Hypertension and Diabetes: Entry Points for Prevention and...

International Journal of Hypertension

Guest Editors: Shanthi Mendis, Eoin O’Brien, Yackoob Kassim Seedat, and Salim Yusuf

Hypertension and Diabetes: Entry Points for Prevention and Control of the Global Cardiovascular Epidemic

Hypertension and Diabetes: Entry Points forPrevention and Control of the GlobalCardiovascular Epidemic

International Journal of Hypertension

Hypertension and Diabetes: Entry Points forPrevention and Control of the GlobalCardiovascular Epidemic

Guest Editors: Shanthi Mendis, Eoin O’Brien,Yackoob Kassim Seedat, and Salim Yusuf

Copyright © 2013 Hindawi Publishing Corporation. All rights reserved.

This is a special issue published in “International Journal of Hypertension.” All articles are open access articles distributed under theCreative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided theoriginal work is properly cited.

Editorial Board

Maciej Banach, PolandV. Batuman, USAClaudio Borghi, ItalyVito M. Campese, USAFrancesco Cappuccio, UKOscar A. Carretero, USASantina Cottone, ItalyChristian Delles, UKDaniel Duprez, USACsaba Farsang, HungaryJohn M. Flack, USAJ. Hall, USAJunichiro Hashimoto, Japan

Kazuomi Kario, JapanTomohiro Katsuya, JapanMarcel Lebel, CanadaKiyoshi Matsumura, JapanAlbert Mimran, FranceShawna D. Nesbitt, USAG. Parati, ItalyStefano Perlini, ItalyRoberto Pontremoli, ItalyHiromi Rakugi, JapanGiuseppe Schillaci, ItalyMarkus Schlaich, AustraliaGary Lee Schwartz, USA

Joseph I. Shapiro, USANaj Sharif, USAHelmy M. Siragy, USAMasayoshi Soma, JapanThomas Unger, GermanyFranco Veglio, ItalyM. Volpe, ItalyB. Waeber, SwitzerlandDonna Wang, USAM. R. Weir, USAYoram Yagil, IsraelXiao-Ping Yang, USA

Contents

Hypertension and Diabetes: Entry Points for Prevention and Control of the Global CardiovascularEpidemic, Shanthi Mendis, Eoin O’Brien, Yackoob Kassim Seedat, and Salim YusufVolume 2013, Article ID 878460, 3 pages

The Rising Burden of Diabetes and Hypertension in Southeast Asian and African Regions: Need forEffective Strategies for Prevention and Control in Primary Health Care Settings, Viswanathan Mohan,Yackoob K. Seedat, and Rajendra PradeepaVolume 2013, Article ID 409083, 14 pages

Gaps in Capacity in Primary Care in Low-Resource Settings for Implementation of EssentialNoncommunicable Disease Interventions, S. Mendis, Igbal Al Bashir, Lanka Dissanayake,Cherian Varghese, Ibtihal Fadhil, Esha Marhe, Boureima Sambo, Firdosi Mehta, Hind Elsayad, Idrisa Sow,Maltie Algoe, Herbert Tennakoon, Lai Die Truong, Le Thi Tuyet Lan, Dismond Huiuinato,Neelamni Hewageegana, Naiema A. W. Fahal, Goitom Mebrhatu, Gado Tshering, and Oleg ChestnovVolume 2012, Article ID 584041, 7 pages

Prevalence of Hypertension and Diabetes and Coexistence of Chronic Kidney Disease andCardiovascular Risk in the Population of the Republic of Moldova, Igor Codreanu, Vera Sali, Sergiu Gaibu,Luminita Suveica, Sergiu Popa, Norberto Perico, Bogdan Ene-Iordache, Sergio Carminati, John Feehally,and Giuseppe RemuzziVolume 2012, Article ID 951734, 8 pages

Diabetes and Coronary Heart Disease: A Risk Factor for the Global Epidemic, Maguy Chiha,Mario Njeim, and Edgar G. ChedrawyVolume 2012, Article ID 697240, 7 pages

Prevalence, Awareness, Treatment and Control of Coexistence of Diabetes and Hypertension in ThaiPopulation, Siriwat Tiptaradol and Wichai AekplakornVolume 2012, Article ID 386453, 7 pages

Hindawi Publishing CorporationInternational Journal of HypertensionVolume 2013, Article ID 878460, 3 pageshttp://dx.doi.org/10.1155/2013/878460

EditorialHypertension and Diabetes: Entry Points for Prevention andControl of the Global Cardiovascular Epidemic

Shanthi Mendis,1 Eoin O’Brien,2 Yackoob Kassim Seedat,3 and Salim Yusuf4

1 Management of Noncommunicable Diseases, World Health Organization, Geneva 1211, Switzerland2 Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Ireland3Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Congella, Durban, South Africa4 Population Health Research Institute, McMaster University, Canada

Correspondence should be addressed to Shanthi Mendis; [email protected]

Received 10 February 2013; Accepted 10 February 2013

Copyright © 2013 Shanthi Mendis et al.This is an open access article distributed under the Creative CommonsAttribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Complications of hypertension are associated with an esti-mated 9.4 million deaths worldwide every year [1]. In 2008,globally, the overall prevalence of hypertension (includingthose on medication for high blood pressure) in adultsaged 25 and over was around 40% [2]. On average, globalpopulation systolic blood pressure decreased slightly between1980 and 2008 [3, 4], although the worldwide prevalence ofobesity has nearly doubled during this period. In 2008, theglobal prevalence of high cholesterol was 40% and prevalenceof diabetes was 10% in adults over 25 years [1].

Most people with diabetes and hypertension also haveother cardiovascular risk factors such as raised lipids [1, 2].To reduce the prevalence and consequences of hypertensionand diabetes a complimentary mixture of population-wideand individual interventions is required. To ensure optimalcoverage of the population with these interventions imple-mentation of public health policies has to be complimentedwith a health system which addresses hypertension throughaffordable strategies [2, 5]. An approach that relies mainly onthe overall risk of individuals is likely to bemore cost effectivethan one focused solely on blood pressure levels or targets.

There are many barriers to the control of hypertensionand diabetes in low- and middle-income countries. Theyinclude the double burden of communicable and noncom-municable diseases, inadequate investment in health andprevention, fragile health systems particularly at primary carelevel, and lack of ormaldistribution of healthworkers. Severalcountries spend less than 50USD per capita per year on

health.This low level of investment is inadequate to effectivelyaddress noncommunicable diseases in a sustainable manner[2].

To address cardiovascular disease, diabetes, and noncom-municable diseases a set of core interventions (Table 1) havebeen identifiedwhich are highly cost effective, affordable, andfeasible to implement even in resource-constrained settings[6]. These interventions address diabetes, hypertension, andtheir key underlying risk factors—unhealthy diet, harmfuluse of alcohol, and physical inactivity. Some of these inter-ventions are feasible in primary care even in low-resourcesettings. For example, people at risk of heart attacks andstroke usually have amodest elevation ofmultiple risk factors,such as smoking, raised blood pressure, raised cholesterol,and/or diabetes. Such people who have medium or highcardiovascular risk can be treated with a multidrug regimenand behavioral modification to reduce the risk of developingfuture heart attacks, strokes, cardiac failure, and kidneydisease. This integrated intervention applied to individualswith an overall moderate or high cardiovascular risk basedon integrating risk based on age or several risk factors is morecost effective than conventional vertical approaches to single-risk-factor interventions [5].

Further, the development and deployment of a cadreof nonphysician health workers, by removing cultural andlegal barriers, will facilitate screening for hypertension anddiabetes. This can lead to prescribing a limited numberof safe, proven, and affordable medicines by nonphysician

2 International Journal of Hypertension

Table 1: A core set of very cost-effective interventions for prevention and control of noncommunicable diseases including cardiovasculardisease [6].

NCD core intervention set (best buys)

Reducing tobacco use(i) Excise tax increases;(ii) smoke-free indoor workplaces and public places;(iii) health information and warnings about tobaco;(iv) bans on advertising and promotion

Population-based interventions addressing NCDrisk factors

Reducing harmful alcoholuse

(i) Excise tax increases on alcoholic beverages;(ii) comprehensive restrictions and bans on alcoholmarketing;(iii) restrictions on the availability of retailed alcohol

Promoting healthy dietsand promoting physicalactivity

(i) Salt reduction when high, reduced salt content inprocessed foods;(ii) replacement of transfats with polyunsaturated fats;(iii) public awareness media campaign about diet andphysical activity

Individual-based interventions addressing NCDsin primary care

Reducing complications inindividuals with CVD anddiabetes

(i) Drug therapy (including glycaemic control fordiabetes mellitus) to individuals who have had a heartattack or stroke, and to persons with a high risk (>30%)of a CVD event in the next 10 years;(ii) providing aspirin to people having an acute heartattack.

health workers [7, 8]. Protocols and tools to estimate costof implementation have also been developed to facilitatedelivery of these very cost-effective interventions [9, 10].WHO estimates show that to implement the interventionslisted in the table for all low- and middle-income countries,the cost of implementation per head of population is low[6]. It amounts to an annual investment of under US$ 1in low-income countries, US$ 1.50 in lower middle-incomecountries, and US$ 3 in upper middle-income countries [6].Expressed as a proportion of current health spending, the costof implementation amounts to 4% in low-income countries,2% in lower middle-income countries, and less than 1% inupper middle-income countries [4].

The special issue aims to highlight solutions that aredesigned to address the global cardiovascular epidemic.

It contains three original research articles and one review.S. Tiptaradol and W. Aekplakhorn estimated the prevalenceof coexistence of diabetes and hypertension and the propor-tion of awareness, treatment, and control of both conditionsusing data from Thai National Health Examination SurveyIII. They found that about half of the diabetes patientsalso had hypertension, conversely about 14% of hypertensivepatients had diabetes, and that more than 80% were unawareof having both conditions.

M. Chiha and colleagues focused on type 2 diabetesmellitus as a risk factor for coronary heart disease. Theysummarize the mechanisms of atherogenesis in diabetes, theimpact of hypertension, the treatment goals in diabetes, andthe epidemiologic consequences of diabetes and heart diseaseon a global scale. They reported that diabetes mellitus isassociated with an increased risk of cardiovascular deathand a higher incidence of cardiovascular diseases includingcoronary artery disease.They highlighted the need for appro-priate screening to help better manage the cardiovascular

events in people with diabetes. I. Codreanu and othersshowcased the International Society of Nephrology (ISN),Global Outreach Program, aimed at building capacity fordetecting and managing chronic kidney disease and itscomplications in low- and middle-income countries usingthe work done in the Republic of Moldova. They concludedthat individuals with hypertension and diabetes should bescreened for the coexistence of renal abnormalities, with theintention of developing disease-specific healthcare interven-tions to reduce CV morbidity and mortality and preventrenal disease progression. S. Mendis and colleagues reportedon a cross-sectional study conducted in eight low- andmiddle-income countries to evaluate the capacity of primarycare facilities to implement basic interventions to addressmajor noncommunicable diseases, including cardiovasculardiseases and diabetes.They identified major deficits in healthfinancing, access to basic technologies and medicines, medi-cal information systems, and the health workforce.

