Preface The iconic Charles Dickens novel A Tale of Two Cities opens with the sentence, “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity”. While this denoted the Dickensian times, it is also applicable to the current status of cardiovascular disease (CVD) across the world. The world has witnessed tremendous advancements in prevention and management, with an amazing decline (of more than 50%) in CVD deaths and disability across most high-income countries of the world. By contrast, in most low- and middle-income countries (LMICs), where the majority of the world’s population lives, deaths due to CVD have increased in the last few decades and have replaced pre-transitional conditions such as infections and nutritional diseases as the leading contributors to deaths. While this is partly explained by a demographic transition that involves population aging, a high burden of premature mortality due to CVD occurs in productive midlife years in the LMICs. The global burden of disease estimates for 2019 calculate that CVD affected 523 million people, almost double the fgure of two decades earlier, with one in three CVD deaths occurring prematurely in people under 70 years of age. The majority of these premature deaths (around 90%) are in the LMICs. There was an air of optimism in the year 2000 when Joe Flower and colleagues, on the occasion of 50 years of American College of Cardiology, wrote “Yet we can now foresee a future in which medi- cal science might actually defeat cardiovascular disease the way it has defeated polio, smallpox, and other serious scourges of the past”. They emphasized the technological advances that would bring this change in the next 50 years, where living to 100 years would be the norm. The current thinking across the world of cardiology emphasizes the individual approach, ignoring the power of preven- tion and public health approaches. Indeed, as a patient told one of us, “It’s not until you are lying on the cold catheterization lab table that you refect on your life choices”, manifesting the crux of the problem for public health: in order to realize the true value of health and engage in preventive actions, many persons must experience a serious health event. This may be in part why the focus on health becomes one of secondary prevention. Only once a person becomes ‘medicalized’, in other words, only when a person becomes a patient, do they beneft from the largest share of our resources and knowledge basis. Pharmaceutical and device industries proffer lifesaving therapies, but for a small proportion of the world’s population: those who are patients and those who can afford them. While competent clinical care helps to save several lives, the cumulative risk of CVD that builds over the preceding years still snips away several years of healthy life expectancy. Many lives are lost or shortened, despite the beneft of medical care, while some die suddenly without getting to see their doctor. A public health approach to CVD has to combine prevention across the life course at both population and individual levels. This textbook shifts the focus from the patient back to the person and the population. In the frst portion, the reader will be guided through the current clinical understanding of CVDs, in paral- lel with key concepts and strategies that can be applied for primary and secondary prevention. We walk through the well-recognized risk factors for its development, one of which (i.e., tobacco) has been successfully addressed on the individual and sociocultural level, but many of which, including diet and physical activity, remain recalcitrant—and are ripe for creative solutions. Uniquely we acknowledge and address social determinants of cardiovascular health. The frst portion of this book justifes the urgent need for a health systems approach, and the latter portion puts forward a framework for such an approach. A public health-focused health system integrates cost-e ffectiveness analyses with technology assessments, surveillance systems, and formal health promotion strategies. The goal of public health is not only to add life to years but add years to life, thereby ensur- ing everyone has a full and fulsome life which embodies health and well-being. This requires a paradigm shift from CVD to focus on cardiovascular health. Achieving cardiovascular health for all by 2030 (the year of the Sustainable Development Goals [SDGs]) is interdependent on synergy between people adopting patterns of healthy living and the systems that enable and support them. This book attempts to emphasize the importance of public health approaches in achieving cardiovascular health through promotive, preventive, and restorative approaches. This basic tenet resonates throughout the following pages. Dorairaj Prabhakaran Shuchi Anand K. Srinath Reddy ix