Dedicated to the Assessment Prevention and Control of

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Prevention and Control of Hypertension: Developing a Global Agenda Campbell, Norm RC, Niebylski, Mark, and World Hypertension Executive “ Prevention and control of hypertension: Developing a Global Agenda”, Current Opinion, Vol 29, No. 4, 2014 http: //www. whleague. org/images/WHL_PCH_Developing_a_global_ agenda. pdf The WHL is a charitable organization comprised of national and regional hypertension societies 1

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally The Journal of Clinical Hypertension • The Official Journal of the World Hypertension League offers free access which can be signed up for by: 1. Go to the Journal of Clinical Hypertension Homepage http: //onlinelibrary. wiley. com/journal/10. 1111/(ISSN)1751 -7176 2. Click on the down arrow next to the Log In/Register Option in the upper right corner of the screen 1. Choose the register option from the lower left corner of the dropdown box 1. On the log in page enter your e-mail address—which will become your user name –and select a password, enter your personal information (This information is not shared with outside parties), select promotional information you might like to receive and hit the submit registration button The WHL is a charitable organization comprised of national and regional hypertension societies 2

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally “An epidemic of chronic non-communicable diseases (NCDs) is threatening national healthcare systems’ sustainability and the economy of many countries. Increased blood pressure is the leading risk for premature death and disability and accounts for approximately 10% of healthcare spending. Four of nine recent United Nations’ targets for reducing NCDs relate directly or indirectly to hypertension. ” 1 The WHL is a charitable organization comprised of national and regional hypertension societies 3

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Purpose: • To provide a brief overview of how nongovernmental organizations can aid prevention and control of hypertension by utilizing the expanded chronic care model • To alert cardiovascular experts and organizations of the need for a paradigm shift whereby the hypertension community may redirect its resource to contribute to achieving the United Nations NCD targets with regard to hypertension • This overview does not address clinical and basic science research needs, but rather, focuses on interventions that could improve prevention, diagnosis, treatment and control based on current knowledge The WHL is a charitable organization comprised of national and regional hypertension societies 4

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Key Points: • An epidemic of NCDs is threatening the sustainability of national healthcare systems and economies of many countries. • Elevated blood pressure is the leading risk for premature death and disability and accounts for approximately 10% of healthcare spending. 2 • Prevention and control of hypertension require a strategic approach that could have a central role for hypertension experts and the hypertension community. • The expanded chronic care model provides a comprehensive framework for developing the hypertension prevention and control strategies outlined in this review. The WHL is a charitable organization comprised of national and regional hypertension societies 5

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Introduction: To assist the United Nation’s Efforts, the World Hypertension League recommends the following actions for the national hypertension organizations: a) Develop a systematic national plan for your organization with regard to the prevention and control of hypertension. b) Develop partnerships to prioritize hypertension prevention and control with government and nongovernment organizations including organizations representing the healthcare workers that manage hypertension. c) Ensure there appropriate hypertension management guidelines that are suited to your national circumstances and develop a plan to ensure all healthcare providers are aware of the guidelines. d) Advocate for national policies, especially those that reduce dietary salt, which would prevent hypertension and NCDs. e) Share your learnings with other national hypertension organizations through the World Hypertension League and the International Society of Hypertension. The WHL is a charitable organization comprised of national and regional hypertension societies 6

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Background and Need: • Globally, increased blood pressure is the leading risk for death and disability and accounts for approximately 10% of healthcare spending. 3 • About 40% of adults age 25 or older have hypertension. 4 • 18% of deaths globally and 7% of disability is attributed to increased blood pressure • An estimated 45% of heart disease and 51% of stroke being caused by increased blood pressure. 5 • Emerging health crises caused by dementia and renal failure also strongly associated with high blood pressure. 6 • Hypertension may also contribute to complications in other prominent conditions such as diabetes mellitus and pregnancy. 7 The WHL is a charitable organization comprised of national and regional hypertension societies 7

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Background and Need Continued: Only recently has the burden of blood pressure related diseases begun to be recognized by world leaders who are struggling with healthcare costs and noncommunicable disease rates. 8 • The World Health Organization (WHO) dedicated World Health Day in 2013 to Hypertension. 9 • The United Nations developed nine chronic disease targets for national actions to be achieved by 2025, of which four relate directly or indirectly to hypertension. 10 The WHL is a charitable organization comprised of national and regional hypertension societies 8