This special issue is released at an opportune momentbecause the theme of the World Health Day on April 7, 2013,is focusing on hypertension to prevent heart attacks andstrokes. The issue reiterates the contribution of raised bloodpressure and diabetes to the global cardiovascular diseaseburden, the necessity to recognize the close associationbetween hypertension, diabetes, renal disease, and other riskfactors on health outcomes, and the need to strengthen healthsystems in low- and middle-income countries in order toscale up prevention and control of hypertension, diabetes,and other noncommunicable diseases.

As countries develop the Action Plan for Preventionand Control of Noncommunicable Diseases 2013–2025 inresponse to the recommendations of the Political Declarationof the United Nations General Assembly on NCDs [11], anemphasis on affordable interventions is essential to efficiently

International Journal of Hypertension 3

tackle the growing burden from NCDs, particularly in low-and middle-income countries.

Shanthi MendisEoin O’Brien

Yackoob Kassim SeedatSalim Yusuf

References

[1] S. S. Lim, T. Vos, A. D. Flaxman et al., “A comparative riskassessment of burden of disease and injury attributable to 67risk factors and risk factor clusters in 21 regions, 1990–2010: asystematic analysis for theGlobal Burden ofDisease study 2010,”The Lancet, vol. 380, no. 9859, pp. 2224–2260, 2012.

[2] World Health Organization, Global Status Report on Noncom-municable Diseases 2010, WHO, Geneva, Switzerland, 2010.

[3] G. Danaei, M. M. Finucane, J. K. Lin et al., “National, regional,and global trends in systolic blood pressure since 1980: system-atic analysis of health examination surveys and epidemiologicalstudies with 786 country-years and 5⋅4 million participants,”The Lancet, vol. 377, no. 9765, pp. 568–577, 2011.

[4] S. S. Anand and S. Yusuf, “Stemming the global tsunami ofcardiovascular disease,”The Lancet, vol. 377, no. 9765, pp. 529–532, 2011.

[5] R. Ndindjock, J. Gedeon, S. Mendis, F. Paccaud, and P. Bovet,“Potential impact of single-risk-factor versus total risk manage-ment for the prevention of cardiovascular events in Seychelles,”Bulletin of theWorldHealthOrganization, vol. 89, no. 4, pp. 286–295, 2011.

[6] Scaling Up Action Against Noncommunicable Diseases: HowMuch Will It Cost? World Health Organization, Geneva,Switzerland, 2011.

[7] G. Parati, M. O. Kilama, A. Faini et al., “A new solar-poweredblood pressure measuring device for low-resource settings,”Hypertension, vol. 56, no. 6, pp. 1047–1053, 2010.

[8] D. O. Abegunde, B. Shengelia, A. Luyten et al., “Can non-physician health-care workers assess and manage cardiovas-cular risk in primary care?” Bulletin of the World HealthOrganization, vol. 85, no. 6, pp. 432–440, 2007.

[9] World Health Organization, Package of Essential Noncommu-nicable Disease Interventions for Primary Health Care, WHO,Geneva, Switzerland, 2010.

[10] WorldHealthOrganization, Prevention and Control of Noncom-municable Diseases: Guidelines for Primary Health Care in LowResource Settings 2012, WHO, Geneva, Switzerland, 2010.

[11] United Nations General Assembly, Political Declaration ofthe High -Level Meeting of the General Assembly on thePrevention and Control of Noncommunicable Diseases, 2011,http://www.un.org/ga/search/view doc.asp?symbol=A/66/L.

Hindawi Publishing CorporationInternational Journal of HypertensionVolume 2013, Article ID 409083, 14 pageshttp://dx.doi.org/10.1155/2013/409083

Review ArticleThe Rising Burden of Diabetes and Hypertension inSoutheast Asian and African Regions: Need for EffectiveStrategies for Prevention and Control inPrimary Health Care Settings

Viswanathan Mohan,1 Yackoob K. Seedat,2 and Rajendra Pradeepa1

1 Madras Diabetes Research Foundation and Dr. Mohan’s Diabetes Specialities Centre, WHO Collaborating Centre forNoncommunicable Diseases Prevention and Control, IDF Centre for Education, 4 Conran Smith Road, Gopalapuram,Chennai 600 086, India

2Nelson R Mandela School of Medicine, University of KwaZulu-Natal, 4013 Congella, Durban, South Africa

Correspondence should be addressed to Viswanathan Mohan; [email protected]

Received 14 September 2012; Revised 25 December 2012; Accepted 9 January 2013

Academic Editor: Salim Yusuf

Copyright © 2013 Viswanathan Mohan et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Aim. To review the available literature on burden of diabetes mellitus (DM) and hypertension (HTN) and its coexistence inSoutheast Asian (SEA) and the African (AFR) regions and to suggest strategies to improve DM and HTN prevention and controlin primary health care (PHC) in the two regions. Methods. A systematic review of the papers published on DM, HTN, andprevention/control of chronic diseases in SEA and AFR regions between 1980 and December 2012 was included. Results. In theyear 2011, SEA region had the second largest number of people with DM (71.4 million), while the AFR region had the smallestnumber (14.7 million). Screening studies identified high proportions (>50%) of individuals with previously undiagnosed HTN andDM in both of the SEA and AFR regions. Studies from both regions have shown that DM and HTN coexist in type 2 DM rangingfrom 20.6% in India to 78.4% in Thailand in the SEA region and ranging from 9.7% in Nigeria to 70.4% in Morocco in the AFRregion.There is evidence that by lifestyle modification bothDM andHTN can be prevented.Conclusion. Tomeet the twin challengeof DM and HTN in developing countries, PHCs will have to be strengthened with a concerted and multipronged effort to providepromotive, preventive, curative, and rehabilitative services.

1. Introduction

Diabetes mellitus (DM) and hypertension (HTN) haveemerged as major medical and public health issues world-wide, and both are important risk factors for coronaryartery disease (CAD), heart failure, and cerebrovasculardisease. DM is increasing in epidemic proportions globally.According to the WHO, the prevalence of DM in adultsworldwide was estimated to be 4.0% in 1995 and is predictedto rise to 5.4% by the year 2025 such that the number ofadults with DM in the world would rise from 135 million in1995 to 300 million in the year 2025 [1]. The recent Burdenof Metabolic Risk Factors of Chronic Diseases Study [2]conducted in 199 countries worldwide to assess the national,

regional, and global trends in diabetes reported that the age-standardized adult diabetes prevalence was 9⋅8% (8.6–11.2) inmen and 9.2% (8.0–10.5) in women in 2008, up from 8.3%(6.5–10.4) and 7.5% (5.8–9.6) in 1980. The number of peoplewith diabetes increased from 153 (127–182) million in 1980to 347 (314–382) million in 2008. The International DiabetesFederation (IDF) has come up with much higher figures in arecent report which estimated that in 2011, 366million peopleworldwide had DM and if this trend continues, by 2030, 552million people, or one in 10 adults, will have DM [3]. Inthe same report, the Western Pacific Region was shown tohave the largest number of people with DM (132 million),followed by Southeast Asian (SEA) region (71.4 million),while the African (AFR) region had the smallest number


(14.7 million) [3]. DM exerts a significant burden resulting inincreasedmorbidity andmortality, decreased life expectancy,and reduced quality of life, as well as individual and nationalincome losses.

Additionally, HTNaffects about one billion peopleworld-wide [4] and it is estimated that by 2025, up to 1.56billion adults worldwide will be hypertensive [5]. Raisedblood pressure (BP) is estimated to cause 7.5 million deaths,which accounts for 57 million disability-adjusted life years(DALYs). The Burden of Metabolic Risk Factors of ChronicDiseases Study reported that in 2008, age-standardised meanSBP worldwide was 128.1mmHg (95% uncertainty inter-val 126.7–129.4) in men and 124.4mmHg (123.0–125.9) inwomen. Globally, between 1980 and 2008, SBP decreased by0.8mmHg per decade in men and 1.0mmHg per decade inwomen [6].Thehigh prevalence ofHTNmakes it a significantfactor for mortality and morbidity. Individuals with HTN areknown to have a twofold higher risk of developing CAD, fourtimes higher risk of congestive heart failure, and seven timeshigher risk of cerebrovascular disease and stroke compared tonormotensive subjects. According to global estimates 62% ofstroke, 49% of CAD, and 14% of other nonfatal cardiovasculardisease (CVD) events are attributed to nonoptimal BP. Ithas been reported that the highest number of deaths andDALYs attributable to high BP occurred in theWHOWesternPacific (WP) and SEA regions [7]. Extensive epidemiologicalstudies conducted in AFR region show that HTN is one ofthe commonest cardiovascular ailments and that BP assumesmore importance with increasing age, particularly in the Sub-Saharan Africa [8].

DM and HTN are also known to coexist in patients[9]. Indeed, there is a strong correlation between changinglifestyle factors and increase in both DM and HTN. Chal-lenges in managing both DM and HTN more effectivelyinclude factors at the patient, provider, and system levels.Epidemiologic studies have an important clinical impactand have led to an increasing appreciation of the value ofepidemiology as a scientific basis for clinical and publichealth practice. As primary health care is the first level ofcontact of the individuals, the family, and the communitywith the national health system, there is an urgent need foran integrated approach at primary health care (PHC) level foraddressing the burden ofHTN andDM.The aimof this paperis to review the available literature on the burden of DM andHTN in the SEA and AFR regions and to suggest strategiesto improve DM and HTN prevention and control in primarycare in the two regions.

2. Burden of Diabetes in SEA and AFR Regions

According to the World Health Organization (WHO), DM,a potentially life threatening disorder, is considered as “anapparent epidemic which is strongly related to life style andeconomic change” [10]. Type 2 DM comprises 90–95% of allcases of DM, and it increases the risk of both macrovasculardiseases (which comprise CAD and cerebrovascular diseaseor “stroke,” and peripheral vascular disease) and microvas-cular diseases (retinopathy, nephropathy, and neuropathy).

Table 1: Number of people with diabetes (in thousands) in the 20–79 age group in countries of Southeast Asia (2011 and 2030) [3].

Region 2011 2030Southeast Asia (SEA) 71400 120900Bangladesh 8406 16837Bhutan 22 41DPR Korea 1508 1934India 61258 101203Indonesia 7292 11802Maldives 15 32Myanmar 2104 3482Nepal 488 1171Sri Lanka 1080 1467Thailand 4014 5454Timor-Leste 30 55

Diabetes creates a huge economic burden not only due to thedirect costs of treatment particularly of its complications, butalso in terms of man hours lost due to the debilitating effectthe disease has on the individual and his or her family andsociety as a whole.

