Translating evidence into policy for cardiovascular disease control in India

These strategies are focussed on the population wide reduction of multiple cardiovascular risk factors. Rose developed the concept of CVD risk as a continuum in a population and showed that all pathophysiological factors were continuously distributed in a population [34]. He opined that high-risk and sick individuals simply represented the extreme end of the statistical distribution. From this hypothesis evolved the concept of population-wide control of risk factors. This would shift the mean levels of risk factors (e.g., cholesterol, systolic BP) in the standard normal curve to the left and decrease number of high-risk individuals. The principal concepts of the Rose hypotheses are continuity of risk and its population impact, more disease in subjects at small risk as compared to less numbers in people with high risk, prediction of cases using population mean of risk factors, difference in causes of CVD among population and individuals, societal characteristics that influence risk, and implications on policy, research and population action [34]. The policy and clinical actions for population actions for prevention are summarised below.

The social issues involved in occurrence of premature CVD and other non-communicable diseases are multiple and include the social gradient, stress, early life events, social exclusion, improper working conditions, lack of social support, addictions including tobacco/alcohol, food scarcity or excess and uneven distribution, lack of proper transport and illiteracy and low educational status [32]. There are macrolevel (governance failure, geopolitics, natural resources decline, economic policies, population growth, demographic trap, etc.) and microlevel (cultural barriers, poverty trap, lack of innovation and savings, absence of trade/business, technological reversal, adverse productivity shock, gender bias, adolescence-related, etc.) factors [30]. Multiple national programs exist in India to improve socioeconomic status of the population ranging from literacy improvement (National Literacy Mission and Right to Education Act) to employment generation (National Rural Employment Guarantee Act) and social security (Women's Health Plan). These policies are directed to the specific social issue or population group but not in context of disease prevention or control. Improving literacy reduces unhealthy behaviours (e.g., smoking) and increases awareness of risk factors [35]. It also promotes adherence to lifestyle and pharmacotherapies for primary and secondary prevention [36]. Both general literacy [37] and health literacy [38] should be part of the National Literacy Mission. Inter-ministerial collaboration is essential for policy implementation on CVD prevention and control (Figure 2) and the Indian National Commission of Macroeconomics and Health which encompasses ministries of health, finance, technical education, human development, youth affairs, sports, women and child development, agriculture, food and civil supplies, industry, commerce and transport is an important step forward [39].

The existing Indian national health programs are directed towards communicable diseases and maternal and child health [40]. Although national program for control of cardiovascular diseases and diabetes has been initiated as a pilot it has not been scaled due to paucity of funds [41]. We believe that it is a priority and the program and must be spread widely and scope and funding substantially increased. National Rural Health Mission of government of India [42] should focus on improvement of healthcare systems for non-communicable diseases and chronic care [43, 44]. The National Urban Health Mission [45] which has been in a planning stage for a long time also needs to be urgently implemented. Clearly a political will to initiate and sustain these programs is needed. Acute cardiovascular events (acute myocardial infarction or stroke) should be deemed notifiable similar to certain infections [40].

An important area for CVD control is healthcare financing by the government. In India the total healthcare spending is about 5% of the gross national product (GNP) but government spends less than 1% of GNP [4]. Treating CHD is expensive [46] but unfortunately all the focus of the government is on development of tertiary care facilities. It is possible to reduce the mortality and burden of CHD by population wide policies [4]. Financing is needed not only for implementation of programs for tobacco, alcohol and dietary fat control but also to improve urban design and provide better education within the existing national programmes. Health insurance for acute and chronic diseases is virtually non-existent in India [47]. More than 80% population pays out of pocket for health related expenses and every year almost 30 million individuals are pushed into poverty for catastrophic healthcare expenditure [48]. India has the most privatised healthcare system in the world (<20% public funding) compared to the US (the most privatised system) where the government health expenditure is about 50% of the total [49]. In GNP terms too, at 0.9 per cent of the governmental health care spending in India is one of the lowest in the world [49]. A few state governments have joined hands with private insurers to provide health-insurance to general population but the impact of such schemes has not been evaluated [50].

Primordial and primary prevention of chronic non-communicable diseases especially CVD and CHD are not major component of medical school curricula in India [40]. At policy level, Medical Council of India should implement this change. Continuing medical education for general physicians, general practitioners and others about advances in cardiovascular and other forms of therapy should be mandatory [51]. Physicians should be encouraged to use global risk-assessment tools such as the Framingham Risk Score [52]. They have to be aware of various CVD guidelines [53]. Although there is evidence in India that devoted clinicians manage their patients according to the guidelines [54], the uptake of preventive efforts is limited [46]. Establishment of systems to address the multi-level contexts that influence the development and maintenance of prevention-related health behaviours is important [33, 55]. Hospitals and health care systems should be encouraged to develop and provide preventive cardiology services and systems for the community [51]. And finally there should be creation and certification for preventive CHD specialists who can train the practitioners and paramedics in strategies of prevention and health promotion. Training of healthcare workers and allied health professionals for systematic or opportunistic screening is important [26, 51, 53]. This would lead to early diagnosis of risk factors and their management. There is also a need for creation of cadre of non-communicable disease health care workers for not only screening but also for ensuring monitoring of individuals and ensuring compliance. These workers should also be trained to educate the populace in early diagnosis of acute CVD events and ensuring referral.