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally United Nations’ Targets Related to Salt Reduction: • To reduce the prevalence of hypertension by 25% • To reduce dietary sodium by 30% • To have 80% coverage of essential cardiovascular medication and technologies (e. g. BP devices) • To reduce non communicable disease by 25% Goals can be found at: Global Risk Network of the World Economic Forum. Global Risks 2009 - A Global Risk Network Report. World Economic Forum , 3 -34. 2009. Cologny/Geneva, Switzerland, World Economic Forum. The WHL is a charitable organization comprised of national and regional hypertension societies 9

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally The Expanded Chronic Care Model: Frameworks for the prevention and control of NCDs have been developed and can form the basis for hypertension prevention and control strategies. 11 • One such approach is the expanded chronic care model that has been used in Canada and elsewhere. 12 • The Expanded Chronic Care Model recognizes the roles of healthy public policy, healthy living environments, healthy communities, reoriented health services delivery, improved decision support for optimum care, enhanced self-care skills of people, partnerships of stakeholders and information systems that can assess the impact of interventions. The WHL is a charitable organization comprised of national and regional hypertension societies 10

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Environmental Factors Contributing to Hypertension: Hypertension is unusual in hunter gather societies, which are physically active, lean and eat unprocessed foods low in salt. Approximately 32% of hypertension is attributable to high dietary salt 18% to low dietary potassium 32% to obesity 18% to lack of physical activity 3% to excess alcohol intake 13 Therefore efforts to prevent hypertension need to focus on improving lifestyles on a population basis 13 The WHL is a charitable organization comprised of national and regional hypertension societies 11

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Combining Healthy Environments with Clinical Interventions: • In order to be successful, clinincal interventions need to be paired with policy and environmental interventions that make healthy lifestyle choices much easier for individuals. 15 • Policies that combine both healthy environments and clinical intervention are indicated to have positive results. • In Canada 5/2 -mm. Hg downward shift in population blood pressure such as could be achieved by reduction in dietary sodium was estimated to double the hypertension control rate and reduce the prevalence of hypertension by 30%. 16 • A similar decrease in blood pressure in the USA was estimated to have a major impact on cardiovascular disease. 17 The WHL is a charitable organization comprised of national and regional hypertension societies 12

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Recommended Public Health Actions for National Hypertension Organizations: Increase awareness that hypertension is largely preventable but is a constant threat to wellbeing as the world’s leading risk for death and disability Increase awareness that hypertension is largely caused by unhealthy eating (especially high dietary salt), physical inactivity, obesity, and excessive alcohol intake Advocate for effective healthy public policies that if implemented could largely prevent hypertension from occurring Most important is for countries and communites to have an effective and comprehensive strategy to reduce dietary salt and to ensure a healthy food supply Increase awareness that hypertension can be inexpensively and easily detected and clinically managed Communites need to programs for all adults to have regular blood pressure assessments linked to effective hypertension management Advocate for affordable antihypertensive drugs accessible to all The WHL is a charitable organization comprised of national and regional hypertension societies 13

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Healthy Blood Pressure Communities: It is difficult for people to make healthy decisions when they live in unhealthy communities. So efforts need to focus on redesigning communities to facilitate physical activity, healthy eating, abstinence from tobacco products, low risk alcohol consumption, blood pressure checks and clinical management. Examples of this include: • The World Hypertension League is developing resources and recommended minimum standards for blood pressure screening programs. It is hoped to pilot test the screening programs for community-based blood pressure screening in 2015. 18 • Yaroslavl Russia has very recently developed a successful community-based program for improving hypertension detection and management within the healthcare system. 19 The WHL is a charitable organization comprised of national and regional hypertension societies 14

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Reoriented Health Services Delivery: The epidemic of NCDs is threatening the sustainability of the health care systems. The ideal system promotes wellness, comprehensively screens for health risks and intervenes to control the risks and diseases at an early stage before premature death and disability and the attendant high-cost illnesses occur The WHL is a charitable organization comprised of national and regional hypertension societies 15

