9/19/2011 NATIONAL
HEART
F
ORUM Non-Communicable Chronic Diseases: Literature
Review 2011 Victoria House, 7th Floor Southampton Row, London WC1B 4AD UK.
Tel. +44 (0) 20 7831 7420 Fax. +44 (0) 20 3077 5959 http://www.heartforum.org.uk This literature review has been compiled by the National Heart Forum’s
information services team. We would like to thank Alexander Macara for
his assistance and for acting as a reviewer for this project.
More information about our work is available from the National Heart
Forum website at:
http://www.heartforum.org.uk/our-work/information-services/
About the National Heart Forum
The National Heart Forum (NHF) is a leading charitable alliance of 65
national organisations working to reduce the risk of coronary heart
disease and related conditions such as stroke, diabetes and cancer.
Our purpose is to co-ordinate public health policy development and
advocacy among members drawn from professional representative
bodies, consumer groups, voluntary and public sector organisations.
2 Contents
Introduction: Non-communicable Chronic Diseases: Interventions and policies for prevention Literature review 2011
4
Method: Search strategy
4
Topic 1: Interventions for better nutrition
6
Paper 1: Smith-Spangler et al. (2010) Population strategies to decrease sodium intake
and the burden of cardiovascular disease: A cost effectiveness analysis - Annals of
Internal Medicine Vol.152, No. 8
6
Paper 2: Webster et al. (2009) The development of a national salt reduction strategy for
Australia - Asia Pacific Journal of Clinical Nutrition Vol. 18 No. 3
7
Paper 3: Ireland et al. (2010) Achieving the salt intake target of 6g/day in the current
food supply in free-living adults using two dietary education strategies - Journal of the
American Dietetic Association Vol. 110
8
Paper 4: Duffey et al. (2010) Food price diet and health outcomes: 20 years of the
cardia study - Archives of Internal Medicine Vol. 170 No. 5
9
Paper 5: Tan, A.S.L. (2009) A case study of the New York City trans-fat story for
international application - Journal of Public Health Policy Vol. 30 No. 1
10
Topic 2: Interventions for prevention of diseases and conditions
11
Paper 1: Bovet et al. (2010) Addressing non-communicable diseases in the Seychelles:
towards a comprehensive plan of action Global Health Promotion Vol. 17 No. 37
11
Paper 2: Unal, B., Capewell, S., Critchley, J.A. (2006) Coronary heart disease policy
models: a systematic review - BMC Public Health Vol. 6 No. 213
12
Paper 3: Prabhakaran et al. (2009) Impact of a worksite intervention program on
cardiovascular risk factors: A demonstration project in an Indian industrial population
Journal of the American College of Cardiology Vol. 53
13
Paper 4: Milat, A., O'Hara, B., Develin, E. (2009) Concepts and new frontiers for
development - What role should health promoters play in lifestyle-based diabetes
prevention programmes in Australia? Health Promotion Journal of Australia Vol.20 No. 2
14
Topic 3 Prevention through tobacco control
Paper 1: Deason et al. (2010) The Ohio cross-cultural tobacco control alliance:
Understanding and eliminating tobacco-related disparities through the integration of
science, practice and policy. American Journal of Public Health, Supplement 1, Vol. 100
No. S1
15
15
17
Appendix
3 Introduction: Non-communicable Chronic Diseases: Interventions and policies for
prevention - Literature review 2011
September 2011 sees the launch of the UN High Level Summit on NCDs. To tie in with this event and
as a service to our website visitors, the National Heart Forum (NHF) has worked to produce an online
review of research on policy interventions to combat chronic diseases.
This review has been compiled by qualified information staff at the NHF, and includes expert
commentary from NHF trustee Alexander Macara.
We have divided the papers included in this review into three different topics. Each topic page
contains links to the papers reviewed, and a commentary on each paper from our expert reviewer.
Topics



Interventions for better nutrition
Interventions for prevention of diseases and conditions
Prevention through tobacco control policies
For more information about how this review has been compiled and carried out, including our search
strategy and inclusion criteria, see the Method section below.
Disclaimer: Please note that the inclusion of an article in this literature review does not imply the
endorsement of that articles content, including the content of any article references, by the National
Heart Forum. The links to articles provided on these papers are for information only. Any views
represented in the expert commentaries associated with each paper are the views of the individual
author and do no necessarily reflect the views of the National Heart Forum.
We regret that we are unable to provide readers with access to the full text of any publication
featured on these pages.
Method: Search strategy
The topic “Effectiveness of health policies in the prevention and treatment of chronic noncommunicable diseases and obesity” was chosen for the literature review. This topic was chosen to
highlight what has been tested in terms of health policy intervention, and what has and hasn’t
worked in this field so far.