An important policy action for CVD prevention and control is enforcement of strict anti-tobacco laws[6]. It is now well recognised that smoking in any form (cigarettes, bidis and others) as well as use of non-smoked tobacco is equally dangerous to health, especially CVD health [56]. Smoking and tobacco use is rampant among the rural subjects and in low socioeconomic status urban subjects [35]. The comprehensive legislation on tobacco control and adoption of the WHO Framework Convention on Tobacco Control (FCTC) by government in India is an important step in this direction [57]. Studies from Europe and North America have reported that strict enforcement of FCTC have resulted in reduced admissions due to CHD and decreased mortality [58]. Indian laws need to be amended to comply with the provisions of the FCTC [59]. There is a considerable gap in policy and its application. According to a survey the enforcement of FCTC in India is less than 20% [60]. The government needs to approve anti-smoking laws and educate the public through organized programs with media support and enforce the tobacco control legislation strictly.

Diet is a very controversial area and the current evidence based practices adopted by the western countries should be carefully evaluated and cautiously implemented [32, 33]. WHO has concluded that as a society moves up the socioeconomic scale there are substantial changes that occur in diet [61]. These include greater consumption of calories, fats, saturated fats, trans-fats, salt, refined carbohydrates and sugars and decreased intake of high-fibre foods, legumes and vegetables. A healthy diet should be the opposite. Guidelines promoted by WHO [61] and Indian national committees [33, 62] suggest: (i) increased intake of fruits and vegetables (at least 500 g per day), legumes and whole grain foods; (ii) reduction of the intake of fried foods, processed foods, soft drinks containing calories, and other unhealthy foods; (iii) limitation on the daily intake of total fat to 25-35% of calories, and saturated fat <7% of the calories, by limiting the use of butter, ghee, full-fat dairy products, trans-fats, and tropical oils (palm oil and coconut oil) and increased intake of mono-unsaturated fats up to 20%; (iv) reduction of the dietary glycemic load by cutting down on the carbohydrates, especially refined carbohydrates; (v) reduction of the intake of salt to <2.5 gm sodium or <6 gm of salt (one teaspoon of salt) per day; and (vi) moderation in the use of nuts, lean meat and fish and alcohol. Government policies are important to translate knowledge into practice [63]. For years the food and nutrition policies of the Indian government have focused on problem of undernutrition [39]. The dual epidemic of under- and over-nutrition needs a different response. Focus should be on a balanced healthy diet that tackles problems of both rather than on overweight/obesity alone. India is, also, unique because more than 90% of consumed food is home-made. Following steps can have major immediate effects: (i) promotion of healthy nutrition in the general population by implementation of various government of India guidelines on chronic diseases, diabetes and obesity; (ii) creation of culturally sensitive health educational material; (iii) subsidies for producing and distributing healthy foods and fruits; (iv) penal taxation on unhealthy saturated and hydrogenated fats and subsidies on vegetable oils; (v) food labelling including portion size, calories, total fat, saturated fat, trans-fat, protein, carbohydrates, sodium, sugar and fibre; (vi) healthy foods availability at schools and work sites; and (vii) reduction of salt content in the processed food.

Salt is important in genesis and perpetuation of hypertension and has a direct correlation with CVD [64]. Indian diet has a very high salt content, typically 10-12 g of salt intake per day as recommended by government agencies [65]. A lower intake is (5-6 g salt/day) suggested by international guidelines [26]. Recommendations regarding alcohol intake for CVD prevention are confusing [66]. The overall harm of alcohol due to high blood pressure, liver disease and accidents and injuries and is much more than protective effects on CVD [67] and as policy alcohol should be discouraged.