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Key Aspects of health care systems that national hypertension organizations can advocate for: 1. Ensure regular blood pressure checks are provided to the adult population utilizing community resources 2. Ensure those indentifed with high readings are informed and linked to people who can make a diagnosis and provide effective treatment 3. Make affordable antihypertensive drugs accessible to all 4. Monitor and evaluate the system to ensure people with hypertension are being identifed, treated and controlled to national standards 5. Ensure the health care system facilitates and supports the development and implementation of health public policy The WHL is a charitable organization comprised of national and regional hypertension societies 16

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Reoriented Health Services Delivery: • Such systems are based on comprehensive equitable systematic costeffective interventions • Successful systems usually have a team of healthcare professionals working together (both physician and non-physician) • For example: the Cuban system has delivered good outcomes and low costs in part by assigning a healthcare team to each community • Another aspect of reoriented healthcare systems that is included in the United Nations recommendations is increased and affordable access to essential cardiovascular (antihypertension) therapies • Hypertension organizations have an important advocacy role to ensure that health systems in their country are evolving to meet the health needs of their population in a sustainable and cost-effective manner and that there is equitable and affordable access to antihypertensive medications. The WHL is a charitable organization comprised of national and regional hypertension societies 17

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Improved Decision Support for Optimum Care: • Improved decision support from a hypertension perspective implies that healthcare professionals managing hypertension are aware of the recommendations for managing hypertension relevant to their local situation • This requires that hypertension recommendations are applicable and easily accessible to healthcare professionals • Developing, adapting and disseminating hypertension recommendations are historically one of the more important functions of hypertension organizations • To be implementable these recommendations need strong input from those who manage hypertension in community-based primary care • Development of hypertension recommendations needs to be viewed as the start of a process rather than an end. Implementation is the critical step The WHL is a charitable organization comprised of national and regional hypertension societies 18

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Key Actions National Hypertension Organizations Recommendations Can Make to Ensure Primary Health Care Professionals are Equipped to Prevent and Control Hypertension: The WHL is a charitable organization comprised of national and regional hypertension societies 19

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally 1. Current evidence-based guidelines for management of hypertension are applicable to the national circumstances. 2. The recommendations include a) Blood pressure is measured at all encounters as a standard to practice b) Equipment that can accurately measure blood pressure and the use of a proper blood pressure measurement protocol. Validated semi or fully automated electronic devices are preferred. c) All to eat healthy diets (low salt, saturated fat, and sugar and that are high in fresh fruits and vegetables), to have regular physical activity and maintain a healthy weight. d) Specific tailored lifestyle advice to those with hypertension The WHL is a charitable organization comprised of national and regional hypertension societies 20

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally 3. That people with hypertension a) Are provided written material on the importance of hypertension, lifestyle and drug management b) Are assessed for tobacco use, diabetes and dyslipidemia and that these risks are managed by national standards. c) That moderate and high risk people with hypertension are recommended antihypertensive treatment d) Use combinations of affordable antihypertensive drugs to treat blood pressure to nationally recognized targets 4. Healthy public policies especially those that promote widespread available affordable healthy foods low in salt, that restrict advertising of unhealthy foods to children, and that provide warning labels on unhealthy foods. The WHL is a charitable organization comprised of national and regional hypertension societies 21

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally • Ensuring people have the skills and knowledge to implement and follow recommendations for prevention and control of hypertension is an important component of any hypertension strategy. • People with or at risk for hypertension but who lack health knowledge and skills are unlikely to be highly adherent to recommended treatments. 20 The WHL is a charitable organization comprised of national and regional hypertension societies 22

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Key Self-Efficacy Skills for Prevention and Control of Hypertension 1. Know the health risks caused by increased blood pressure 2. Know their blood pressure through regular blood pressure checks 3. Eat a diet high in fresh fruits and vegetables while avoiding salt, sugar and fatty foods, and excess alcohol intake 4. Have regular physical activity every day 5. Keep a healthy body weight by healthy eating and undertaking regular activity The WHL is a charitable organization comprised of national and regional hypertension societies 23

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Key Self-Efficacy Skills for Prevention and Control of Hypertension 6. Avoid all tobacco products 7. If provided antihypertensive medications take them regularly and make sure your blood pressure is well controlled 8. Ask the people who make policy in your community to ensure the community has healthy foods (fresh fruits and vegetables and foods and beverages low in salt, sugar and fat) and safe places for people to be active The WHL is a charitable organization comprised of national and regional hypertension societies 24