The search strategy for our literature review covered the following databases: PubMed, Global Health,
and the Cochrane database. We were limited to the number of databases available to us to search
both by staff time and resource availability. Due to limitations and differences between each database
searched (such as differences between thesaurus terms and structures) the search had to be adapted
to fit each database. However, every effort was made to ensure that search terms used were as
consistent as possible.
Initially the search strategy was not limited by date as it was uncertain how many papers would be
found and whether limiting by date would reduce the number of results found to too small a number.
However, as the search progressed and the results were pooled it became clear that a date would be
necessary in order to make the project manageable with the time and staff resources available. A
date limit was set to include only papers published in the last 5 years (from 2006 onwards).
All searches were carried out on 24 June 2011
4 The search results were imported into Reference Manager where a duplicates search and elimination
was carried out. The remaining results were hand sifted by abstract, according to inclusion criteria:
‐
‐
‐
‐
‐
Study or review of effectiveness of healthcare policy intervention
Covering prevention of non-communicable chronic disease
Not screening
English language papers only
Papers published in the last 5 years
A further sift of full text of papers selected by abstract was then carried out. The final count of
articles meeting all criteria after completion of the full text sift was 10.
The search stages and results figures for each stage are shown diagrammatically below (figure 1,
p.2). Full details of the search terms are given in the appendix to this document (see p.3).
Figure 1: Literature review search strategy
PubMed
301 records
Global Health
95 records
Cochrane database
27 records
Total after search
423 records
After de-duplication
410 records
After sift on selection criteria based on article abstract
112 records
After review of full text paper:
10 records
5 Topic 1: Interventions for better nutrition
Our search identified 5 different papers relating to interventions aiming in some way to improve the
diet of a population. The interventions discussed in these papers include a ban on trans-fats in New
York City, a study looking at how price of healthy and unhealthy foods could affect intake of these
foods, and several studies looking at strategies to decrease population intake levels of salt.
Paper 1: Smith-Spangler et al. (2010) Population strategies to decrease sodium intake
and the burden of cardiovascular disease: A cost effectiveness analysis - Annals of
Internal Medicine Vol. 152, No. 8
Objective: To assess the cost-effectiveness of 2 population strategies to reduce sodium intake:
government collaboration with food manufacturers to voluntarily cut sodium in processed foods,
modelled on the United Kingdom experience, and a sodium tax.
Conclusion: Strategies to reduce sodium intake on a population level in the United States are likely
to substantially reduce stroke and MI incidence, which would save billions of dollars in medical
expenses.
Commentary by our reviewer
The role of excess salt intake, mostly from processed foods, in raising blood pressure and increasing
the risk of cardiovascular disease is incontestable.
A mathematical (Markov) model was created to project the cost-effectiveness over the lifetime of U.S.
adults aged 40 to 85 years of two conjectured government population strategies to reduce sodium
intake. One was voluntary collaboration with food manufacturers to cut sodium in processed foods,
modelling on the UK Food Standards Agency’s project which achieved an estimated 9.5% decrease in
population sodium intake over five years. The other was an excise tax on sodium at the industrial
levels similar to that on cigarettes.
Data were drawn from the national Census, routine household expenditure surveys, and relevant
studies including the Framingham Heart Study and the Cardiovascular Health Study and a recent
meta-analysis. It was estimated that collaboration with industry would cost more in the U.S. than in
the UK and that any tax revenue would subsidise the cost of lower-sodium foods for low income
consumers who would be disproportionately affected by a large increase in the cost of food with
consequential nutritional deficiencies. Assumptions were evaluated extensively in sensitivity analyses
including the use of two alternate relationships between sodium intake and blood pressure.
The analysis showed that governmental efforts to reduce population sodium intake were likely to
avert myocardial infarctions and strokes substantially, increase quality of life (QALYs) and reap large
reductions in medical costs of which 66% would accrue for persons aged 65 and above.
The authors acknowledge that it was not known whether the reduced sodium intake could be
sustained as consumers are free to add salt at table, or whether further reductions were achievable.
Moreover, reductions in sodium intake may lead to increased consumption of fats and sugars thereby
increasing other health risks. Conversely the consumption of carbonated beverages which
complement sodium intake may fall. Such unintended or unpredictable consequences – positive or
negative – of strategies for sodium reduction should be monitored. It was noted that minority
populations were under-represented in the mostly white Framingham study which informed the
models predictions, and that those – such as African Americans – with a higher incidence of heart
attacks may benefit more than the general population from reduced blood pressure. The role of
6 complementary lifestyle interventions such as increasing the intake of fresh fruit and vegetables,
decreasing calorie and fat intake, and promoting physical activity was recognised.
