Neglected Global Epidemics: three growing threats evidence and provided recommendations for nutrient intake goals for the prevention of CVD and other noncommunicable diseases(7) A coherent policy framework, encompassing legislation, regulation and mass education is critical for CVD prevention and control, since individual behaviour change is difficult in the absence of conducive environmental alterations. A suggested stepwise framework for a com prehensive response to CVD prevention and control is outlined in Table 6. 1 and can be modi- fied according to national needs, goals and targets Table 6.1 A stepwise approach for prevention and control of noncommunicable diseases Individual high-risk approach Resource level National level Community level Step 1 WHO Framework Convention on Local infrastructure plans indude the Context-specific management guide Tobacco Control (FCTC)is ratified in the provision and maintenance of accessible lines for noncommunicable diseases and safe sites for physical activity (such have been adopted and are used at all Tobacco control legislation consistent as parks and pedestrian-only areas). health care levels. with the elements of the FCTC is Health-promoting community projects A sustainable, accessible and affordable enacted and enforced include participatory actions to cope supply of appropriate medication is Anational nutrition and physical activity, predispose to risk of noncommunicable asele for priority noncommunicable with the environmental factors that policy consistent with the Globa trategy is developed and endorsed at diseases: inactivity, unhealthy diet, A system exists for the consi Cabinet level: sustained multisectoral tobacco use, alcohol use, etc. uality application of clinica action is evident to reduce fat intake, Active health promotion programmes and for the clinical audit reduce salt (with attention to iodized focusing on noncommunicable diseases offered salt where appropriate), and promote are implemented in different settings fruit and vegetable consumption. villages, schools and workplaces. for recall of patients with hypertension is Health impact assessment of publi y is carried out(for example ort, urban planning, taxation, and Tobacco legislation provides for Sustained, well-designed programmes ms are in place for selective and Expanded incremental increases in tax on tobacco, are in place to promote ted prevention aimed at high-risk and a proportion of the revenue is tobacco-free lifestyles, e.g. smoke. lations, based on absolute levels earmarked for health promotion ee public places, smoke-free sports; Food standards legislation is enacted and enforced: it includes nutrition healthy diets, e.g. low-cost, low-fat lab foods, fresh fruit and vegetables; Sustained, well-designed, national hysical activity, e.g. "movement"in fferent domains occupational and programmes (counter-advertising) are in place to promote non-smoking Step 3: Country standards are established that Recreational and fitness centres are Opportunistic screening, case-finding Optimal regulate marketing of unhealthy food available for community use. and management programmes are to children Capacity for health research is built Support groups are fostered for tobacco within countries by encouraging studies cessation and overweight reduction on noncommunicable diseases Appropriate diagnostic and therapeutic interventions are implemented Adapted from: (8)
Neglected Global Epidemics: three growing threats 89 evidence and provided recommendations for nutrient intake goals for the prevention of CVD and other noncommunicable diseases (7). A coherent policy framework, encompassing legislation, regulation and mass education is critical for CVD prevention and control, since individual behaviour change is difficult in the absence of conducive environmental alterations. A suggested stepwise framework for a comprehensive response to CVD prevention and control is outlined in Table 6.1 and can be modified according to national needs, goals and targets. Table 6.1 A stepwise approach for prevention and control of noncommunicable diseases Resource level Step 1: Core Step 2: Expanded Step 3: Optimal Context-specific management guidelines for noncommunicable diseases have been adopted and are used at all health care levels. A sustainable, accessible and affordable supply of appropriate medication is assured for priority noncommunicable diseases. A system exists for the consistent, highquality application of clinical guidelines and for the clinical audit of services offered. A system for recall of patients with diabetes and hypertension is in operation. Systems are in place for selective and targeted prevention aimed at high-risk populations, based on absolute levels of risk. Opportunistic screening, case-finding and management programmes are implemented. Support groups are fostered for tobacco cessation and overweight reduction. Appropriate diagnostic and therapeutic interventions are implemented. Population approaches Individual high-risk approach Adapted from: (8). National level WHO Framework Convention on Tobacco Control (FCTC) is ratified in the country. Tobacco control legislation consistent with the elements of the FCTC is enacted and