Regular physical activity is extremely important for CVD prevention [68]. The recommended physical activity is 30-to-45 minutes of moderate-intensity activity such as brisk-walking every day. In India, work-related physical activity is confined to rural and urban low socioeconomic status subjects [69], while leisure time physical activity is limited to a motivated few in urban areas [70]. Evidence from Europe and North America reports beneficial effect on population based initiatives on increasing physical activity with a public health perspective [71]. Occupational physical activity and creating separate time for employees has been the focus of international agencies [72]. There are examples of multiple comprehensive worksite health promotion programs that focus on improvement of physical activity [73, 74]. In India, an industrial worksite intervention program reported significant change in health related behaviours with reduced tobacco use and increased physical activity [75]. Habit of active participation in physical activity programs, games and sports begins in early childhood and track to adulthood, therefore, physical education should be given greater emphasis in schools and colleges [76]. Yoga can be part of the physical activity among the school children as its regular participation not only improves physical capacity but also improves adherence to other strategies for improving health [33]. In a study in India 40000 school children in were provided educational intervention for a 6 month period which resulted in improved health literacy and health behaviours at one year [77]. Policy changes have to be implemented and it is heartening to note that national and state-level educational boards have included chronic disease prevention in the course curriculum.

Urban planning is important for public health and can improve human well-being, emphasize needs assessment and service delivery, manage complex social systems, focus at the population level, and rely on community-based participatory methods [72, 78]. The current development of cities has been haphazard and most are conglomeration of houses and narrow lanes with no place to walk safely [79]. For CVD prevention there should be encouragement of construction and use of foot-paths and bicycle-paths. A uniform urban development policy is needed which should not only be guided by aesthetics but also by the health needs of the population. Traditionally, these plans include planning for community needs in transportation, housing, commercial/office buildings, natural resource utilization, environmental protection, and health-care infrastructure [78].

This strategy focuses on control of risk factors [26]. Although a large number of CVD risk are described interventions focussed on the major risk factors (smoking, high BP, high LDL cholesterol, low HDL cholesterol and diabetes) have shown to lead to substantial decline in incidence of CVD [80]. Primary prevention strategy should focus on improving healthcare delivery and target-oriented control of risk factors [68].

In India the healthcare delivery mechanisms are very chaotic [4]. For proper delivery of chronic health care the medical infrastructure needs to be structured like a pyramid [45]. In this pyramid the maximum emphasis has to be at the primary level, i.e. at the level of first contact that should be easily accessible (both physically and in terms of affordability) by everyone. Each successive rung needs to be equipped to perform more complex tasks for more complex conditions. This has to be followed up with a referral system along this pyramid [51]. Such a system minimises waste (viz. in the form of trivial or self-limiting illnesses being treated at district or state level hospitals) and enhances accessibility. In India on paper we have such a system in operation [45] but in reality this system is woefully inadequate. The infrastructure below the district level is rudimentary. This places enormous burden on facilities at state and district levels. The reason for this is two-fold. First, while in a pyramid the strength of the base is most important, we somehow have this erroneous notion that the excellence of the system depends on the apex, i.e., specialty hospitals in metropolitan centres. As a policy, preventive healthcare and chronic disease surveillance should be delivered by primary care physicians or trained community health workers [81]. As a large proportion of population in India receives healthcare from non-governmental sector [82], at a policy level there should be an effective integration of government and non-government agencies involved in delivery of primary health care [83] (Figure 2).

Aggressive primary prevention is critical to preventing CVD in those who are in high-risk category with the four key objectives: (i) avoidance of all tobacco products and passive exposure to tobacco, (ii) control of dyslipidemia, (ii) control of blood pressure, and (iii) control of blood glucose and diabetes through intense lifestyle modification and medications if necessary [1, 5, 53]. Community worker based model for chronic disease risk factor control has been tried in many settings with variable results [81]. This strategy is useful in management of infections, pregnancy related outcomes and malnutrition. Trials are underway in India to assess their importance in chronic diseases. Use of practitioners of alternative systems of medicine could be important for chronic diseases risk factor management [83]. India has a strong tradition of religiosity and all gurus recommend prudent lifestyle- with focus on smoking cessation, balanced diet, physical exercise and mental relaxation- important for CVD control.

Acute cardiovascular disease management and appropriate long term medical care is crucial in preventing CVD related mortality [84]. A substantial reduction in CVD related mortality in high income countries is due to better acute coronary care and long term management [25]. On the other hand availability of care and its standard is variable in low income countries [1]. There is need to develop better quality CVD care systems and manpower in these countries.

There is a need to develop publicly funded primary and secondary healthcare systems for acute CVD care [51]. Acute coronary events should be made a notifiable condition. In India, management practices in acute coronary syndromes are guidelines driven and optimal [54]. Guidelines recommend that lifestyle changes recommended above, aspirin, beta-blockers, angiotensin converting enzyme (ACE) inhibitors and statins be used in all patients with CVD [84]. There was low use of secondary prevention therapies in Europe and North America in late 1990's but the situation has improved due to policy focus on better management [85]. In India there is low use of various evidence based medicines, especially statins and beta-blockers and a rapid decline in use as the patients move from tertiary to secondary and primary care [86]. This is due to multiple barriers to proper management at healthcare systems, healthcare providers and patient level. Health systems related barriers are in the realm of government policy and action and need major efforts.