Epidemiological studies have shown that DM is increas-ing rapidly in people of South Asian, African, and AfricanCaribbean origins [11]. The WHO and IDF have utilizedmethods that combine available country data at regularintervals and extrapolated estimates for remaining countrieswithout data. In 2000, according to WHO, the prevalence ofDM among the 46 countries of the WHO AFR region wasestimated at 7.02 million people and among the 11 countriesof the SEA region to be 4.69 million [12]. The number ofindividuals with DM in the SEA region in the year 2011and the projected figures for the year 2030 are presentedin Table 1 [3]. There are significant differences betweenand within countries because of the geographical diversityin socioeconomic growth rates, demographic and lifestylechanges, and perhaps differences in ethnic susceptibility toDM. For example, the prevalence of DM in Sub-SaharanAfrica ranges from 1% in rural Uganda to 12% in urban Kenya[13, 14] and 8.1% in urban and 2.3% in rural Bangladesh[15]. In India, the recent ICMR-INdia DIABetes (ICMR-INDIAB) Study reported the prevalence of DM (both knownand newly diagnosed) in 4 regions of the country: 10.4% inTamilnadu, 8.4% in Maharashtra, 5.3% in Jharkhand, and13.6% in Chandigarh (Union Territory) [16]. The overallnumber of people with DM in India in 2011 based on thisstudy was estimated to be 62.4 million [16], and this wasconfirmed by the Diabetes Atlas (5th edition) of the IDF,which gave a figure of 61.3 million people with DM in Indiain the age group of 20–79 years [3]. Figure 1 presents thetrends in age-standardised DM prevalence in the SEA regionbetween 1980 and 2008 formen andwomen as reported in theBurden of Metabolic Risk Factors of Chronic Diseases Study[2].

The recent NFHS 3 data [17], which studied urban andrural residents (all women aged 15–49 and all men aged15–54) in 29 states of India during the year 2005-2006,


5.8 6.37.8

9.97.9 7.6

8.29.2

02468

101214

1980 1990 2000 2008Year

Prev

alen

ce (%

)

Bangladesh

(a)

02468

101214

Prev

alen

ce (%

)

Bhutan

7 7.810.1

12.6

8.5 8.810.2 12

1980 1990 2000 2008Year

(b)

02468

101214

Prev

alen

ce (%

)

DPR Korea

8.9 8.2 7.7 7.5

9.4 8.47.8 7.7

1980 1990 2000 2008Year

(c)

02468

101214

Prev

alen

ce (%

)

India

7.5 8.29.7 10.8

8 8.39.7

11.1

1980 1990 2000 2008Year

(d)

Indonesia

7.5 7.5 7.5 7.1

8.4 7.9 7.7 6.6

02468

101214

1980 1990 2000 2008

Prev

alen

ce (%

)

Year

(e)

02468

101214

Prev

alen

ce (%

)

Year

Maldives

8.1 8.6 8.4 7.5

8 8.3 8.5 7.8

1980 1990 2000 2008

(f)

02468

101214

Prev

alen

ce (%

)

Year

Myanmar

7.2 7.6 7.77.1

7.7 7.6 7.2 6.1

1980 1990 2000 2008

(g)

02468

101214

Prev

alen

ce (%

)

Year

Nepal

5.4 67.6

9.37.3 7.58.6

9.8

1980 1990 2000 2008

(h)

Sri Lanka

8.5 9 9 8.67.8 8.4 9.2 9.3

02468

101214

1980 1990 2000 2008Year

Prev

alen

ce (%

)

FemaleMale

(i)

Thailand

Year

7.8 8.3 8.57.1

7 7.7 8.57.3

1980 1990 2000 200802468

101214

Prev

alen

ce (%

)

FemaleMale

(j)

Timor-Leste

Year

6.9 7.4 7.3 6.96.9 7 7 6.4

1980 1990 2000 200802468

101214

Prev

alen

ce (%

)

FemaleMale

(k)

Figure 1: Trends in age-standardised diabetes prevalence in the SEA region between 1980 and 2008 for male and female population [2].

reported that more than two percent of men and womenhad self-reported DM. The number of women who had DMranged from 282 per 100,000 women in Rajasthan to 2,549per 100,000 women in Kerala. In five other states (TamilNadu, Goa, Tripura, West Bengal, and Delhi) the number ofwomen with DMwas relatively high (above 1,500 per 100,000women). Only five states hadDMprevalence levels below 500per 100,000 men (Jammu and Kashmir, Mizoram, HimachalPradesh, Rajasthan, and Uttar Pradesh).

It has also been reported that there is a dramatic increasein the prevalence of type 2 DM in the African regions [18]. Instudies done between the 1960s and early 1980s, prevalenceof type 2 DM was mostly lower than 1%, except in SouthAfrica and Cote d’Ivoire [19]. However, currently DM ratesare rising in many parts of Africa [20]. According to the

Burden of Metabolic Risk Factors of Chronic Diseases Study,the DM prevalence in 2008 was higher in North Africa andwas the lowest in Sub-Saharan Africa [3] and the prevalenceranged from 1% in rural Uganda to 12% in urban Kenya[21]. Studies from Sub-Saharan Africa report prevalence ratesof 2.5–8% in rural and urban communities in West Africa[22–24] and 1–12% in rural and urban communities in EastAfrica [14, 25–27]. Prevalence rates of 3–10% were noted inurban and rural populations in South Africa [28, 29], while inCentral Africa the figures ranged from 2.9% to 6.2% in ruraland urban communities [30, 31] which are comparable withrates in developed countries. In a recent community-basedscreening for DM conducted simultaneously in four majorCameroonian cities, the sex-specific-age-adjusted prevalenceof DM (for men and women) had dramatically risen to 10.1%


and 11.2%, respectively [32]. The number of individuals withDM in the AFR region in the year 2011 and the projectedfigures for the year 2030 are presented in Table 2 [3].

One of the unfortunate aspects of DM is that more thanhalf of the people with DM are unaware of the condition.The rate of undiagnosed DM is high in both of the SEA andAFR regions. In the ICMR-INDIAB Study the prevalence ofundiagnosed DM among residents of Tamil Nadu, Maha-rashtra, Jharkhand, and Chandigarh were 44%, 70%, 51%,and 50% [16]. The AFR region has the highest proportion ofundiagnosed DM, at least 78% [3].

3. Burden of HTN in SEA and AFR Regions

In developed countries of the world, the prevalence ofHTN isbeginning to stabilize or decrease, thanks to prevention andcontrol measures [33]. Parallelly the prevalence rates of CVD(both CAD and stroke) are also beginning to fall [34, 35].In contrast, in the developing regions of the world such asSEA and AFR hypertension and CVD rates continue to rise.Extensive epidemiological studies show that HTN is one ofthe commonest cardiovascular ailments in AFR and SEAregions. Approximately one-third of the adult populationhas high BP and nearly 1.5 million deaths occur due toHTN each year in the SEA region. Studies in India haveshown an increasing trend in the prevalence of HTN amongurban adults: men 30%, women 33% in Jaipur (1995); men44%, women 45% in Mumbai (1999); men 31%, women 36%in Thiruvananthapuram (2000); men 36%, women 37% inJaipur (2002); 21.1% in Chennai (2003). Among the ruralpopulations, HTN prevalence inmen was 24% and in women17% in Rajasthan (1994) [36]. The CURES Study reporteda prevalence of 23.2% HTN among men and 17.1% amongwomen in South India [37]. HTN is responsible for 57% ofall stroke mortality and 24% of all CAD mortality in India.In Thailand, the age-adjusted prevalence of HTN was 25%in men and 24% in women [38]. In Bangladesh, prevalencerates of systolic and diastolic HTN were 14.4 and 9.1 percent,respectively, with prevalence of systolic HTN significantlyhigher in rural than in urban participants [39].

In addition, there is an approximately 89% increase inSub-Saharan Africa from 2000 through 2025 versus a 24%increase in more developed countries. Among the WHOregions, the prevalence of HTN was the highest in Africa,where it was 46% for both sexes combined. Both men andwomen have high rates of raised BP in the African region,with prevalence rates over 40% [40]. It has been reportedthat the prevalence of HTN is increasing rapidly in Sub-Saharan Africa and occurring in young and active adults [8].Age-adjusted prevalence urban studies have shown that inthe adult population of Durban, HTN was the highest inZulus (25%), intermediate inWhites (17.2%), and the lowest inIndians (14.2%). However, in contrast, the prevalence of HTNin rural areas was lower: 4.1% in Ghana, 5.9% in Nigeria, 7%in Lesotho, and 7.37% in the rural Zulu [41].

A recent systematic analysis of health examination sur-veys and epidemiological studies in 199 countries and territo-ries with 786 country-years and 5.4 million participants has

Table 2: Number of people with diabetes (in thousands) in the 20–79 age group in countries of African region (2011 and 2030) [3].

Country 2011 2030Algeria 1435 2351Angola 185 383Benin 71 143Botswana 94 134Burkina Faso 175 371Burundi 94 191Cameroon 501 913Cape Verde 13 25Central African Republic 58 99Chad 197 401Comoros 23 48Congo 95 176Cote d’Ivoire 407 813DR Congo 731 1422Equatorial Guinea 14 26Eritrea 95 192Ethiopia 1377 2629Gabon 69 124Gambia 12 26Ghana 517 1036Guinea 182 324Guinea-Bissau 19 33Kenya 769 1683Lesotho 29 52Liberia 51 97Madagascar 428 832Malawi 352 747Mali 100 217Mauritania 61 119Mauritius 138 196Mozambique 295 581Namibia 74 135Niger 284 620Nigeria 3055 6113Rwanda 126 275Sao Tome and Principe 4 8Senegal 146 296Seychelles 4 5Sierra Leone 72 127South Africa 1947 2548Swaziland 14 22Togo 81 153Uganda 308 690United Republic of Tanzania 473 1107Zambia 244 432Zimbabwe 551 1053

looked at the national, regional, and global trends in systolicBP (SBP) for adults 25 years and older since 1980 [6].The SBProse inOceania, EastAfrica, and South and SoutheastAsia for


Table 3: Trends in age-standardized mean SBP in selected Africa region between 1980 and 2008 for male and female population [6].