enforced. A national nutrition and physical activity policy consistent with the Global Strategy is developed and endorsed at Cabinet level; sustained multisectoral action is evident to reduce fat intake, reduce salt (with attention to iodized salt where appropriate), and promote fruit and vegetable consumption. Health impact assessment of public policy is carried out (for example: transport, urban planning, taxation, and pollution). Tobacco legislation provides for incremental increases in tax on tobacco, and a proportion of the revenue is earmarked for health promotion. Food standards legislation is enacted and enforced; it includes nutrition labelling. Sustained, well-designed, national programmes (counter-advertising) are in place to promote non-smoking lifestyles. Country standards are established that regulate marketing of unhealthy food to children. Capacity for health research is built within countries by encouraging studies on noncommunicable diseases. Community level Local infrastructure plans include the provision and maintenance of accessible and safe sites for physical activity (such as parks and pedestrian-only areas). Health-promoting community projects include participatory actions to cope with the environmental factors that predispose to risk of noncommunicable diseases: inactivity, unhealthy diet, tobacco use, alcohol use, etc. Active health promotion programmes focusing on noncommunicable diseases are implemented in different settings: villages, schools and workplaces. Sustained, well-designed programmes are in place to promote: • tobacco-free lifestyles, e.g. smokefree public places, smoke-free sports; • healthy diets, e.g. low-cost, low-fat foods, fresh fruit and vegetables; • physical activity, e.g. “movement” in different domains (occupational and leisure). Recreational and fitness centres are available for community use
The World Health Report 2003 Unfortunately, in most countries the response to CVd prevention and control is still based on the infectious disease paradigm. Consequently, the global and national capacity to re- spond to CVd epidemics is woefully inadequate. Few countries have implemented compre hensive prevention and control policies(9)and development of capacity, especially for policy research, has not kept pace with the epidemiological transition. The gaps between the needs for CVd prevention and control and the capacity to meet them will grow even wider unless urgent steps are taken. Global norms are needed to balance the otherwise unrestrained influences of powerful ac tors. To promulgate such norms, public health professionals need to learn how to influence the deliberations of bodies such as the World Trade Organization- where health issues are Increasins gly considered-and to develop stronger ways of dealing with products with health impacts. A combination of multistakeholder and intergovernmental codes and other non- binding measures may be required. The Framework Convention on Tobacco Control, de- scribed in the following section, is one example of a legally binding global norm. WHO and governments cannot confront the challenges of CVD prevention and control alone. As with tobacco control, partnerships and interactions with international consumer groups and global commercial multinationals are essential. WHO is developing a Global Strategy on Diet, Physical Activity and Health as a strategic framework within which WHO and Member States can work together across sectors in preventing CVD and other noncommunicable dis eases. This population-wide prevention strategy is based on extensive consultations with stakeholders: Member States, the United Nations and intergovernmental organizations, civil society and the private sector Globally, there is still only limited advocacy for the CVd prevention and control agenda. What there is tends to be fragmented. The lack of unified advocacy for health promotion Box 6.1 Measuring progress: integrated surveillance of noncommunicable disease risk factors The goal of surveillance is to monitor emerging patterns and trends in get started in surveillance and prevention activities for noncommunicable major cardiovascular disease(CVD)and other noncommunicable dis- diseases. By increasing local capacity, STEPS aims to achieve data com- ease(NCD)risk factors and to measure the effectiveness of prevention parability over time and between countries. Many Member States have interventions in countries. Two tools have now been trained in the STEPS methodology developed for this purpose The approach is designed to build on existing STEPwise approach to Surveillance(STEPS)of surveillance activities, but can also be intro- noncommunicable disease risk factors(10) duced as a new methodology to countries where there are no surveillance systems cur STEPS is a sequential process, starting rently in place. Data collected using the STEPwise approach is fed into the WHO Glo- haviours by the use of questionnaires (Step bal NCD InfoBase 1), then moving to simple physical measure- The WHO Global NCD InfoBase is a da ments(Step 2), and only then recommending tabase designed to hold existing country-level the collection of blood samples for biochemi- data on risk factors of noncommunicable dis. cal