This study impressed as a model for modelling as a tool for assisting in the development of policies
for the prevention of preventable disease.
Alexander Macara, August 2011
Paper 2: Webster et al. (2009) The development of a national salt reduction strategy for
Australia - Asia Pacific Journal of Clinical Nutrition Vol. 18 No. 3
Objective: This paper outlines the development of a salt reduction strategy for Australia by the
organisation AWASH (Australian Division of World Action on Salt and Health).
Conclusion: Although evidence does suggest that it is possible to achieve a meaningful reduction in
the level of population salt consumption, the authors argue that based on the experience of other
nation's salt reduction programmes such as that of the UK Food Standard's Agency, this is likely to be
a lengthy process.
Commentary by our reviewer
The World Health Organization has shown that elevated blood pressure is the leading cause of
disease – notably cardiovascular – worldwide after under-nutrition and unsafe sex, and one-half of its
effects arise in individuals with levels below 140/90 mm Hg. Excess dietary salt raises blood pressure
in both the short and long term: its reduction can substantially reduce blood pressure levels and avert
serious vascular complications whilst being projected to be highly cost-effective.
The Australian Division of AWASG (World Action on Salt and Health) developed a comprehensive
strategy to reduce population salt intakes. A three-pronged approach similar to that of the United
Kingdom’s Food Standards Agency, with appropriate adaptation, was decided for Australia to reduce
average salt consumption from an estimated average of nine to six grams daily over five years, by
reducing its content in processed and catering food, increasing consumer awareness and clear food
labelling. This “Drop the Salt” campaign was launched in 2007.
Industry has responded positively, all the media have been fully engaged, and government is
committed. Evaluation requires measurement of population salt intakes using 24 hour urinary
analyses which was planned for 2010.
There is published evidence that meaningful falls in population consumption of salt can be achieved
although the national target is optimistic in the light of the UK experience of a reduction from 9.5g to
8.6g in five years to 2008.
The authors affirm the potential for the programme to deliver major health gains, but recognise that
this depends upon the effective management of industry and government.
Commentary by: Alexander Macara, August 2011
7 Paper 3: Ireland et al. (2010) Achieving the salt intake target of 6g/day in the current
food supply in free-living adults using two dietary education strategies - Journal of the
American Dietetic Association Vol. 110
Objective: There are national targets for salt intake of 6 g salt/day in Australia and the United
States. Despite this, there is limited knowledge about the effectiveness of dietary education in
reducing salt intake to this level. The objective of this study was to investigate whether dietary
education enabled a reduction in salt consumption.
Conclusion: In an 8-week parallel study, 49 healthy free-living adults were recruited from the
Adelaide community by newspaper advertisement. In a randomized parallel design, participants
received dietary education to choose foods identified by either Australia's National Heart Foundation
Tick symbol or by the Food Standards Australia and New Zealand's low-salt guideline of 120 mg
sodium/100 g food. Barriers to salt reduction were: limited variety and food choice, difficulty when
eating out, and increased time associated with identifying foods. The authors conclude that dietary
sodium reduction is possible among free-living individuals who received dietary advice.
Commentary by our reviewer
The risk of cardiovascular disease increases, as does salt intake, along a continuum of blood pressure
from relatively low “normal” levels. It has been predicted that a population reduction in salt intake
would reduce stroke and ischaemic heart disease by 22% and 16% respectively.
This study investigated whether dietary education reduced salt consumption. 49 healthy adults aged
20 to 75 with control over their food intake were recruited in Adelaide by newspaper advertisement,
of whom 22 and 21 – all white – were randomly allocated to Australia’s National Heart Foundation’s
Tick Programme which assists individuals to identify healthier supermarket items or to the Food
Standards Australia and New Zealand low-salt guidelines respectively. Sodium excretion was assessed
by 24 hour urinary analyses at baseline and at weeks four and eight.
Dietary education was provided in groups of four or five in 15 minute sessions by the same
nutritionist and participants were advised to “continue their usual dietary patterns” whilst
paradoxically identifying reduced salt foods. A second ten minute individual session was held at week
four. Dietary assessment was conducted by the same investigator using the multiple-pass 24 hour
recall and the food intake data were analysed using a computerised database. Body weight, height
and BMI were recorded. Participants’ experiences were recorded by a short self-administered
questionnaire.
Statistical analyses were detailed and results demonstrated that reducing salt intake to recommended
levels is possible with simple dietary education. Participants “may have underestimated their dietary
intake” although a positive correlation between reported sodium intake and 24 hour sodium excretion
supported the usefulness of a 24 hour diet recall. Considerable weight loss was not explained.