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Partnerships of Stakeholders: • The implementation of various components of a comprehensive hypertension strategy is beyond the scope of hypertension organizations. • It spans governmental organizations, civil society, the corporate sector and the breadth of most healthcare professions. • Hypertension organizations require strong partnerships to help implement and lead hypertension strategies. • Perhaps the easiest and highest priority partnerships to develop are those with the healthcare professional organizations that represent the clinicians that manage most hypertension on a day-to-day basis. • Hypertension organizations can ensure involvement of primary care organizations in the development and implementation of hypertension recommendations. The WHL is a charitable organization comprised of national and regional hypertension societies 25

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Information Systems: • A system to monitor and evaluate the impact of a hypertension strategy is critical to determine where the initial focus of hypertension prevention and control efforts should be, and helps assess the ongoing impact of interventions. 21 • The WHO works with many countries to implement a comprehensive chronic disease survey called WHO STEP-wise approach to surveillance ‘STEPs” that assess blood pressure among other health parameters. 22 The WHL is a charitable organization comprised of national and regional hypertension societies 26

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Information Systems: • Hypertension strategies need to have the results of national hypertension surveys integrated into them. • The World Hypertension League has developed recommendations for standardized analysis of hypertension surveys to aid the tracking of key hypertension prevention and control indicators over time and between countries to identify best practices The WHL is a charitable organization comprised of national and regional hypertension societies 27

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Discussion: • A strategic approach to prevention and control of hypertension that incorporates hypertension organizations in lead roles is very likely to assist in the efforts to achieve the United Nations chronic disease targets. • To take a lead role, most hypertension organizations will require a paradigm shift towards prevention and control efforts. • These efforts are best guided by an overarching strategy The WHL is a charitable organization comprised of national and regional hypertension societies 28

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Discussion Continued: • Some countries and communities that have had success in preventing and controlling hypertension implemented comprehensive strategic approaches. • The USA and Canada have achieved rates of control of hypertension of 50% or more in part based on sequential updated hypertension strategies. • Korea, Germany, Finland the UK have achieved remarkable improvements in control using different approaches that relate to more comprehensive health reform. 23 • The World Hypertension League is developing a strategic approach to aid national hypertension organizations in contributing more extensively to prevention and control of hypertension, particularly in low and middle income countries. The WHL is a charitable organization comprised of national and regional hypertension societies 29

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Conclusion: A systematic strategic approach is required to optimally prevent and control hypertension. An approach that addresses healthy public policy, living environments, communities, reoriented health services delivery, improved decision support for optimum care, enhanced self-care skills of people, partnerships of stakeholders and information systems. National hypertension organizations are well positioned to lead the development and implementation of such strategies in partnership with governmental and additional nongovernmental organizations. The WHL is a charitable organization comprised of national and regional hypertension societies 30

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally References: 1. Campbell, N, Niebylski, M. “Prevention and Control of Hypertension: Developing a Global Agenda. ” Current Opinion Vol 29, No. 4, 2014. http: //www. whleague. org/images/WHL_PCH_Developing_a_global_agenda. pdf 2. Campbell, N, Niebylski, M. “Prevention and Control of Hypertension: Developing a Global Agenda. ” Current Opinion Vol 29, No. 4, 2014. http: //www. whleague. org/images/WHL_PCH_Developing_a_global_agenda. pdf) 3. Lim SS, Voz T, Flaxman Ad, Danaei, G et al. “A comparative risk assessment of burden of disease and injury attributable to 67 risk clusters in 21 regions, 1990 -2010: a systematic analysis for the Global Burden of Disease Study 2010”. Lancet 2013; 380: 2224 -2260, Gaziano Ta, Bitton A, Anand S, Weinstein MC. ” The global cost of nonoptimal blood pressure”. J Hypertens 2009; 27: 1472 -1477 4. World Health Organization. “A global Brief on Hypertension: Silent Killer, Global Public Health Crisis. World Health Day 2013”. Report, 1 – 39. Geneva, Switzerland: World Health Organization; 2013. 5. World Health Organization. “A global Brief on Hypertension: Silent Killer, Global Public Health Crisis. World Health Day 2013”. Report, 1 – 39. Geneva, Switzerland: World Health Organization; 2013. 6. Udani S, Lazich I, Bakris GL. “Epidemiology of hypertensive kidney disease”. Nat Rev Nephrol 2011; 7: 11– 21. , Levi MN, Macquin-Mavier I, Tropeano AI, et al. “Antihypertensive classes, cognitive decline and incidence of dementia: a network meta-analysis”. J Hypertens 2013; 1073– 1082. 7. Chen G, Mc. Alister F A, Walker R L, etal. “Cardiovascular outcomes in framing- ham participants with diabetes: the importance of blood pressure”. Hypertension 2011; 57: 891– 897 The WHL is a charitable organization comprised of national and regional hypertension societies 31