assessment(Step 3). This framework builds eases Its strength is that the data can be dis a common approach to defining core variables played and used to derive a single best for surveys, surveillance and monitoring sys Core prevalence estimate for any given country. This ms. The goal is to achieve data comparabil. approach allows transparency in the use of y over time and between countries. The country data sources. It is a major improve methodology has been developed in close collaboration with WHO re. ment on previous WHO estimates, which, in the absence of such a rela- gional offices and is easily adaptable to the needs of Member States. It tional database, relied on selected studies which may have excluded offers an entry point for low-income and middle-income countries to many available sources and lacked transparency
90 The World Health Report 2003 Unfortunately, in most countries the response to CVD prevention and control is still based on the infectious disease paradigm. Consequently, the global and national capacity to respond to CVD epidemics is woefully inadequate. Few countries have implemented comprehensive prevention and control policies (9) and development of capacity, especially for policy research, has not kept pace with the epidemiological transition. The gaps between the needs for CVD prevention and control and the capacity to meet them will grow even wider unless urgent steps are taken. Global norms are needed to balance the otherwise unrestrained influences of powerful actors. To promulgate such norms, public health professionals need to learn how to influence the deliberations of bodies such as the World Trade Organization – where health issues are increasingly considered – and to develop stronger ways of dealing with products with health impacts. A combination of multistakeholder and intergovernmental codes and other nonbinding measures may be required. The Framework Convention on Tobacco Control, described in the following section, is one example of a legally binding global norm. WHO and governments cannot confront the challenges of CVD prevention and control alone. As with tobacco control, partnerships and interactions with international consumer groups and global commercial multinationals are essential. WHO is developing a Global Strategy on Diet, Physical Activity and Health as a strategic framework within which WHO and Member States can work together across sectors in preventing CVD and other noncommunicable diseases. This population-wide prevention strategy is based on extensive consultations with stakeholders: Member States, the United Nations and intergovernmental organizations, civil society and the private sector. Globally, there is still only limited advocacy for the CVD prevention and control agenda. What there is tends to be fragmented. The lack of unified advocacy for health promotion Box 6.1 Measuring progress: integrated surveillance of noncommunicable disease risk factors The goal of surveillance is to monitor emerging patterns and trends in major cardiovascular disease (CVD) and other noncommunicable disease (NCD) risk factors and to measure the effectiveness of prevention interventions in countries. Two tools have been developed for this purpose: the WHO STEPwise approach to Surveillance (STEPS) of noncommunicable disease risk factors (10) and the WHO Global NCD InfoBase (11). STEPS is a sequential process, starting with gathering information on key health behaviours by the use of questionnaires (Step 1), then moving to simple physical measurements (Step 2), and only then recommending the collection of blood samples for biochemical assessment (Step 3). This framework builds a common approach to defining core variables for surveys, surveillance and monitoring systems. The goal is to achieve data comparability over time and between countries. The methodology has been developed in close collaboration with WHO regional offices and is easily adaptable to the needs of Member States. It offers an entry point for low-income and middle-income countries to get started in surveillance and prevention activities for noncommunicable diseases. By increasing local capacity, STEPS aims to achieve data comparability over time and between countries. Many Member States have now been trained in the STEPS methodology. The approach is designed to build on existing surveillance activities, but can also be introduced as a new methodology to countries where there are no surveillance systems currently in place. Data collected using the STEPwise approach is fed into the WHO Global NCD InfoBase. The WHO Global NCD InfoBase is a database designed to hold existing country-level data on risk factors of noncommunicable diseases. Its strength is that the data can be displayed and used to derive a single best prevalence estimate for any given country. This approach allows transparency in the use of country data sources. It is a major improvement on previous WHO estimates, which, in the absence of such a relational database, relied on selected studies which may have excluded many available sources and lacked transparency. Biochemical measurements Physical measurements Questionnaires Core Expanded Option 1 Option 3 Option 2 Step 1 Step 3 Step 2