The limitations of the study included a limited variety of appropriate foods eating out. The innate
appeal of the taste of salt fell with restricted exposure to high salt foods, which is consistent with
findings elsewhere.
The most relevant limitation, due to limited resources, was the small sample size, with large majority
(circa 80%) of women compared to the minima of 60 required for 80% and 160 to claim statistical
significance respectively. Understandably “blinding” of participants and observers was not possible.
Further work is obviously required to confirm the effectiveness and sustainability of the approach.
Alexander Macara, August 2011
8 Paper 4: Duffey et al. (2010) Food price diet and health outcomes: 20 years of the cardia
study - Archives of Internal Medicine Vol. 170 No. 5
Objective: Despite surging interest in taxation as a policy to address poor food choice, US research
directly examining the association of food prices with individual intake is scarce. The authors aimed to
carry out such research by examining the associations between food price, dietary intake, overall
energy intake, weight, and homeostatic model assessment insulin resistance using conditional log-log
and linear regression models.
Conclusion: Policies aimed at altering the price of soda or away-from-home pizza may be effective
mechanisms to steer US adults toward a more healthful diet and help reduce long-term weight gain
or insulin levels over time.
Commentary by our reviewer
The 20 year multi-centre longitudinal CARDIA study (Coronary Artery Risk Development in Young
Adults) studied associations between food price, dietary and overall energy intake, weight and
homeostatic model assessment of insulin resistance (HOMA/IR). Compared to extensive datasets on
tobacco price and smoking it was the first dietary study in the U.S. to examine both the direct effects
of a price change in the intake of a particular food (“own-price elasticity”) and the indirect effects on
substitutes and complementary foods (“cross-price elasticity”).
Black and white adults aged 18 to 50 years were drawn from four cities to create a balanced
representation of age, sex, ethnicity and education status in each location. The baseline survey was
completed on 5115 subjects, with six follow-up examinations, ultimately retaining 72%. At baseline,
dietary history was assessed, followed by a comprehensive quantitative food frequency questionnaire.
At each subsequent examination, self-reported information on socio-demographic factors and
selected health behaviours was collected: physical activity was assessed and adjustment was made
for the cost of living, the consumer price index being used to take account of inflation. Statistics of
beverage prices, energy per person and consumption of each food group were analysed and 2-step
marginal effect models were used to estimate the association between price change and
consumption. Finally, regression models were used to examine the association between daily total
energy intake, body weight and HOMA, adjusting for socio-demographic and lifestyle factors as well
as the values of hypothesised complementary and replacement foods, the cost of living and the
passage of time. In the final sample, subjects were excluded who were pregnant, taking anti-diabetic
medication, or providing incomplete price data.
Results were presented in detailed tables with extensive footnotes, including estimated model
coefficients of the association between price and consumption, and the price elasticity of percentage
change in energy from specified foods (“soda”, whole milk, burger and pizza) associated with a 10%
change in their price.
The authors claim that their findings provide strong evidence to support the potential health benefits
of taxing selected foods and beverages. If the higher price elasticities for tobacco typically found for
children, teenagers and the elderly applied to beverages, the impact of a minimal tax of 18% which
was unsuccessfully proposed in the state of New York might be greater than that estimated in young
adults. They advocate the examination of the relationship between price and the consumption of
“healthful” food. They recognise that although their hypothesised tax would aid reduced rates of
diabetes and weight loss, it would not resolve the obesity epidemic “in its entirety” and may face
opposition from food manufacturers and sellers. Verb sap!
Alexander Macara, August 2011
9 Paper 5: Tan, A.S.L. (2009) A case study of the New York City trans-fat story for
international application - Journal of Public Health Policy Vol. 30 No. 1
Objective: The author presents a case study on the New York City ban on trans fats describing the
formulation, public consultation, implementation and evaluation of the policy.
Conclusion: The New York experience leads the author to propose a strategic framework for food
policy development for international policymakers who are considering similar regulations. The
framework includes four domains: (1) background research, (2) stakeholder support, (3) effective
policy implementation and (4) evaluation and dissemination.
Commentary by our reviewer
In the context of evidence that artificial trans-fats is generally associated with heart disease which is
the leading cause of death, this article describes the application of New York City’s (NYC) 2007 transfat regulation which prohibits the use of trans-fatty acids in food preservation in all the city’s food
outlets with exemptions for trace amounts and packaged and manufactured foods. It reviews the
stages of formulation, public consultation, implementation and evaluation.