Selected Africa region Mean systolic blood pressure (mmHg)Female Male

Year 1980 1990 2000 2008 1980 1990 2000 2008Algeria 130.8 131 130.5 129.9 132.4 130.4 129.2 130Angola 130.1 129.9 129.9 130.1 135.2 133.6 132.4 133.6Cameroon 125.9 125.9 125.6 127.3 132.8 130.1 128.8 131.3Cote d’Ivoire 130.3 130.5 130.7 131.5 136.5 133.2 132.7 134.6DR Congo 129.7 129.3 128.1 129.4 134.0 131.6 130.4 132.7Ethiopia 116.6 120.1 123.3 126.6 123.1 124.5 126.4 129.6Ghana 125.7 127.6 129 128.3 130.5 129 129.1 129.5Kenya 123.7 124.9 127.3 129.9 128.2 127.7 128.9 132.1Mozambique 127.8 130.0 132.6 135.4 133.4 132.5 134 137.5Nigeria 131 131.8 133.9 135.5 134.5 130.1 130 132.8South Africa 133.2 132.3 130 131 135.4 133.6 131.3 133.8Uganda 126.3 129.2 132.0 134.5 130.7 130.7 132.4 135.6United Republic of Tanzania 122.6 125.6 127.9 130.8 126.4 126.4 128.2 131.6Zimbabwe 128.7 130.4 130.8 132 130.8 130.3 130.2 131.9

both sexes and in West Africa for women, with the increasesranging from 0.8 to 1.6mmHg per decade in men and 1.0 to2.7mmHg per decade in women. Table 3 shows the trendsin age-standardised mean SBP in selected African regionbetween 1980 and 2008 for male and female population asreported in the Burden of Metabolic Risk Factors of ChronicDiseases Study [6].

Control of HTN in Sub-Saharan Africa is poor and targetBP<140/90mmHgon treatment occurred in<1% inTanzania[42] and 7% in Blackmales and 15% in Black females in SouthAfrica [43]. Obstacles to adherence include (a) long durationof therapy, (b) complicated regimens, (c) cost of drugs, (d)side effects of medication, (e) lack of specific appointmenttime, (f) long waiting period at clinic or office, (g) lack ofconsistent and continuous primary care, (g) instructions notunderstood, (h) organic brain damage (memory deficit), and(i) medicines not available. The patient and illness character-istics include (a) asymptomatic nature of the condition; (b)chronic conditions require constant attention; (c) there are noimmediate consequences of stopping treatment for example,one does not feel sick; (d) social isolation; (f) disrupted homesituation; and (g) psychiatric illnesses.

Significant numbers of individuals with HTN in both ofthe SEA and AFR regions are unaware of their condition and,among those diagnosed with HTN, treatment is frequentlyinadequate. HTNwas estimated to have caused 46,888 deathsor 9% of all deaths and 390,860 DALYs or 2.4% of all DALYsin South Africa in 2000. Overall, 50% of stroke, 42% of IHD,72% of hypertensive disease, and 22% of other CVD burdensin adult males and females (30+ years) were attributable tohigh BP [44]. InThailand, burden of diseases defined as totalDALY loss attributed to HTN was 5.5% in both men andwomen [45].

4. Coexistence of Diabetes and Hypertension

HTN is a common comorbid condition in DM and viceversa. DM and HTN coexist in approximately 40% to 60%of patients with type 2 DM [46, 47]. HTN may precede theonset of DM. In about 95% cases, it is essential HTN andthe rest may be secondary HTN. In some cases, both HTNand DM may be present at the time of initial diagnosis [48].The Hypertension in Diabetes Study (HDS)-I conducted todetermine the prevalence of HTN in newly diagnosed type2 diabetic patients reported that 39% of the patients werehypertensive at the time of diagnosis of DM [49].

There is considerable evidence for an increased preva-lence of HTN in diabetic persons from other populations[50]. In a study conducted in American Indian and AlaskaNative communities to estimate the prevalence of clinicalHTN and assess the coexistence with DM, 37% of diabeticindividuals were diagnosedwithHTN [51]. In the same study,the relative risk ofHTN in the diabetic populations comparedwith the nondiabetic populations varied from 4.7 to 7.7 [52].It has also been shown that in hypertensive patients agaging40–59 years, of three different ethnic groups living in SouthLondon, aremore likely to haveDM, and, conversely, patientswith DM have a greater chance of having HTN [52]. In alarge prospective cohort study that included 12,550 adults, thedevelopment of type 2 DM was almost 2.5 times as likely inpersons with HTN than in their normotensive counterparts[50, 53].

Both essential HTN and DM affect the same major targetorgans. The common denominator of hypertensive/diabetictarget organ-disease is the vascular tree. People with coex-isting DM and HTN are at increased risk of developingatherosclerosis, retinopathy, renal failure, and nontraumatic


amputations and CVD [54]. Moreover, it has been shownthat lowering BP in high risk patients with DM can reducedeaths from strokes, overall mortality, and CVD events andcan slow the progression of renal disease in patients withtype 2 DM [55]. Left ventricular hypertrophy and CADare much more common in diabetic hypertensive patientsthan in patients suffering from HTN or DM alone [56].HTN substantially increases the risk of both macrovascularand microvascular complications in DM. In studies such asthe Systolic Hypertension in the Elderly Program (SHEP)and the Systolic Hypertension in Europe Study (Syst-Eur),those with coexisting DM had an approximate doubling incardiovascular morbidity and mortality [55, 57].

Studies show that glycaemic control is effective in reduc-ing microvascular complications. However “tight” HTN con-trol appears to be more effective than glycaemic control inreducing microvascular events particularly kidney disease.Clinical trials have demonstrated the importance of intensivetreatment of HTN among patients with DM. The UKPDSshowed that each 10mmHg decrease in mean SBP wasassociatedwith 12% reduction in the risk for any complicationrelated to DM, 15% reduction in deaths related to DM, 11%reduction in myocardial infarction, and 13% reduction inmicrovascular complications [58].

TheHypertension inDiabetes Study (HDS)-II [59], whichlooked at the degree to which HTN is a risk factor formacrovascular and microvascular complications in type 2DM, reported that hypertensive patients had a greater inci-dence than normotensive patients of death from diabetes-related, mainly cardiovascular events and a greater incidenceof diabetes-related death and major morbidity combined,including myocardial infarctions, angina, strokes, and ampu-tation.

Studies from SEA region have shown that DM andHTN coexist in type 2 DM. In India about 50% of diabeticindividuals have HTN [60, 61]. In the Screening India’sTwin Epidemic (SITE) cross-sectional study conducted in 10Indian states [62] DM and HTN were coexistent in 20.6%patients, which demonstrate that the substantial burden ofDM and HTN is on the rise in India. According to theThailand Diabetes registry, the prevalence of HTN in adultThai type 2 diabetic patients was 78.4 [63]. Among 745subjects with known DM, who participated in the FourthKorea National Health and Nutrition Examination Survey in2007 and 2008, the prevalence of HTN was reported to be55.5% [64]. In a study conducted in seven urban populationsof Nepal, 36.7% of the diabetic subjects had HTN, whileof all subjects with HTN, 29.1% had DM (known or newlydiagnosed) [65].

African studies have reported high prevalence of HTNin DM, although most are clinic based. A high prevalencerate of 66.4% was reported in Cameroonian type 2 diabeticpopulation (African Blacks) [66]. A study conducted inKenya during the year 2005 to determine the proportion ofspecific cardiovascular risk factors in ambulatory patientswith type 2 DM reported that 50% of the patients had HTN[67]. In a Nigerian clinic population, HTN andDM coexistedin 9.7% of the patients studied [68]. The recent EPIDIAMStudy conducted in 525 type 2 diabetic individuals in three

Moroccan regions reported that 70.4% of the individuals hadHTN [69]. Another study conducted in Benin City, Nigeria,reported that 54.2% of the diabetic individuals hadHTN [70].

5. Strategies and Interventions toPrevent/Control Diabetes and Hypertensionin Primary Care Settings

In most developing countries, till recently, the priorities ofhealth care had been the prevention and control of com-municable diseases. However now the attention has begunto shift to the control and prevention of noncommunicablediseases (NCDs) including DM, HTN, CAD, and stroke inview of the rising trend of NCDs. For this, an integratedapproach to the prevention and management, irrespective ofcause, is needed in primary health care settings [71]. Chronicdisease interventions selected for use in primary health caremust lead to productive changes in risk status and outcomes,be cost effective, and be financially and logistically feasible,which are available for implementation across a range ofresource settings [72].

Within this context of restrained economic conditions, inthe SEA and AFR regions, the greatest gains in controllingthe DM and HTN epidemics lie in their prevention, or atleast early detection and adequate control. For most low-income and middle-income countries, the major obstacle tothe control of BP-related diseases is the absence of appropriateprimary health care services [73]. The commonality of manyrisk factors for HTN and DM justifies an integrated approachto the prevention and control of both. Both problems haveto be tackled at several levels, that is, primordial, primary,secondary, and tertiary prevention (Figure 2). “Primordialprevention” refers to reduction of the risk factors ofDM/HTNand thereby decreasing the risk of developing DM in thefuture. “Primary prevention” refers to prevention (or post-ponement) of the condition in those in a prediabetes/HTNstage. “Secondary prevention” refers to prevention of com-plications in those who have already developed DM/HTN.Finally the term “Tertiary prevention” is used to describelimiting physical disability and preventing progression to endstage complications in those who have already developedsome associated complications.

Primordial prevention depends on health policiesthat create a congenial environment and promote healthybehaviours and population wide education programs,which in turn depends on many factors, including politicalcommitment, advocacy by health professionals, andinvolvement of community leaders and the mass media[74]. The “rule of halves” has shown that more than 50%of people with DM or HTN remain undiagnosed, amongthose detected, 50% do not take treatment, and finallyamong those who take treatment, over 50% are not undercontrol. Thus overall only 6–8% of subjects with DM orHTN remain adequately controlled [75, 76]. This poses ahuge challenge and underscores the need to urgently raiseawareness in the community at large. Attempts shouldbe made to detect DM/HTN early before irreversibleorgan damage occurs and to provide them with the best


End stage complications

Prediabetes/Pre-HTN

Diabetes/HTN

Earlycomplications

Primordial prevention

Primary prevention

Secondary prevention

Tertiary prevention

Strategies:AwarenessprogrammesScreening for diabetes/HTN/riskfactors

Strategies:Lifestyle modificationDietary changesWeight reductionIncreasing physicalactivityCessation of smokingReduce alcohol

Strategies:Screening forcomplications

Strategies:At PHC for early complicationsReferral to tertiarycentre for late complications

For example,obesity,physical inactivity,stress, smoking,and alcohol intake

(“Population”approach)

(“High risk”approach)

(Good control ofdiabetes/HTN)

(Treatment ofcomplications)

↑ Risk factors

Figure 2: Strategies for prevention for diabetes and hypertension at different levels.

possible and yet affordable treatment. Beaglehole et al. [71]have emphasized that management of chronic diseases isfundamentally different from acute care, relying on severalfeatures including opportunistic case finding for assessmentof risk factors, detection of early disease, identification ofhigh risk status, a combination of pharmacological, andpsychosocial interventions, often in a stepped-care fashion,and finally long-term followup with regular monitoringand promotion of adherence to treatment. Therefore, effortsshould be made for detection through screening and earlymanagement at the community level. Screening activitiesare an important component of any prevention/controlprogramme and are particularly important in population athigh risk for developing DM/HTN (e.g., older individuals,some ethnic groups) and those with limited access to medicalcare (e.g., some minorities, migrants) (Figure 2). Luckily,unlike screening for some diseases, for example, cancer,screening for DM/HTN or prediabetes/HTN is fairly simple.In addition, a standardized algorithm of management canhelp in the rational use of available resources at the primarycare level.