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally References: 8. Global Risk Network of the World Economic Forum. “Global Risks 2009 - A Global Risk Network Report”. World Economic Forum, 3– 34. 2009. Cologny/ Geneva, Switzerland, World Economic Forum 9. World Health Organization. “’A global Brief on Hypertension: Silent Killer, Global Public Health Crisis. World Health Day 2013”. Report, 1 – 39. Geneva, Switzerland: World Health Organization; 2013 10. Global Risk Network of the World Economic Forum. ” Global Risks 2009 - A Global Risk Network Report. World Economic Forum”, 3 -34. 2009. Cologny/Geneva, Switzerland, World Economic Forum 11. Campbell N, Young ER, Drouin D et al: “A Framework for Discussion on How to Improve Prevention, Management and Control of Hypertension in Canada”. Can J Cardiol 2012, 28: 262 -269. 12. United Nations General Assembly. “Note by the Secretary-General transmitting the report of the Director-General of the World Health Organization on the prevention and control of noncommunicable diseases”. Report , 1 -19. 2013. New York, USA, Department for General Assembly and Conference Management. 15. . Committee on Public Health Priorities to Reduce and Control Hypertension in the U. S. Population, Institute of Medicine of the National Academies. “A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension”. Report , v-173. 2010. Washington, DC, USA, National Academies Press. 16. World Health Organization: “Interventions on diet and physical activity: what works: summary report. WHO 2009”, 1 -48. 17. Whelton PK, He J, Appel LJ et al. : ” Primary Prevention of Hypertension. Clinical and Public Health Advisory From the National High Blood Pressure Education Program”. JAMA 2002, 288: 1882 -1888 The WHL is a charitable organization comprised of national and regional hypertension societies 32

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally References: 18. Campbell NR, Neal BC, Mac. Gregor GA: “Interested in developing a national programme to reduce dietary salt? ” J Hum. Hypertens 2011, 25: 705 -710. 19. Mozheyko M, Eregin S, Vigdorchik A et al. : “Changes in hypertension treatment in the Yaroslavl region of Russia: improvements observed between 2 cross-sectional surveys”. J Clin Hypertens (Greenwich. ) 2013, 15: 918 -924. 21. World Health Organization: "Adherence to long-term therapies: evidence for action". Geneva, Switzerland: World Health Organization; 2003. 22. Campbell NR, Mc. Alister FA, Quan H: "Monitoring and Evaluating Efforts to Control Hypertension in Canada: Why, How, and What It Tells Us Needs to Be Done About Current Care Gaps". Can J Cardiol 2013, 29: 564 -570. 23. United Nations General Assembly. “Note by the Secretary-General transmitting the report of the Director-General of the World Health Organization on the prevention and control of noncommunicable diseases. Report” , 1 -19. 2013. New York, USA, Department for General Assembly and Conference Management. The WHL is a charitable organization comprised of national and regional hypertension societies 33

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally This Power. Point was based on the paper: Campbell, Norm RC, Niebylski, Mark, and World Hypertension Executive “ Prevention and control of hypertension: Developing a Global Agenda”, Current Opinion, Vol 29, No. 4, 2014 http: //www. whleague. org/images/WHL_PCH_Developing_a_glo bal_agenda. pdf This Power. Point was created by: Kimbree Redburn This Power. Point was reviewed by: Norm Campbell The WHL is a charitable organization comprised of national and regional hypertension societies 34