Consumer surveys indicated that a majority of American households, who consumed over one third of
calorie intake outside their homes, were aware of the risks of trans-fats, many checked food labels,
and some were aware of the earlier Danish legislation, yet they consumed significant amounts; 80%
through processed foods. Political will to support public health measures had been mobilised by a ban
on smoking in public places and at least one food manufacturer among several who had already
reformulated their products had benefitted economically.
The global scientific evidence was marshalled and applied in comprehensive education and regulatory
activities. The majority of restaurants were compliant before inspection commenced under the
regulation as part of routine hygienic surveillance and almost all complied promptly after it.
NYC’s experience has served as a model for others, notably California. San Francisco added a menulabelling regulation requiring nutrient information. Unintended consequences were recognised such as
a potential increased in the intake of natural saturated fats and manufactured foods containing transfats but early research suggested that the introduction of menu labelling in 1990 and public education
on calorie sources would minimise such risks.
It was too early to observe changes in health outcomes or risk factors, although the Danish
experience over several years previously indicated a fall in the population intake of trans fats. A
strategic framework based on the NYC experience is recommended to assist others mounting similar
programmes.
It is encouraging to see evidence of success in securing the co-operation of all “stakeholders”
including industry and to speculate that it may see benefit in responding to a clear public health
message.
Alexander Macara, August 2011
10 Topic 2: Interventions for prevention of diseases and conditions
This topic contains four papers covering interventions to reduce incidence of diseases and their risk
factors including cardiovascular diseases and diabetes. The papers cover interventions from as far
and wide as the Seychelles and India and Australia. The interventions discussed include worksite
health plans, heart disease reduction policy models and the role of health workers in promoting
healthy lifestyle behaviours.
Paper 1: Bovet et al. (2010) Addressing non-communicable diseases in the Seychelles:
towards a comprehensive plan of action - Global Health Promotion Vol. 17 No. 37
Objective: This article reviews the different steps taken during the past 20 years for the prevention
and control of non-communicable diseases (NCDs) in the Seychelles. National surveys revealed high
levels of several cardiovascular risk factors and prompted an organized response, starting with the
creation of an NCD unit in the Ministry of Health.
Conclusion: Significant policy was developed including comprehensive tobacco legislation and a
School Nutrition Policy that bans soft drinks in schools. NCD guidelines were developed and
specialized ‘NCD nurses’ were trained to complement doctors in district health centers. Decreasing
smoking prevalence is evidence of success, but the rising diabesity epidemic calls for an integrated
multi-sector policy to mould an environment conducive to healthy behaviors.
Commentary by our reviewer
This review charts the first two decades in the development of a comprehensive national plan of
action for the prevention and control of non-communicable diseases (NCDs) in the mall African Island
state of the Seychelles. This ambitious policy anticipated the World Health Organisation’s 2008 Global
Strategy to guide national action.
Already on the late 1980’s the Seychelles was in rapid demographic transition with the now familiar
and disturbing epidemiological evidence of burgeoning cardiovascular disease, cancer and “diabesity”.
Surveys of NCD risk factors – initially in 1989 in collaboration with the University of Lausanne, a WHO
Collaborating Centre for NCDs in developing countries and others, revealed the high population
prevalence of modifiable risk factors for NCD. This prompted the creation of an NCD unit in the
Ministry of Health and an integrated, multi-sectoral policy “to mould an environment conducive to
healthy behaviours” with campaigns targeting the general population, high risk groups and
individuals. Surveillance mechanisms were supplemented by focused research which highlighted
overweight among children and tobacco use.
Emphasis was first placed on high profile awareness campaigns aimed at the general population and
an NCD related school curriculum, followed by hypertension and diabetes screening in public places
and workplaces. Primary health care, hampered by the paucity of a stable medical workforce, was
strengthened by the training of “NCD nurses” deployed in district health centres. Guidelines for the
diagnosis and treatment of cardiovascular diseases and diabetes were developed. Public health was
promoted by inter alia, a campaign to increase the consumption of fruit and vegetables, dietary
guidelines, a health promotion policy, a national committee for tobacco control, a Tobacco Control Act
to implement the WHO Framework Conventions, and a national school nutrition policy. Physical
activity was encouraged, with the advocation of changes in fiscal, agricultural and transport policy,
but it was not clear how much progress had been made by the time of publication.
11 The importance of leadership and commitment at every level and in every sector was emphasised – it
would have been premature to claim any specific results beyond the establishment of the national
policy.
Incidentally it was noted that all but one of the 17 references cited the lead author of the paper.