The next step after having the high risk group detectedis to advise lifestyle modifications (primary prevention).While age and ethnicity are non-modifiable risk factors,physical inactivity and waist circumference, dietary andsmoking habits, and so forth can be modified. Evidencefromhigh-income settings shows that interventions to reducerisk behaviours (dietary modifications, increase exercise,and stop smoking) in people with serious risk factors orpreexisting disease such as HTN, DM, and CVD are moresuccessful in achieving reductions in risk factors and, in somecircumstances, improving clinical outcomes [77]. The highrisk group can be empowered through health education onlifestyle modification (LSM) and their benefits with the helpof community health workers.

Landmark studies like the Da Qing Study in China [78],Finnish Diabetes Prevention Study [79], and the DiabetesPrevention Programme (DPP) [80] have clearly shown thatmeasures of LSM help in preventing DM. Both of theFinnish Diabetes Prevention Study and the DPP in the USAshowed that lifestyle change can significantly reduce therisk of development of type 2 DM by 58% in individualswith IGT and demonstrated that modest weight change andachievable physical activity goals can translate into significantrisk reduction [78, 79].TheDaQing Study [78], conducted ina Chinese population, reported that diet, exercise, and diet-plus-exercise interventions were associated with 31%, 46%,and 42% reductions in risk of developing DM, respectively.The Indian Diabetes Prevention Programme (IDPP) showedthat progression to DM from impaired glucose tolerance(IGT) can be prevented by 28.5% with LSM and 26.4% withwith metformin (MET) in individuals who were younger,leaner, and more insulin resistant as compared with thecontrol group [81]. However, there was no added benefit fromcombining LSM +MET (28.2%) [81].

There are also several clinical trials exploring the efficacyof lifestyle modifications to reduce BP. A prospective studyon 8302 Finnish men and 9139 women aged 25 to 64 yearswithout a history of antihypertensive drug use, CAD, stroke,and heart failure at baseline showed that subjects with heavygrade of physical activity had lower prevalence of HTN [82].Of the three lifestyle changes—weight reduction, sodiumreduction, and stress management tested in 2182 partici-pants with prehypertension in the Trials of HypertensionPrevention-phase I (TOHP-I)—weight reduction was themost effective strategy, producing a net weight loss of 3.9 kgand a BP change of −2.3/−2.9mmHg [83]. TOHP-II [84]demonstrated that in overweight adults with high-normalBP, weight loss, and reduction in sodium intake, individuallyand in combination, were effective in lowering systolic and


diastolic BP, especially in the short term (6months). Further-more, it concluded that the effects on average BP declinedover time (48 months) and reductions in HTN incidencewere achieved.The PREMIER clinical trial [85] reported thatindividuals with above-optimal BP, including stage 1 HTN,can make multiple lifestyle changes that lower BP and reducetheir CVD risk.

While all efforts must be taken to prevent DM/HTN,what about the people who already have these conditions?Unless proper care is provided to these individuals, theycould face a huge burden of complications in the future.Three landmark studies on glycemic control in DM, namely,the Diabetes Complications and Control Trial (DCCT), theUnited Kingdom Prospective Diabetes Study (UKPDS), andKumamoto Study [86–88], have clearly documented the ben-eficial effects of glycemic control in preventingmicrovascularcomplications in diabetic patients. However, mere glycemiacontrol alone may not be sufficient to prevent CVD asshown in the UKPDS Study where despite a 16% reductionin MI, it did not reach statistical significance. Thus it isclear that a much prolonged approach controlling glucose,blood pressure, and lipids is needed to prevent CVD indiabetic subjects as shown by STENO-2 Study [89]. Indeeda tight DM control may even be harmful in older high riskpatients as shown by the Action to Control CardiovascularRisk in Diabetes (ACCORD) Trial [90], which showed thataiming for a glycated hemoglobin around 6.0% could resultin increased mortality. Thus the overall consensus is that aglycated hemoglobin of less than 7% would be adequate [91].Skyler et al. [92] have suggested that glycemic control may beimportant beforemacrovascular disease is well developed buthas less impact when vascular disease is advanced. The samegroup recommends that for primary and secondary CVDrisk reduction in diabetic patients, the evidence-based rec-ommendations for blood pressure treatment, including lipid-lowering with statins, aspirin prophylaxis, smoking cessation,and healthy lifestyle behaviors outlined by American HeartAssociation (AHA) and the American Diabetes Association(ADA) guidelines [91, 93] should be followed.

It is thus clear that it is important to improve levels of careat several health care settings, namely, primary, secondary,and tertiary. Unfortunately, there is an acute shortage ofgeneral physicians in rural areas. Thus at the primary level,the existing primary health centres (PHCs) and rural clinicsmust be strengthened. This includes providing basic trainingto the doctors and paramedical staff as well as communityhealth workers as well as improving the facilities availableat the PHCs, for example, essential medicines, glucometers,blood pressure apparatus, and so forth. Screening can besuccessfully done by nonphysicians as shown in the Chunam-pet Rural Diabetes Prevention Project (CRDPP) [94]. Largescale screening for DM/HTN is possible, but it then becomesan ethical issue to provide basic care, for example, low costgeneric drugs and follow-up care.

Studies in which the effectiveness of professional inter-ventions (postgraduate education of health care) combinedwith local consensus procedures and/or reminders and/oraudit and feedback were compared with usual care havereported an improved diabetes care [95, 96]. Another study

which evaluated education for both health care professionalsand patients showed that the intervention improved glycatedhemoglobin, body weight, and triglycerides [97]. Properreferral systems for treatment must also be available. Mea-sures should be taken to increase the adherence to practiceguidelines and improve both primary care doctors’ andpatients’ knowledge. Evaluating and auditing of adherence tothe national guidelines and management in primary health-care should be done regularly to ensure that appropriate careis provided. There is ample evidence from many developedand developing countries to show that type 2 DM and HTNare routinelymanaged by nurses/health workers/pharmacistsin primary care centres in conjunction with a physicianthrough patient education, patient and family counseling,and close monitoring of health outcomes [98–103]. Mex-ico’s Veracruz Initiative for DM awareness (VIDA) showedthe potential of implementing chronic disease managementprinciples in low-resource primary healthcare settings, wherehealth workers received in-service training on DM manage-ment, including foot care, and also learned about principlesof effective health care for chronic disease as represented bythe chronic care model [102]. A similar approach has beenadopted in rural South Africa for DM, HTN, and asthma andresulted in successful control of the disorders [103].

Application of technology can also be used to controlthe twin epidemic. Telemedicine, which is an integration ofelectronic information andmedical technology, could help tobring specialized healthcare to the remotest and underservedareas in developing countries [104]. Telemedicine is anexciting new technology which can help in integration of allurban and rural health care centers and improve the quality ofmedical services in the presently underserved and impover-ished sections particularly in remote rural areas of developingcountries. The potential of this tool is particularly significantin SEA and AFR regions where specialists are few and wheredistances and the quality of the infrastructure hinder themovement of physicians or patients. There is evidence inboth of these regions to show that this technology can nullifythe gap in providing quality health care where health careprofessionals cannot reach out to people with chronic diseasewho need their services [94, 105–108]. The Chunampet RuralDiabetes Prevention Project (CRDPP), which was developedto provide mass screening and DM health care and preven-tion to rural India through a combination of telemedicineand personalized care and employment of local youth (bothmen and women), demonstrated that the model is not onlysuitable for prevention and control ofDMbut also reduces theburden of other chronic NCDs such as HTN in low-resourcerural settings [94]. Thus, novel methods such as this must bedeveloped to provide health care, in general, and, in particu-lar, DM and HTN prevention, which is accessible, affordable,and acceptable to rural people in developing countries.

In addition, the existing infrastructure at governmenthospitals, which provide secondary level of care, shouldbe improved to screen and provide basic treatment forDM-related complications or CVD/stroke in addition tosome laboratory support, for example, lipid profile, glycatedhemoglobin, microalbuminuria, or serum creatinine esti-mation and ECG. In addition, Public Private Partnerships


Table 4: Action plans for prevention/control of diabetes and hypertension in different health care settings.

Detection Diabetes education Equipment Medicines

Primary careLarge scale screeningusing high risk categoryapproach

Through communityworkers—training ofcommunity workers inscreening activities

Basic equipment likeGlucometer, BPapparatus

Essential low cost generic drugsto be made available at all PHCs

Secondary care

Confirmation ofdiagnosis Screening forcomplications ofdiabetes and co-morbidconditions

(i) Physicians(ii) Paramedicals

OphthalmologyBasic laboratory support

Insulin, oral hypoglycemic drugs,ACE inhibitors, calciumantagonists, ARBs, statins,aspirin, and otherantihypertensive drugs

Tertiary care Treatment ofcomplications

(i) Diabetologists(ii) Ophthalmologists(iii) Nephrologists(iv) Cardiologists

Advanced equipment(i) Laserphotocoagulation(ii) Fundus camera(iii) Cardiac care(iv) Dialysis unit(v) Transplantation

All of above and costlier drugs ortreatments

could be encouraged if the Government cannot provide allthe necessary infrastructure or personnel to accomplish this[109]. Providing large scale insurance benefits to those belowthe poverty line can help to prevent them from getting into a“debt trap” because of illness-related health care expenditure[110].

A small percentage of individuals (about 5%) willultimately need tertiary care facilities for management oftheir advanced stage of complications [94], for example,Laser photocoagulation for diabetic retinopathy, dialysis ortransplantation for renal failure, coronary angiography orbypass/angioplasty for CAD, or limb salvage proceduresor amputations for advanced diabetic foot disease (tertiaryprevention). For these procedures, help of tertiary carecentres would be needed. Again, costs, quality control, andaccountability could be ensured bymutually acceptable termsand some or all of these costs could be defrayed by insuranceschemes specifically meant to benefit people. Table 4 sum-marizes some of the action plans to prevent/control DM andHTN.

