Case management guide for diabetes, heart disease and related conditions

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The UK Department for International Development has made available Type 2 Diabetes, Cardiovascular Disease, Obesity and Hyperlipidaemia Care in Adults: Case Management Desk Guide. This document guides health care workers on the screening, detection and management of type 2 diabetes and its related conditions (hypertension, obesity, high cholesterol, alcoholism and smoking). The guide is currently in draft form.

Click here to access a PDF of the guide.

Mexico study: Heart disease risk determined by quality of fat

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Quality, rather than quantity of fat, is the determinant of heart disease risk, according to a study conducted in Mexico. The study found that although fat intake among three-quarters of Mexicans fell within World Health Organization recommendations, their saturated fat and trans fat intake exceeded healthy diet recommendations–placing them at higher risk for heart disease.

Around 60 percent of Mexicans surveyed had a high intake of saturated fats and a low intake of polyunsaturated fats, which help reduce the risk of heart disease and promote cardiovascular health.

“Public policies should be enacted to reduce the intake of saturated fats by improving the quality of baking lard and promoting the consumption of defatted milk,” the study recommended. These two foods are among the main sources of saturated fats in the Mexican diet.

In addition, consumption of foods rich in n-3 and n-6 fatty acids (such as fish and nuts) are very low in the typical Mexican diet; thus, alternatives like promoting a larger consumption of canola or soy bean oils or addition of n-3 fatty acids to cooking oils from other sources must be considered, the study concluded.

1. Ramírez-Silva I, Villalpando S, Moreno-Saracho JE, Bernal-Medina D. Fatty acids intake in the Mexican population. Results of the National Nutrition Survey 2006. Nutrition & Metabolism 2011; 8: 33. (open access)

Management of diabetes and associated cardiovascular risk factors in seven countries

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A substantial proportion of individuals with diabetes remain undiagnosed and untreated, both in developed and developing countries, according to a multi-country study using nationally representative health examination surveys from Colombia, England, Iran, Mexico, Scotland, Thailand and the United States.

The figures range from 24 percent of women in Scotland and the United States to 62 percent of men in Thailand. The proportion of individuals with diabetes reaching treatment targets for blood glucose, arterial blood pressure, and serum cholesterol was very low, ranging from one percent of male patients in Mexico to about 12 percent in the United States. Income and education were not found to be significantly related to the rates of diagnosis and treatment anywhere except in Thailand, but in the three countries with available data insurance status was a strong predictor of diagnosis and effective management, especially in the United States.

Based on this comparison of how well these seven countries are performing in terms of population-level management of diabetes, hypertension and high cholesterol, the study researchers make the following recommendations:

  1. It is critical to track diabetes care at the population level and to focus on actual outcomes, rather than on the process of care. It is also critical to study other countries with larger numbers of individuals with diabetes, such as China and India, for which nationally representative studies are not readily available.
  2. It is important to prioritize the development and implementation of national guidelines and the use of new incentive programs for the management of hypertension and high cholesterol among individuals with diabetes in developing countries. The study findings suggest that such progress may be more feasible and more likely to have a larger population health impact than blood glucose control.
  3. There are opportunities for innovation in providing incentives, in the technology of diabetes management and in improving financial access to care.

Real progress at the population level in the management of diabetes will likely require all three: monitoring performance in meeting treatment targets, expanding management of hypertension and high cholesterol in individuals with diabetes, and innovations in the delivery of and access to care.

The estimated global prevalence of diabetes is around 6.4 percent and more than 280 million people in the world have diabetes—the majority live in the developing world. Projections indicate that diabetes accounted for almost four million deaths worldwide in 2010. The burden of diabetes will only continue to grow, since the number of adults with diabetes in developing countries is projected to rise by more than two-thirds between 2010 and 2030.

1. Gakidou E, Mallinger L, Abbott-Klafter J, et al. Management of diabetes and associated cardiovascular risk factors in seven countries: a comparison of data from national health examination surveys. Bulletin of the World Health Organization 2011; 89: 172-183. (open access)

Effective control of high cholesterol remains low worldwide

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The percentage of people with high cholesterol who are effectively treated remains small in selected high- and middle-income countries, according to a World Health Organization study. Many of those affected are unaware of their condition. Lowering total serum cholesterol levels is an ideal strategy for reducing the burden of cardiovascular disease.

The study analyzed data sampling close to 80,000 adults age 40-79 years from England, Germany, Japan, Jordan, Mexico, Scotland, Thailand and the United States. The proportion of undiagnosed individuals was highest in Thailand (78 percent) and lowest in the United States (16 percent). The fraction diagnosed but untreated ranged from nine percent in Thailand to 53 percent in Japan. The proportion being treated who had attained evidence of control ranged from four percent in Germany to 58 percent in Mexico. Time series estimates showed improved control of high total serum cholesterol over the past two decades in England and the United States.

“These findings support the growing recognition that cardiovascular diseases are not merely ‘diseases of affluence’ and that some middle-income countries are beginning to face a double burden of both chronic and communicable diseases,” the study said.

The study recommended that programs designed to achieve higher detection and control of high blood cholesterol should be developed and implemented. Dried blood spot technology offers a new and affordable approach to screening in low-income settings. At the same time, better chronic disease surveillance is needed to monitor and guide these programs.

“Untreated high blood cholesterol represents a missed opportunity in the face of a global epidemic of chronic diseases,” the study concluded.

1. Roth GA, Fihn SD, Mokdad AH, et al. High total serum cholesterol, medication coverage and therapeutic control: an analysis of national health examination survey data from eight countries. Bulletin of the World Health Organization 2011; 89: 92-101. (open access)

India: NNRTI drugs raise cholesterol in HIV patients with TB

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Studies have shown that the Indian population in general has a high risk of cardiovascular disease (because of genetic and other factors), and there is concern that HIV infection and treatment with antiretroviral therapy (ART) may increase that risk.

A study conducted in south India found that HIV-positive patients with tuberculosis (TB) who initiated once-daily nonnucleoside reverse-transcriptase inhibitor (NNRTI)–based ART under went complex changes in their cholesterol levels, highlighting the importance of screening and treating other cardiovascular disease risk factors. The patients were also treated with rifampicin-based thrice-weekly antituberculosis treatment.

After 12 months of receiving NNRTI-based ART, HDL, LDL and total cholesterol levels increased significantly. The results that around 25 percent of patients who received an NNRTI-based regimen had an abnormal lipid profile at one year should alert physicians to this outcome and encourage testing, the study authors said.

“Although the current World Health Organization guidelines do not recommend routine monitoring of lipid levels for patients receiving first-line antiretroviral treatment, patients would benefit from an assessment of lipid profiles and other cardiovascular risk factors followed by counseling on risk-reduction strategies,” the study said. “As patients continue to enjoy longer lives as a result of effective treatment, it is important to consider and minimize long-term adverse effects of the disease and its treatment.”

1. Padmapriyadarsini C, Kumar SR, Terrin N, et al. Dyslipidemia among HIV-infected patients with tuberculosis taking once-daily nonnucleoside reverse-transcriptase inhibitor–based antiretroviral therapy in India. Clinical Infectious Diseases 2011; 52(4): 540-546. (open access)