Alexander Macara, August 2011
Paper 2: Unal, B., Capewell, S., Critchley, J.A. (2006) Coronary heart disease policy
models: a systematic review - BMC Public Health Vol. 6 No. 213
Objective: The prevention and treatment of coronary heart disease (CHD) is complex. A variety of
models have therefore been developed to try and explain past trends and predict future possibilities.
The aim of this systematic review was to evaluate the strengths and limitations of existing CHD policy
models.
Conclusion: Existing CHD policy models vary widely in their depth, breadth, quality, utility and
versatility. Few models have been calibrated against observed data, replicated in different settings or
adequately validated. Before being accepted as a policy aid, any CHD model should provide an
explicit statement of its aims, assumptions, outputs, strengths and limitations.
Commentary by our reviewer
This paper reports the first comprehensive systematic review of coronary heart disease models. 75
articles describing 42 models were finally included, of which the best six models are summarised,
other being detailed in appendices. The objective was to assess the quality of the methodology rather
than simply to comment on reported results. Most of the models were restricted to young and middle
aged adults although two were extended to age 84. The search was limited to sources in the English
language including articles from the WHO, Canada and the Netherlands. None of the models
specifically considered non-Caucasian populations.
The authors defined a coronary heart disease policy model as any mathematical tool which may help
to explain or predict the outcome of interventions or the implementation of a new strategy at a
population level. Users should not necessarily have to understand the implicit assumptions of
limitations.
The search strategy was run in electronic databases supplemented by manual search of relevant
articles and reviews. Two reviewers independently checked and evaluated for inclusion over 4500
papers including all those which addressed a defined population and reported on one or more key
outcomes. A pre-piloted form was used for data extraction and a grading system was developed
based on sensitivity, validity and transparency of the model.
The models varied widely in their breadth, depth, quality, utility and versatility. Few attempted a
comprehensive consideration of all major risk factors and standard treatments. Few had been
calibrated against observed data, replicated in different settings or adequately evaluated. The
majority explicitly stated their key assumptions, but only a third provided illustrations or examples.
Only one fifth cited limitations of their methodology, which varied widely. The IMPACT CHD mortality
model was notable for is potential to estimate the proportion of a change in mortality over time that
might be attributed to changes in risk factors or specific treatments.
12 It is acknowledged that the methodological challenges are formidable, especially in the assessment of
validity which was rarely reported. Outcomes most commonly reported were cost effectiveness,
number of deaths prevented, life-years gained or coronary heart disease incidence. A majority
included one or more risk factors for primary prevention and a fifth considered only treatments.
It was concluded that coronary heart disease models do offer a potentially valuable tool for policy
developments, but the need to include a clear statement of their aims, assumptions, outputs
strengths and limitations and to be validated against minimum quality criteria.
Commentary by: Alexander Macara, August 2011
Paper 3: Prabhakaran et al. (2009) Impact of a worksite intervention program on
cardiovascular risk factors: A demonstration project in an Indian industrial population Journal of the American College of Cardiology Vol. 53
Objective: India is experiencing an accelerated epidemiological transition with a consequent increase
in the burden of CVD risk factors both in community-based studies and in industrial populations. The
authors hypothesize that a comprehensive CVD risk factor reduction program comprising of a
multipronged strategy of health promotion, high-risk primary prevention, and policy level or
environmental changes and using existing infrastructure in the participating industries would yield
substantial reductions in CVD risk factors. They outline the methods of developing such a
comprehensive CVD prevention and health promotion program, present the results of this program,
and discuss their implications.
Conclusion: The data suggest that a worksite approach in health promotion programs on
cardiovascular risk factors can be implemented and can have a positive impact on intermediate CVD
outcomes in developing countries. A comprehensive approach targeting multiple risk factors and a
systematic, randomized, controlled design with adequate power to detect the impact of the expected
changes on hard cardiovascular end points is warranted.
Commentary by our reviewer
India is experiencing an accelerated epidemiological transition with a consequent increase in the
burden of cardiovascular (CVD) risk factors. The equivocal results of preventive population
programmes in the developed world need not apply, and the hypothesis was that a multi-pronged,
CVD risk factor strategy of health promotion, high-risk primary prevention and policy level changes
could succeed.
This CVD risk factor survey between 2003 and 2007 covered ten different industrial sites representing
different regions, including all the employees and their family members between the ages of 10 and
69. More than three-fourths of the study population had above primary school education.
Age group in deciles and a sex-stratified multi-stage random sampling technique was used for the
baseline surveys and detailed data were obtained from 800 subjects at each site including major risk
factors for CHD and biochemical parameters, with strict quality control. Three sites dropped out
before the intervention stage due to economic instability or lack of management support, and a
fourth participated only in the repeat risk factor survey, serving as a comparative population – not
strictly a “control” – although the characteristics of the two groups seemed to be broadly similar.
