Guest blog from our member organization, the African Heart Network

By Mrs Bola Ojo, Executive Secretary, African Heart Network

March 8th is International Women’s Day — an opportunity to celebrate the achievements of women and also to remind the world about the challenges that heart disease and stroke pose not only to women and global health but also to sustainable development worldwide.  African Heart Network (AHN) is committed to working in partnership to reduce the cardiovascular disease (CVD) burden in Africa and the inequalities that come along with it.

Misperceived as a “man’s disease”, CVD has too long been neglected in the women’s health arena.  In actuality, it causes 8.6 million deaths in women, each year, making it their number one killer. In response to this, World Heart Federation members around the globe, including seven in Africa, have started the Go Red for Women campaign, originally conceived by the American Heart Association, to raise awareness about the specific vulnerabilities women face with regard to CVD. AHN has joined in this fight to raise awareness of CVD risk and draw attention to the fact that many deaths in women are in fact preventable. Poor nutrition with inadequate intake of fruit and vegetables as well as the consumption of diets high in trans or saturated fats, physical inactivity and tobacco use all increase the risk of developing CVD.  The good news is that these risk factors are modifiable.

Given the limited financial resources of many countries in Africa, health education is  a key strategy for preventing the increasing trend of CVDs.  A massive health campaign transmitted through local radio in multiple languages can help inform populations on a large scale about improving diets by reducing the intake of sodium, sugar and trans and saturated fats. This would reach both rural and urban poor communities.  And it must be accompanied by campaigns to call for better access to health foods, including product reformulation.

While communicable and preventable diseases including malaria, HIV/AIDS and tuberculosis are still prevalent, CVD and non-communicable diseases (NCDs) within Africa are on the rise and are expected to be on par with communicable diseases in the next few years. Globalization and urbanization in Africa is resulting in increased exposure to risk factors as people move out of villages and into cities, a traditional diet rich in fruit and vegetables is gradually being replaced by one rich in calories from animal fats and low in complex carbohydrates. This dietary change is combined with a decrease in physical activity as people move away from traditional farming into sedentary jobs.

More than a health concern, research indicates that CVDs and other NCDs contribute to household poverty. This leads to health inequalities in all countries and poses a major impediment to achievement of the Millennium Development Goals (MDGs).  Women should be at the centre of the CVD discussion, not only because of their personal risk of dying from CVD but also due to their role within families and communities. Differences in the status of women and men lead to disparate opportunities to the claim of human rights, including the right to health. The status of women also places them at greater risk of being exposed to certain CVD risk factors. Furthermore, their traditional role as caretaker of the family could allow women to become empowered as effective champions of heart-healthy behaviours for the entire household.

As we celebrate, International Women’s Day 2012, let’s unite in our call for concrete action around  women’s health issues to be taken. Together, in partnership, let us rally governments, civil society and communities to take responsibility and address the “call of our hearts!” Tell us what you are doing to celebrate International Women’s Day via twitter: twitter.com/worldheartfed.

Love cities?  This Valentine’s week, in my first-ever video blog, I explain why the World Heart Federation is calling for urgent action to protect children’s heart health in the world’s most populous cities. Click on the picture below to watch the video:

To find out more, download the report >

Johanna Ralston, CEO, World Heart Federation

When World Heart Federation board member Dr. Kingsley Akinroye spoke from the floor of the United Nations on September 20th, as part of a line-up of speakers that included heads of state, ministers of health and royalty, it was a moment in history for the World Heart Federation and the global CVD movement.   Referencing his role as head of the African Heart Network, Kingsley noted that not only was cardiovascular disease an urgent health issue in Africa, but that there was much that could be done already to address it and other NCDs, from expanding smokefree laws that have successfully been implemented in South Africa, Mauritius and Nigeria, to increasing access to essential meds and addressing rheumatic heart disease (RHD).   By countering scepticism about disease burden with the facts, and concerns about cost with solutions, Kingsley’s words achieved two of the goals of the meeting: raising awareness of NCDs as an urgent health issue, and demonstrating that many solutions are within our grasp, and are far more affordable than continuing along our current path of  minimal primary or secondary prevention in most countries, and treatment largely limited to late stage, high cost intervention  for those who can afford it.

In general, we are very pleased with the meeting, and proud that our members were so instrumental in ensuring its success, as marked by the attendance of 34 heads of state and a schedule that was extended by several hours to accommodate the numbers of Member States who wanted to make statements.  We were delighted that both Russia and Australia made strong financial commitments to addressing NCDs in low and middle income countries, and that the reports by World Economic Forum and World Health Organisation on the costs of inaction and affordability of prevention and basic treatment were so well received.  But now, the real work begins.  The meeting was, as Sir George Alleyne – channelling Winston Churchill – describes it, “the end of the beginning.”