According to the United Nations Joint Program onHIV/AIDS, 33.2 million adults and children are living withthese infections worldwide. Of these, two to three millionare estimated to be in South Asia [111]. Many low- andmiddle-income countries, particularly the AFR region, facea double burden of disease from infectious diseases suchas HIV/AIDS and NCDs [112]. The health systems in suchcountries are weak and are severely challenged by the weightof a double burden of disease. Recently, a compelling casehas also been made for coordinated or “diagonal” approachto HIV/AIDS and NCD prevention and control as theyshare many similarities that make them ideal candidatesfor a coordinated approach [112–114]. There is paucity ofdata on the integration of care for HIV, DM, and CVD inseveral low-income and middle-income countries althoughthey coexist [115]. A review on care delivery models forDM andHIV/AIDS in Sub-Saharan Africa revealed potentialelements for cross-fertilization which includes rapid scale-up

approaches through the public health approach by simplifi-cation and decentralization; community involvement, peersupport, and self-management strategies; and strengtheninghealth services [112]. A Cambodian study demonstrated thefeasibility of integrating care for HIV/AIDS, DM, and HTNwithin the setting of chronic disease clinics and reported over70% retention of patients after 24 months [116]. HIV/AIDSmodels have a lot of experience with activating communityand peer support for patients, which can be followed inprevention of chronic diseases including HTN and DM.Therefore, lessons from these studies reveal that there isno need to reinvent the wheel, as experiences with HIVprogrammes can be leveraged to NCD programmes, andvice versa. With appropriate resources and support, suchapproaches could be used in primary health care.

6. Conclusion

Both DM and HTN present huge challenges in developingcountries, particularly in the SEA and AFR regions. Healthcare systems should be strengthened for early detection andeffective treatment of those affected with both DM andHTN.Strategies to prevent/control HTN and DM should be popu-lation based, incorporating multilevel, multicomponent, andsocioenvironmental approaches and integrating communityresources with public health and clinical care. According tothe chronic care model put forth by WHO in 2002, six areasneed improvement to facilitate chronic care: communityresources; health systems; self-management support; deci-sion support; delivery system redesign; and clinical infor-mation systems [117], all of which give greater emphasis tothe need for policy changes and empowering the community[118]. Based on this, various interventions/strategies havebeen suggested to improve health care for chronic diseaseas shown in Figure 3. There is an urgent need to improvemonitoring andmanagement of risk factors through primarycare linked programmes. Policy and system changes areessential to reduce risk in populations, including legislation


Improved case management

Appropriate medication therapy

management

Physician education directed at latest

guidelines, management

Support from community

health workers

Telemedicine to facilitate remote

physician consultation

Audit and feedback

Patient reminder systems

Patient education to promote understanding

of disease, self-management

Electronic patient registries for

proactive management

Continuous quality improvement

Physician reminders to prompt actions based on patient

needs

Early detection

Interventions/strategies

Figure 3: Interventions/strategies to improve health care for chronic disease.

and public education to reduce dietary fat, salt and sugar,food pricing policies, tobacco control, and changes to healthcare delivery systems to explicitly support prevention/controlof DM and HTN. Ultimately, prevention of DM/HTN needs“political will”, societal and community support, and ofcourse behavioral change on the part of the individuals andtheir families.

References

[1] H. King, R. E. Aubert, and W. H. Herman, “Global burdenof diabetes, 1995–2025: prevalence, numerical estimates, andprojections,” Diabetes Care, vol. 21, no. 9, pp. 1414–1431, 1998.

[2] G. Danaei, M.M. Finucane, Y. Lu et al., “National, regional, andglobal trends in fasting plasma glucose and diabetes prevalencesince 1980: systematic analysis of health examination surveysand epidemiological studies with 370 country-years and 2⋅7million participants,” The Lancet, vol. 378, no. 9785, pp. 31–40,2011.

[3] N. Unwin, D. Whiting, L. Guariguata, G. Ghyoot, and D.Gan, Eds., Diabetes Atlas, International Diabetes Federation,Brussels, Belgium, 5th edition, 2011.

[4] A. V. Chobanian, G. L. Bakris, H. R. Black et al., “The seventhreport of the joint national committee on prevention, detection,evaluation, and treatment of high blood pressure: the JNC 7report,” The Journal of the American Medical Association, vol.289, no. 19, pp. 2560–2572, 2003.

[5] P. M. Kearney, M. Whelton, K. Reynolds, P. Muntner, P. K.Whelton, and J. He, “Global burden of hypertension: analysisof worldwide data,” The Lancet, vol. 365, no. 9455, pp. 217–223,2005.

[6] G. Danaei, M. M. Finucane, J. K. Lin et al., “National, regional,and global trends in systolic blood pressure since 1980: system-atic analysis of health examination surveys and epidemiologicalstudies with 786 country-years and 5⋅4 million participants,”The Lancet, vol. 377, no. 9765, pp. 568–577, 2011.

[7] C. M. M. Lawes, S. Vander Hoorn, M. R. Law, P. Elliott, S.MacMahon, and A. Rodgers, “Blood pressure and the globalburden of disease 2000. Part 1: estimates of blood pressurelevels,” Journal of Hypertension, vol. 24, no. 3, pp. 413–422, 2006.

[8] L. H. Opie and Y. K. Seedat, “Hypertension in sub-SaharanAfrican populations,” Circulation, vol. 112, no. 23, pp. 3562–3568, 2005.

[9] R. M. Lago, P. P. Singh, and R. W. Nesto, “Diabetes and hyper-tension,” Nature Clinical Practice Endocrinology & Metabolism,vol. 3, no. 10, p. 667, 2007.

[10] H. King andM. Rewers, “Diabetes in adults is now a third worldproblem.World Health Organization ad hoc diabetes reportinggroup,” Ethnicity & Disease, vol. 3, supplement, pp. S67–S74,1993.

[11] J. Oldroyd, M. Banerjee, A. Heald, and K. Cruickshank, “Dia-betes and ethnic minorities,” Postgraduate Medical Journal, vol.81, no. 958, pp. 486–490, 2005.

[12] “WHO Country and regional data on diabetes,” http://www.who.int/diabetes/facts/world figures/en/index1.html, http://www.who.int/diabetes/facts/world figures/en/index5.html.

[13] E. Sobngwi, F. Mauvais-Jarvis, P. Vexiau, J. C. Mbanya, and J. F.Gautier, “Diabetes in Africans. Part 1: epidemiology and clinicalspecificities,”Diabetes &Metabolism, vol. 27, no. 6, pp. 628–634,2001.

[14] D. L. Christensen, H. Friis, D. L. Mwaniki et al., “Prevalenceof glucose intolerance and associated risk factors in rural andurban populations of different ethnic groups inKenya,”DiabetesResearch and Clinical Practice, vol. 84, no. 3, pp. 303–310, 2009.

[15] A. Hussain, M. A. Rahim, A. K. A. Khant, S. M. K. Ali, and S.Vaaler, “Type 2 diabetes in rural and urban population: diverseprevalence and associated risk factors in Bangladesh,” DiabeticMedicine, vol. 22, no. 7, pp. 931–936, 2005.

[16] R. M. Anjana, R. Pradeepa, M. Deepa et al., “Prevalenceof diabetes and prediabetes (impaired fasting glucose and/orimpaired glucose tolerance) in urban and rural India: phaseI results of the Indian Council of Medical Research-INdia


DIABetes (ICMR-INDIAB) study,” Diabetologia, vol. 54, no. 12,pp. 3022–3027, 2011.

[17] International Institute for Population Sciences (IIPS) andMacro International, “National Family Health Survey (NFHS-3), 2005-06: India: Volume I.Mumbai: IIPS,” 2007.

[18] Y. K. Seedat, “Diabetes mellitus in South African Indians,”British Journal of Diabetes & Vascular Disease, vol. 5, no. 5, pp.249–251, 2005.

[19] D.G.McLarty, C. Pollitt, andA. B.M. Swai, “Diabetes inAfrica,”Diabetic Medicine, vol. 7, no. 8, pp. 670–684, 1990.

[20] J. C. N.Mbanya, A. A.Motala, E. Sobngwi, F. K. Assah, and S. T.Enoru, “Diabetes in sub-Saharan Africa,” The Lancet, vol. 375,no. 9733, pp. 2254–2266, 2010.

[21] V. Hall, R. W.Thomsen, O. Henriksen, and N. Lohse, “Diabetesin Sub Saharan Africa 1999–2011: epidemiology and publichealth implications. A systematic review,” BMC Public Health,vol. 11, p. 564, 2011.

[22] A. Fisch, E. Pichard, T. Prazuck, H. Leblanc, Y. Sidibe, and G.Brucker, “Prevalence and risk factors of diabetes mellitus inthe rural region of Mali (West Africa): a practical approach,”Diabetologia, vol. 30, no. 11, pp. 859–862, 1987.

[23] N.M. Balde, I. Diallo,M. D. Balde et al., “Diabetes and impairedfasting glucose in rural and urban populations in Futa Jallon(Guinea): prevalence and associated risk factors,” Diabetes andMetabolism, vol. 33, no. 2, pp. 114–120, 2007.

[24] O. O. Oladapo, L. Salako, O. Sodiq, K. Shoyinka, K. Adedapo,and A. O. Falase, “A prevalence of cardiometabolic risk factorsamong a rural Yoruba south-western Nigerian population: apopulation-based survey,” Cardiovascular Journal of Africa, vol.21, no. 1, pp. 26–31, 2010.

[25] T. J. Aspray, F. Mugusi, S. Rashid et al., “Rural and urbandifferences in diabetes prevalence in Tanzania: the role ofobesity, physical inactivity and urban living,”Transactions of theRoyal Society of TropicalMedicine andHygiene, vol. 94, no. 6, pp.637–644, 2000.

[26] W.Mathenge, A. Foster, and H. Kuper, “Urbanization, ethnicityand cardiovascular risk in a population in transition in Nakuru,Kenya: a population-based survey,” BMC Public Health, vol. 10,article 569, 2010.

[27] D. Maher, L. Waswa, K. Baisley, A. Karabarinde, N. Unwin,andH.Grosskurth, “Distribution of hyperglycaemia and relatedcardiovascular disease risk factors in low-income countries:a cross-sectional population-based survey in rural Uganda,”International Journal of Epidemiology, vol. 40, no. 1, pp. 160–171,2011.

[28] N. S. Levitt, J. M. Katzenellenbogen, D. Bradshaw, M. N.Hoffman, and F. Bonnici, “The prevalence and identification ofrisk factors for NIDDM in urban Africans in Cape Town, SouthAfrica,” Diabetes Care, vol. 16, no. 4, pp. 601–607, 1993.

[29] A. A. Motala, T. Esterhuizen, E. Gouws, F. J. Pirie, and A.K. Mahomed, “Diabetes and other disorders of glycemia in arural South African community: prevalence and associated riskfactors,” Diabetes Care, vol. 31, no. 9, pp. 1783–1788, 2008.

[30] E. Sobngwi, J. C. Mbanya, N. C. Unwin et al., “Physical activityand its relationship with obesity, hypertension and diabetes inurban and rural Cameroon,” International Journal of Obesityand Related Metabolic Disorders, vol. 26, no. 7, pp. 1009–1016,2002.

[31] MOH,Cameroon Burden of Diabetes Project (Cambod): BaselineSurvey Report,Ministry ofHealth, Cambodia, Cameroon, 2004.

[32] J. B. Echouffo-Tcheugui, A. Dzudie, M. E. Epacka et al.,“Prevalence and determinants of undiagnosed diabetes in anurban sub-Saharan African population,” Prim Care Diabetes,vol. 6, no. 3, pp. 229–234, 2012.