Response throughout ranged from 82.9% to 98.3%.
13 The intervention was comprehensive at every level, drawing on sociological theory and contemporary
approaches to effect behaviour change in order to promote a healthy diet, physical activity and
avoidance of tobacco. Individuals with risk factors were referred to healthcare and targets were
provided for risk factor reduction. In the “control” site some health promotion was organised by
management and the use of tobacco was banned, as in the intervention sites.
Statistical analyses compared percentage changes in risk factor levels including the use of a mixed
linear regression model. A physical activity scoring system was developed based on self-reporting.
Results were fully reported, studied and discussed.
The cumulative effect of a significant reduction on both systolic and diastolic blood pressure with an
increase in HDL cholesterol levels and a reduction in smoking led to a significant reduction in
individuals’ Framingham risk scores. Costs were low.
Despite the limitations of the non-randomisation design and the self-reporting of several measures
not subject to verification, it was argued that the overall consistency in the trends showed that a
worksite approach can have a positive impact on intermediate CVD outcomes in developing countries.
A comprehensive approach targeting multiple risk factors and a randomised research design with
power to demonstrate the impact of achievable reductions in cardiovascular risk factors seems to be
warranted.
Alexander Macara, August 2011
Paper 4: Milat, A., O'Hara, B., Develin, E. (2009) Concepts and new frontiers for
development - What role should health promoters play in lifestyle-based diabetes
prevention programmes in Australia? - Health Promotion Journal of Australia Vol. 20 No.
2
Objective: As the prevalence of many chronic diseases, particularly type 2 diabetes continues to
increase, Australia’s health system must be able to respond in an appropriate and cost-effective way.
These efforts have been enhanced recently by a number of Council of Australian Governments’
initiatives that have seen an increased focus on lifestyle-based secondary prevention of chronic
disease, in particular for diabetes. This paper aims to stimulate interest and debate in relation to the
role that health promotion practitioners can play in shaping lifestyle-based diabetes prevention
programs in Australia.
Conclusion: State and national governments have substantially increased their investment in
lifestyle-based diabetes prevention programs in Australia. If they are found to be effective and cost
effective they are likely to attract additional investment and make up an increasing proportion of the
prevention budget and accordingly, should not be ignored by the field of health promotion.
Commentary by our reviewer
This paper described and debates the functions of health promotion, advocating increased activity in
life-style based secondary prevention in tackling the rapid growth of diabetes in Australia.
Type 2 diabetes was estimated in 2007 to affect 7.5% of the adult Australian population; another
16.4% had pre-diabetes. The socioeconomic gradient was clear, with prevalence almost twice as high
in the lowest group and threefold in the indigenous population compared with the highest group.
14 Australian governments responded to the challenge with a number of initiatives with “a focus on
prevention across the continuum, early detection and treatment, continuity of care and selfmanagement”.
The cost-effectiveness of lifestyle based secondary prevention was confused by two conflicting
studies in the early 2000’s of the U.S. Diabetes Prevention Program due to different assumptions
about progression to diabetes used in the modelling, but that programme’s intensive lifestyle
modification approach, although expensive, was significantly more cost-effective than
pharmacotherapy. Later RCTs of such interventions have shown reductions (of 29% in India, 68% in
Japan) in diabetes risk.
Experience indicates that intervention is most effective when delivered to individuals at high risk by
specially trained health professionals in existing health settings and with community supports.
However evidence-based programmes may be, they are more readily implemented when they are
compatible with organisation and professional norms. Programmes should target those people “who
need them most and not just the worried well”. They need to be culturally and linguistically adapted
for minority groups. The availability of resources such as pedometers and exercise equipment is
desirable.
Partnerships are regarded as essential to effective health promotion, both to integrate preventive
programmes into existing healthcare and to involve players outside the health sector. A shared vision
is sought. Commercial partners are not envisaged.
Empowerment of participants with an emphasis on making the best use of available resources and
normal routines that can be changed (e.g. walking rather then driving and using stairs rather than
lifts) assists them to maintain behaviour change when a programme ends.
There is no suggestion that primary and tertiary prevention should be diminished, but it is concluded
that secondary preventive interventions can demonstrate their value and win increased support.
Alexander Macara, August 2011
Topic 3: Prevention through tobacco control
The single paper identified in this section discusses the development of a tobacco control alliance to
address health related disparities arising as a result of tobacco use by underserved populations.