Next steps include, over the coming months, ensuring that targets and accountability initiatives that were not part of the final declaration are fully developed and agreed to.  We will be communicating with our members and through the NCD Alliance on steps you can take.  It is also critical that we start to advocate for inclusion of NCDs including CVD in the successors to the Millennium Development Goals; the current MDG’s expire in 2015 and plans for the next global set of development goals will start to be developed soon.   As New Zealands’s Sir Peter Gluckman, Chief Science Advisor to the Prime Minister, noted, the “NCD and MDG agendas are inextricably intertwined.”  Again, we will keep our members updated about the process and ways to get involved.   In the meantime, we also need to continue to build evidence for what works at the country level, and to continue to support NCD plans, as well as national and regional alliances.

I’ll close with a quote from David Bloom of the Harvard School of Public Health, author of the World Economic Forum report on the cost of “business as usual” in addressing NCDs, who noted that NCDs are becoming “ a major impediment to economic growth and the mitigation of poverty. That finding, we hope, will be more than enough evidence for economic leaders to accord NCD prevention, screening and treatment much higher priority than they currently do.”

Question: What do you see as the most important next step for the CVD community following the Summit?

Johanna Ralston, CEO, World Heart Federation

Next week, global leaders will meet at the United Nations to take on some of the world’s greatest killers: cancer, diabetes, chronic respiratory disease, heart disease, and stroke. The UN High-Level Meeting on the Prevention and Control of Non-Communicable Diseases on September 19–20, has the potential to finally address these leading causes of death and disability, which until now have been largely ignored.

Yet when we wake up on Sept. 21, how much will have changed? Will there be a new Global Fund to fight noncommunicable diseases (NCDs)? Will key stakeholders, such as those involved in urban planning, agriculture, trade and current global health priorities, be as engaged as they need to be to realize ambitious goals of measurably reducing disease? Will the public even know what an NCD is — even though more than 60 percent of deaths worldwide are from noncommunicable diseases, the majority from cardiovascular disease?

The answer to all of these questions is: not yet. September 21 will be the start of the real work. The problems of NCDs are complex, but we have many opportunities to alter the course of what has become a global crisis.

There are a number of concrete steps that countries and health systems can take immediately to strengthen their commitment to reducing noncommunicable diseases. They can ratify and implement the Framework Convention on Tobacco Control, the world’s first public health treaty. Many countries already have the makings of NCD plans in existing cancer plans, tobacco control programs and strategies for diabetes and cardiovascular disease. They may also have specific programs to address respiratory disease, mental health and other issues. Health systems can make essential drugs, such as aspirin and statins, available immediately and at a low cost because many are off patent.

As leading researchers and public health officials said in an April 2011 Lancet article, “An effective response to NCDs requires government leadership and coordination of all relevant sectors and stakeholders, reinforced through international cooperation.”

In the end, we will need to make compromises and learn to share resources with people and institutions with whom we are not accustomed to collaborating. We will need to delay gratification and risk unpopularity in some of our choices. And we will likely not see the payoff in our lifetimes. But with time, effort and investment, we will see results.

We were delighted to see well known chef Jamie Oliver call on the UN to address world obesity rates at the Summit later this month. In a speech made earlier this week in Zurich and covered by several news outlets Oliver noted that in low- and middle-income countries, “Diet-related diseases are two of the top five causes of premature death for people under 60 years old. They look set to create an absolute catastrophe over the next 30 to 40 years if nothing changes.”

His words were backed up by Sir David King in The Lancet, who noted that the epidemic is not about laziness or overeating but rather about the types of physical activity and food options that are available. Individuals’ options for what to eat are increasingly restricted to calorie-packed, low-cost “convenience” foods that are readily available, cooked in high fat oils and with lots of added sugar and salt for quick flavor and long-term preservation. As King notes, “Our biology has stepped out of kilter with society.”

We applaud Jamie Oliver for taking on this issue, and for drawing attention to the Summit. In particular, we know Oliver carries a message that resonates with a younger audience, empowering people to fight for the ability to choose what they eat and how they eat it – essential elements in the fight against cardiovascular diseases. At the World Heart Federation, we believe that, while options around early detection and treatment are of critical importance, the issue of having choices that may prevent heart disease and stroke in the first place are of utmost urgency. People deserve the right to have food options, access to safe places to move, and environments free from smoke and from marketing of tobacco and alcohol.

We believe that these types of choices become more limited in the crowded urban environments where most people live and work, especially in low and middle income countries. Limitations around food extend beyond fast food to what is often known as street food – cheap foods sold in markets and on sidewalks, that contain high fat oils, salts, and other ingredients that place heart health at risk. We were pleased to see the newest version of the UN outcomes document finally contain language on the need to restrict trans- and saturated-fats and sugars. We were sorry, however, that our target to reduce global salt consumption to less than 5 mg per day was not included.

The World Heart Federation agrees with Jamie Oliver’s view that in order to see change we must create an educated consumer. At the centre of all this should be children; research tells us that childhood nutrition strongly influences the chances of developing cardiovascular and non-communicbale diseases later in life. Furthermore, children are often the most vulnerable to marketing schemes. If fast food adverts and processed food packaging are targeted at children, health promotion materials must be targeted at children as well. The World Heart Federation has teamed up with the Union of European Football Associations (UEFA) to try to do exactly this through our Eat for Goals campaign, featuring well-know European football stars offering their favourite heart healthy recipes.