[33] K. Okrainec, D. K. Banerjee, and M. J. Eisenberg, “Coronaryartery disease in the developingworld,”AmericanHeart Journal,vol. 148, no. 1, pp. 7–15, 2004.

[34] A. R. Davies, L. Smeeth, and E. M. D. Grundy, “Contribution ofchanges in incidence and mortality to trends in the prevalenceof coronary heart disease in the UK: 1996–2005,” EuropeanHeart Journal, vol. 28, no. 17, pp. 2142–2147, 2007.

[35] T. Laatikainen, J. Critchley, E. Vartiainen, V. Salomaa, M.Ketonen, and S. Capewell, “Explaining the decline in coronaryheart disease mortality in Finland between 1982 and 1997,”American Journal of Epidemiology, vol. 162, no. 8, pp. 764–773,2005.

[36] R. Gupta, “Trends in hypertesnion epidemiology in India,”Journal of Human Hypertension, vol. 18, pp. 73–78, 2004.

[37] V. Mohan, M. Deepa, S. Farooq, M. Datta, and R. Deepa,“Prevalence, awareness and control of hypertension inChennai:the Chennai Urban Rural Epidemiology Study (CURES-52),”Journal of Association of Physicians of India, vol. 55, pp. 326–332,2007.

[38] P. Suriyawongpaisal, “Cardiovascular risk factor levels in urbanand rural Thailand: the International Collaborative Study ofCardiovascular Disease in Asia (InterASIA),” European Journalof Cardiovascular Prevention and Rehabilitation, vol. 10, no. 4,pp. 249–257, 2003.

[39] M. A. Sayeed, A. Banu, J. A. Haq, P. A. Khanam, H.Mahtab, andA. K. Azad Khan, “Prevalence of hypertension in Bangladesh:effect of socioeconomic risk factor on difference between ruraland urban community,” Bangladesh Medical Research CouncilBulletin, vol. 28, no. 1, pp. 7–18, 2002.

[40] Global Health Observatory (GHO), “Raised Blood pressure,”2012, http://www.who.int/gho/ncd/risk factors/blood pres-sure prevalence text/en/index.html.

[41] Y. K. Seedat, “Hypertension in developing nations in sub-Saharan Africa,” Journal of Human Hypertension, vol. 14, no. 10-11, pp. 739–747, 2000.

[42] R. Edwards, N. Unwin, F. Mugusi et al., “Hypertension preva-lence and care in an urban and rural area of Tanzania,” Journalof Hypertension, vol. 18, no. 2, pp. 145–152, 2000.

[43] K. Steyn, T. A. Gaziano, D. Bradshaw, R. Laubscher, and J.Fourie, “Hypertension in South African adults: results from thedemographic and health survey, 1998,” Journal of Hypertension,vol. 19, no. 10, pp. 1717–1725, 2001.

[44] R. Norman, T. Gaziano, R. Laubsher, K. Steyn, andD. Bradshaw,“Estimating the burden of disease attributable to high bloodpressure in South Africa in 2000,” South African MedicalJournal, vol. 97, no. 8, pp. 692–698, 2007.

[45] Ministry of Public Health, Thailand Health Profile 2005-2006,Bureau of Policy and strategy, Ministry of Public Health,Nonthaburi, Thailand, 2007.

[46] J. R. Sowers, M. Epstein, and E. D. Frohlich, “Diabetes, hyper-tension, and cardiovascular disease an update,” Hypertension,vol. 37, no. 4, pp. 1053–1059, 2001.

[47] C. Arauz-Pacheco, M. A. Parrott, and P. Raskin, “The treatmentof hypertension in adult patients with diabetes,” Diabetes Care,vol. 25, no. 1, pp. 134–147, 2002.

[48] R. Klein, B. E. K. Klein, K. E. Lee, K. J. Cruickshanks, and S.E. Moss, “The incidence of hypertension in insulin-dependent


diabetes,” Archives of Internal Medicine, vol. 156, no. 6, pp. 622–627, 1996.

[49] R. Turner, I. Stratton, V. Fright, R. Holman, S. Manley, and C.Cull, “Hypertension in Diabetes Study (HDS): I. Prevalence ofhypertension in newly presenting type 2 diabetic patients andthe association with risk factors for cardiovascular and diabeticcomplications,” Journal of Hypertension, vol. 11, no. 3, pp. 309–317, 1993.

[50] M. Berraho, Y. El Achhab, A. Benslimane, K. El Rhazi, M.Chikri, and C. Nejjari, “Hypertension and type 2 diabetes: across-sectional study in Morocco (EPIDIAM Study),” The PanAfrican Medical Journal, vol. 11, p. 52, 2012.

[51] B. A. Broussard, S. E. Valway, S. Kaufman, S. Beaver, and D.Gohdes, “Clinical hypertension and its interactionwith diabetesamong American Indians and Alaska Natives: estimated ratesfromambulatory care data,”Diabetes Care, vol. 16, no. 1, pp. 292–296, 1993.

[52] F. P. Cappuccio, A. Barbato, and S. M. Kerry, “Hypertension,diabetes and cardiovascular risk in ethnicminorities in theUK,”British Journal of Diabetes & Vascular Disease, vol. 3, no. 4, pp.286–293, 2003.

[53] J. R. Sowers and M. Epstein, “Diabetes mellitus and associatedhypertension, vascular disease, and nephropathy. An update,”Hypertension, vol. 26, no. 6 I, pp. 869–879, 1995.

[54] J. Stamler, O. Vaccaro, J. D. Neaton, and D. Wentworth,“Diabetes, other risk factors, and 12-yr cardiovascular mortalityfor men screened in the multiple risk factor intervention trial,”Diabetes Care, vol. 16, no. 2, pp. 434–444, 1993.

[55] J. D. Curb, S. L. Pressel, J. A. Cutler et al., “Effect of diuretic-based antihypertensive treatment on cardiovascular disease riskin older diabetic patients with isolated systolic hypertension,”The Journal of the American Medical Association, vol. 276, no.23, pp. 1886–1892, 1996.

[56] E. Grossman and F. Messerli, “Hypertension and diabetes,”Advances in Cardiology, vol. 45, pp. 82–106, 2008.

[57] J. Tuomilehto, D. Rastenyte, W. H. Birkenhager et al., “Effects ofcalcium-channel blockade in older patients with diabetes andsystolic hypertension,” The New England Journal of Medicine,vol. 340, no. 9, pp. 677–684, 1999.

[58] United Kingdom Prospective Diabetes Study Group, “Tightblood pressure control and risk ofmacrovascular andmicrovas-cular complications in type 2 diabetes: UKPDS 38,” BMJ, vol.317, no. 7160, pp. 703–713, 1998.

[59] Hypertension in Diabetes Study (HDS): II, “Increased risk ofcardiovascular complications in hypertensive type 2 diabeticpatients,” Journal of Hypertension, vol. 11, pp. 319–325, 1993.

[60] R. B. Singh, R. Beegom, V. Rastogi, S. S. Rastogi, andV. Madhu, “Clinical characteristics and hypertension amongknown patients of non-insulin dependent diabetes mellitus inNorth and South Indians,” Journal of the Diabetic Association ofIndia, vol. 36, pp. 45–50, 1996.

[61] S. Jain and J. C. Patel, “Diabetes and hypertension,” Journal ofthe Diabetic Association of India, vol. 23, pp. 83–86, 1983.

[62] S. R. Joshi, B. Saboo,M.Vadivale et al., “Prevalence of diagnosedand undiagnosed diabetes and hypertension in India–resultsfrom the Screening India’s Twin Epidemic (SITE) study,” Dia-betes Technology andTherapeutics, vol. 14, no. 1, pp. 8–15, 2012.

[63] P. Bunnag, N. Plengvidhya, C. Deerochanawong et al., “Thai-land diabetes registry project: prevalence of hypertension,treatment and control of blood pressure in hypertensive adultswith type 2 diabetes,” Journal of the Medical Association ofThailand, vol. 89, no. 1, pp. S72–S77, 2006.

[64] H. S. Lee, S. S. Lee, I. Y. Hwang et al., “Prevalence, aware-ness, treatment and control of hypertension in adults withdiagnosed diabetes: the Fourth Korea National Health andNutrition Examination Survey (KNHANES IV),” Journal ofHuman Hypertension, 2012.

[65] U.K. Shrestha,D. L. Singh, andM.D. Bhattarai, “Theprevalenceof hypertension and diabetes defined by fasting and 2-h plasmaglucose criteria in urban Nepal,” Diabetic Medicine, vol. 23, no.10, pp. 1130–1135, 2006.

[66] M. Ducorps, B. Bauduceau, H. Mayaudon, E. Sonnet, L.Groussin, and C. Castagne, “Prevalence of hypertension in aBlack African diabetic population,” Archives des Maladies duCoeur et des Vaisseaux, vol. 89, no. 8, pp. 1069–1073, 1996.

[67] C. F. Otieno, V. Vaghela, F. W. Mwendwa, J. K. Kayima, andE. N. Ogola, “Cardiovascular risk factors in patients with type2 diabetes mellitus in Kenya: levels of control attained atthe outpatient diabetic Clinic of Kenyatta National Hospital,Nairobi,” East African Medical Journal, vol. 82, no. 12, pp. S184–S190, 2005.

[68] O. O. Ogunleye, S. O. Ogundele, J. O. Akinyemi, and A. O.Ogbera, “Clustering of hypertension, diabetes mellitus anddyslipidemia in a Nigerian population: a cross sectional study,”African Journal of Medicine & Medical Sciences, vol. 41, pp. 191–195, 2012.

[69] M. Berraho, Y. El Achhab, A. Benslimane, K. El Rhazi, M.Chikri, and C. Nejjari, “Hypertension and type 2 diabetes: across-sectional study in Morocco (EPIDIAM Study),” The PanAfrican Medical Journal, vol. 11, p. 52, 2012.

[70] B. C. Unadike, A. Eregie, and A. E. Ohwovoriole, “Prevalence ofhypertension amongst persons with diabetes mellitus in BeninCity, Nigeria,” Nigerian Journal of Clinical Practice, vol. 14, pp.300–302, 2011.

[71] R. Beaglehole, J. Epping-Jordan, V. Patel et al., “Improving theprevention and management of chronic disease in low-incomeand middle-income countries: a priority for primary healthcare,”The Lancet, vol. 372, no. 9642, pp. 940–949, 2008.

[72] D. T. Jamison, J. G. Breman, A. R. Measham et al., Eds., DiseaseControl Priorities in Developing Countries, World Bank andOxford University Press, Washington, DC, USA, 2nd edition,2006.

[73] S. MacMahon, M. H. Alderman, L. H. Lindholm, L. Liu, R. A.Sanchez, and Y. K. Seedat, “Blood-pressure-related disease is aglobal health priority,”The Lancet, vol. 371, no. 9623, pp. 1480–1482, 2008.