Paper 1: Deason et al. (2010) The Ohio cross-cultural tobacco control alliance:
Understanding and liminating tobacco-related disparities through the integration of
science, practice and policy. American Journal of Public Health, Supplement 1, Vol. 100
No. S1
Objective: The authors examined the development of a process designed to eliminate tobaccorelated disparities in the state of Ohio and described how a cross-cultural work group used a multi
component community planning process to develop capacity to address such disparities.
Conclusion: The CCTCA appeared to be an effective way to begin mobilizing agencies serving
underserved populations by providing an operational structure to address tobacco-related disparities.
The alliance also successfully implemented culturally competent community-based programs and
policies to help eliminate disparities.
15 Commentary by our reviewer
Disparities in awareness, prevention and control of tobacco in underserved communities are reflected
universally in the greater disease experience of minority groups. This paper describes how a crosscultural work group which became the Cross-cultural Tobacco Control Alliance (CCTCA) “used a multicomponent community planning process to develop capacity to address such disparities” in the U.S.
state of Ohio between 2005 and 2009. Data collection was crucial to this process, which was guided
by principles set out in a community development model designed to eliminate population disparities.
The process involved a Case Study including telephone interviews to evaluate the process and
outcome of the state’s community planning policy, and Focus Groups. Finally, an “appreciative
enquiry framework” was applied to guide the development of an organisational structure.
The Case Study which involved members of organisations working on behalf of deprived populations
was underpinned by researchers from the Ohio Tobacco Prevention Foundation using triangulation
methods to develop a strategic action plan. It was adjudged to be effective based on perceptions of
members although one half of them did not complete the evaluation forms.
The Focus Groups which comprised representatives of 13 underserved populations alongside
representatives of organisation serving them elicited their members’ use of tobacco, cessation
attempts and reasons for failing to quit. Problems included the small numbers of some minority
groups limiting quantitative measurement and distrust by some members of enquirers intruding on
privacy despite having given written informed consent.
Cultural differences were instructive. Native Americans discriminated between the use of tobacco in
religious rituals and commercial abuse (normal smoking). Amish adults who predominantly used
smokeless tobacco were unaware both of tobacco advertising and cessation services and accepted
experimentation with risky practices including tobacco use during adolescence. Others cited various
reasons for not using cessation aids, or failing to quit: gay men regarded hazards such as HIV/AIDS
as a greater priority; chemically dependent individuals used tobacco to help them cope with ceasing
to use other drugs; some individuals were concerned that nicotine controlled their body. Human
rights intervened. Although many participants supported smoke free legislation there was concern
about government interference with personal rights.
The appreciative enquiry approach developed a detailed structure whereby CCTA would work closely
with the Ohio Department of Health. Impediments to implementing action plan strategies were
pleaded as including the lack of professional marketing experience, competing commitments of
committee members and the eventual loss of OSH (Office of Smoking and Health) funding.
The reader was left with concern that although much commendable effect has succeeded in revealing
useful information and insights, it is questionable whether effective action will result.
Commentary by: Alexander Macara, August 2011
16 Appendix: Search terms and search structure by database
PubMed
301 records found
#1
#2
#3
#4
#5
#6
Search manage* or preventat* or preventi* or control* or controll*
Search "Health Policy"[Mesh]
Search ((("Diabetes Mellitus, Type 2"[Mesh]) OR "Heart Diseases"[Mesh]) OR "Vascular
Diseases"[Mesh]) OR "Neoplasms"[Mesh]
Search effective* or efficien*
Search #2 and #4
Search #5 and #3 and #1
Global Health
95 records found
#1
#2
#3
#4
#5
#6
#7
cardiovascular diseases/ or heart diseases/ or vascular diseases/
diabetes/
cancer/
1 or 2 or 3
(effective* or manage* or efficien* or prevent* or control*).mp. [mp=abstract, title, original
title, broad terms, heading words]
health policy/
4 and 5 and 6
Cochrane library
27 records found
#1
#2
#3
#4
#5
#6
#7
#8
MeSH descriptor Heart Diseases explode all trees
MeSH descriptor Vascular Diseases explode all trees
MeSH descriptor Health Policy explode all trees
(effective* or efficien* or prevent* or manage* or control*):ti,ab,kw
MeSH descriptor Diabetes Mellitus, Type 2 explode all trees
MeSH descriptor Neoplasms explode all trees
(#1 OR #2 OR #5 OR #6)
(#3 AND #4 AND #7)
Total records found: 423
After de-duplication: 410 records
After sift on selection criteria using article abstracts: 112 records
After full text sift: 10 records
17 National Heart Forum 2011
This review has been produced as a supporting document for the NHF’s eResearch
Briefing Service, a free email alerting service on chronic disease prevention. For
more information about this service and to sign-up visit our website
http://www.heartforum.org.uk/resources/news-and-alerts/
18