The global obesity epidemic, and cardiovascular disease which will often be the result, needs to be addressed and committed to by governments in the outcomes document at the Summit and beyond. We urge others with a voice and a platform to join Jamie Oliver in his fight to bring a Food Revolution to the UN. The world needs to be made aware of the Summit and the critical role it can play in fighting this new epidemic. With less than two weeks until the Summit, there is not much time and lots to be done. We thank Jamie Oliver for taking a lead on this and urge you to join his campaign by signing the Food Revolution petition today.

“Do you think there is need for a Food Revolution?”

Johanna Ralston, CEO, World Heart Federation

Many of our members have been reaching out to ask if we could please clear up all the confusion around salt.  At the World Heart Federation we have been setting targets for years around reducing sodium intake, and recently consulted with our 192 member organizations to finalize cardiovascular disease (CVD) specific goals, including the reduction of salt intake to less than 5 grams per day by 2025. This target was a top priority for our members and was included in the NCD Alliance outcomes document to lobby for political support at the upcoming UN High-Level Meeting on Non-Communicable Diseases (NCDs). This goal is in line with both the World Health Organization’s recommendations and those made by The Lancet.
A recent Cochrane review has raised questions about whether sodium reduction really affects CVD mortality, based on a meta-analysis of seven randomized, controlled trials. Three of these trials were in people with normal blood pressure, two were in people with high blood pressure, one was in a mixed population of normal blood pressure and high blood pressure, and one was in people with heart failure. The purpose of the meta-analysis was to assess whether advice to reduce salt intake changed one’s risk of death or CVD. The review found that people with salt reduction had an overall decrease in blood pressure.  However, mortality rates and cardiovascular events were not significantly lowered among either people with normal blood pressure or those with high blood pressure and patients with heart failure actually showed an increased risk for all-cause mortality after salt restriction. There have been interesting commentaries on this study at ProCor and “theheart.org” which raise important questions about the evidence presented in the study and salt reduction strategies. Addressing sample size, confidence intervals in the studies noted were wide enough to indicate that the studies may have lacked enough subjects to produce clear results. Finally, as Dr Nancy R. Cook from Harvard Medical School suggests, the studies included were not designed to test the effects of sodium reduction interventions on CVD events and mortality:  an overall decrease in blood pressure is not the same as a reduction in cardiovascular events. It is much easier and more common to see reduction in blood pressure as a result of salt reduction approaches, than a reduction in myocardial infarctions (heart attacks) or death.  And yet the study also looked at salt reduction in people with heart failure and came to a surprising conclusion:  there was higher mortality among this group than among those without heart failure. Again, commentaries have noted that study size may have impacted this finding, and that a well designed longitudinal study on the topic using diverse populations is needed.

So, what do we make of all of this, other than that the evidence suggesting health benefits to sodium reduction far outweigh the downsides? Authors of a recent commentary in The Lancet have refuted the findings of the Cochrane Review. After reanalyzing the studies, they have concluded that a small reduction in daily salt intake (2g) does in fact result in a significant reduction in cardiovascular events  (a 20% reduction), therefore supporting the recent Best Buy published by WHO.  Despite the discrepencies, the Cochrane Review does raise two important points that we need to address by harnessing the advantages of the current political environment around NCDs: the need for more and better research; and the need to have a multi-sectoral approach to salt reduction. We need research that takes into account different populations and ethnicities, the extraordinary diversity of diets, and a host of other factors for which studies are either non-existent or too brief or small to give us informative and accurate data. More broadly, as the lead author suggests, salt reduction is not simply about telling people to reduce the amount of table salt they use. Other measures, including multi-sectoral partnerships that work with governments, NGOs and the private sector are key to effectively reducing salt intake, as the majority of salt consumed is “hidden” in processed and packaged foods. The upcoming UN High-Level Meeting on NCDs provides us the opportunity to address both of these issues: we need to develop and advocate for a strong research agenda for the years to come, and we need to develop and implement a comprehensive strategy to decrease the intake of “hidden” salt – which requires partnerships with both governments and the private sector. Thus, while we can do much with what we know now – and we do know enough to support salt reduction strategies, awareness and research is still needed to truly address salt consumption.

Question:  What is the role of the private sector in addressing salt?

Other related links:

• The review on the Cochrane Collaboration’s website >
• “Reduced dietary salt for the prevention of Cardiovascular Disease – American Journal of Hypertension 2011; 24:843-853”
• Reuters article discussing the review >
• “Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials” – F He, G MacGreggor – The Lancet 2011; published online 30 July 2011
• “Modest salt reduction lowers your risk of a heart attack or stroke” – WASH press release
• WHO Global Status Report on Non-Communicable Diseases 2010 – World Health Organization; April 2011