[74] D. Lemogoum, Y. K. Seedat, A. F. B. Mabadeje et al., “Rec-ommendations for prevention, diagnosis and management ofhypertension and cardiovascular risk factors in sub-SaharanAfrica,” Journal of Hypertension, vol. 21, no. 11, pp. 1993–2000,2003.

[75] R. Deepa, C. S. Shanthirani, R. Pradeepa, and V. Mohan, “Is the“rule of halves” in hypertension still valid?—Evidence from theChennaiUrbanPopulation Study,”The Journal of theAssociationof Physicians of India, vol. 51, pp. 153–157, 2003.

[76] I. Ranjit Unnikrishnan, R. M. Anjana, and V. Mohan, “Impor-tance of controlling diabetes early—the concept of metabolicmemory, legacy effect and the case for early insulinisation,”Journal of Association of Physicians of India, vol. 59, supplement,pp. 8–12, 2011.

[77] S. Ebrahim, “Chronic diseases and calls to action,” InternationalJournal of Epidemiology, vol. 37, no. 2, pp. 225–230, 2008.

[78] G. Li, Y. Hu, W. Yang et al., “Effects of insulin resistanceand insulin secretion on the efficacy of interventions to retard


development of type 2 diabetes mellitus: the DA Qing IGT andDiabetes Study,”Diabetes Research and Clinical Practice, vol. 58,no. 3, pp. 193–200, 2002.

[79] J. Tuomilehto, J. Lindstrom, J. G. Eriksson et al., “Prevention oftype 2 diabetes mellitus by changes in lifestyle among subjectswith impaired glucose tolerance,” The New England Journal ofMedicine, vol. 344, no. 18, pp. 1343–1350, 2001.

[80] W.C.Knowler, E. Barrett-Connor, S. E. Fowler et al., “Reductionin the incidence of type 2 diabetes with lifestyle intervention ormetformin,”The New England Journal of Medicine, vol. 346, no.6, pp. 393–403, 2002.

[81] A. Ramachandran, C. Snehalatha, S. Mary, B. Mukesh, A.D. Bhaskar, and V. Vijay, “The Indian Diabetes PreventionProgramme shows that lifestyle modification and metforminprevent type 2 diabetes in Asian Indian subjects with impairedglucose tolerance (IDPP-1),”Diabetologia, vol. 49, no. 2, pp. 289–297, 2006.

[82] G. Hu, N. C. Barengo, J. Tuomilehto, T. A. Lakka, A. Nissinen,and P. Jousilahti, “Relationship of physical activity and bodymass index to the risk of hypertension: a prospective study inFinland,” Hypertension, vol. 43, no. 1, pp. 25–30, 2004.

[83] The Trials of Hypertension Prevention Collaborative ResearchGroup, “The effects of nonpharmacologic interventions onblood pressure of persons with high normal levels. Results ofthe trials of hypertension prevention, phase I,” The Journal ofthe American Medical Association, vol. 267, no. 9, pp. 1213–1220,1992.

[84] J. A. Cutler, “Effects of weight loss and sodium reductionintervention on blood pressure and hypertension incidencein overweight people with high-normal blood pressure: thetrials of hypertension prevention, phase II,” Archives of InternalMedicine, vol. 157, no. 6, pp. 657–667, 1997.

[85] L. J. Appel, “Effects of comprehensive lifestyle modification onblood pressure control: main results of the PREMIER clinicaltrial,”The Journal of the American Medical Association, vol. 289,no. 16, pp. 2083–2093, 2003.

[86] TheDiabetes Control and Complications Trial Research Group,“The effect of intensive treatment of diabetes on the develop-ment and progression of long-term complications in insulin-dependent diabetes mellitus,” The New England Journal ofMedicine, vol. 329, pp. 977–986, 1993.

[87] R. Turner, “Intensive blood-glucose control with sulphony-lureas or insulin compared with conventional treatment andrisk of complications in patients with type 2 diabetes (UKPDS33),”The Lancet, vol. 352, no. 9131, pp. 837–853, 1998.

[88] M. Shichiri, H. Kishikawa, Y. Ohkubo, and N. Wake, “Long-term results of the Kumamoto Study on optimal diabetescontrol in type 2 diabetic patients,” Diabetes Care, vol. 23, no.2, pp. B21–B29, 2000.

[89] P. Gæde, H. Lund-Andersen, H. H. Parving, and O. Pedersen,“Effect of a multifactorial intervention on mortality in type 2diabetes,”The New England Journal of Medicine, vol. 358, no. 6,pp. 580–591, 2008.

[90] The Action to Control Cardiovascular Risk in Diabetes StudyGroup, “Effects of intensive glucose lowering in type 2 diabetes,”The New England Journal of Medicine, vol. 358, pp. 2545–2559,2008.

[91] American Diabetes Association, “Standards of medical care indiabetes-2008,” Diabetes Care, vol. 31, supplement 1, pp. S12–S54, 2008.

[92] J. S. Skyler, R. Bergenstal, R. O. Bonow et al., “Intensive glycemiccontrol and the prevention of cardiovascular events: implica-tions of the ACCORD, ADVANCE, and VA diabetes trials:

a position statement of the American Diabetes Association anda scientific statement of the American College of CardiologyFoundation and the American Heart Association,” DiabetesCare, vol. 32, no. 1, pp. 187–192, 2009.

[93] J. B. Buse, H. N. Ginsberg, G. L. Bakris et al., “Primary preven-tion of cardiovascular diseases in people with diabetes mellitus:a scientific statement from the AmericanHeart Association andthe American Diabetes Association,” Circulation, vol. 115, no. 1,pp. 114–126, 2007.

[94] S. A. Mazzuca, F. Vinicor, R. M. Einterz, W. M. Tierney,J. A. Norton, and L. A. Kalasinski, “Effects of the clinicalenvironment on physicians’ response to postgraduate medicaleducation,” American Educational Research Journal, vol. 27, no.3, pp. 473–488, 1990.

[95] E. M. Benjamin, M. S. Schneider, and K. T. Hinchey, “Imple-menting practice guidelines for diabetes care using problem-based learning: a prospective controlled trial using firm sys-tems,” Diabetes Care, vol. 22, no. 10, pp. 1672–1678, 1999.

[96] D. Litaker, L. C. Mion, L. Planavsky, C. Kippes, N. Mehta, and J.Frolkis, “Physician-nurse practitioner teams in chronic diseasemanagement: the impact on costs, clinical effectiveness, andpatients’ perception of care,” Journal of Interprofessional Care,vol. 17, no. 3, pp. 223–237, 2003.

[97] L. Jovanovic, “Closing the gap: effect of diabetes case manage-ment on glycemic control among low-income ethnic minoritypopulations. The California Medi-Cal type 2 diabetes study,”Diabetes Care, vol. 27, no. 1, pp. 95–103, 2004.

[98] H. M. Choe, S. Mitrovich, D. Dubay, R. A. Hayward, S. L.Krein, and S. Vijan, “Proactive case management of high-riskpatients with type 2 diabetes mellitus by a clinical pharmacist:a randomized controlled trial,” American Journal of ManagedCare, vol. 11, no. 4, pp. 253–260, 2005.

[99] R. A. Gabbay, I. Lendel, T. M. Saleem et al., “Nurse casemanagement improves blood pressure, emotional distress anddiabetes complication screening,” Diabetes Research and Clini-cal Practice, vol. 71, no. 1, pp. 28–35, 2006.

[100] Pan American Health Organization, Veracruz Project for theImprovement of Diabetes Care (VIDA): Final Report, PAHO,Washington, DC, USA, 2007.

[101] T. L. Gary, M. Batts-Turner, H. C. Yeh et al., “The effectsof a nurse case manager and a community health workerteam on diabetic control, emergency department visits, andhospitalizations among urban African Americans with type 2diabetes mellitus: a randomized controlled trial,” Archives ofInternal Medicine, vol. 169, no. 19, pp. 1788–1794, 2009.

[102] R. Coleman, G. Gill, and D. Wilkinson, “Noncommunicabledisease management in resource-poor settings: a primary caremodel from rural South Africa,” Bulletin of the World HealthOrganization, vol. 76, no. 6, pp. 633–640, 1998.

[103] A. Pal, V. W. A. Mbarika, F. Cobb-Payton, P. Datta, and S.McCoy, “Telemedicine diffusion in a developing country: thecase of India (March 2004),” IEEE Transactions on InformationTechnology in Biomedicine, vol. 9, no. 1, pp. 59–65, 2005.

[104] A. Geissbuhler, O. Ly, C. Lovis, and J. F. L’Haire, “Telemedicinein Western Africa: lessons learned from a pilot project in Mali,perspectives and recommendations,” AMIA. Annual Sympo-sium Proceedings, pp. 249–253, 2003.

[105] C. O. Bagayoko, H. Muller, and A. Geissbuhler, “Assessmentof Internet-based tele-medicine in Africa (the RAFT project),”ComputerizedMedical Imaging andGraphics, vol. 30, no. 6-7, pp.407–416, 2006.


[106] V. T. Bai, V. Murali, R. Kim, and S. K. Srivatsa, “Teleophthal-mology-based rural eye care in India,” Telemedicine Journal ande-Health, vol. 13, no. 3, pp. 313–321, 2007.

[107] V. Prathiba and M. Rema, “Teleophthalmology: a model foreye care delivery in rural and underserved areas of India,”International Journal of Family Medicine, vol. 2011, Article ID683267, 4 pages, 2011.

[108] V. Mohan, M. Deepa, R. Pradeepa et al., “Prevention of diabetesin rural India with a telemedicine intervention,” Journal ofDiabetes Science and Technology, vol. 6, no. 6, pp. 1355–1364,2012.

[109] V. Patel, S. Chatterji, D. Chisholm et al., “Chronic diseases andinjuries in India,” The Lancet, vol. 377, no. 9763, pp. 413–428,2011.

[110] A. Kapur, “Economic analysis of diabetes care,” Indian Journalof Medical Research, vol. 125, no. 3, pp. 473–482, 2007.

[111] R. Rodrigo and S. Rajapakse, “Current Status of HIV/AIDS inSouth Asia,” Journal of Global Infectious Diseases, vol. 1, pp. 93–101, 2009.

[112] J. van Olmen, F. Schellevis, W. Van Damme, G. Kegels, and F.Rasschaert, “Management of chronic diseases in sub-SaharanAfrica: cross-fertilisation between HIV/AIDS and diabetescare,” Journal of Tropical Medicine, vol. 2012, Article ID 349312,10 pages, 2012.

[113] R. Geneau and G. Hallen, “Toward a systemic research agendafor addressing the joint epidemics of HIV/AIDS and noncommunicable diseases,” AIDS, vol. 26, supplement 1, pp. S7–S10, 2012.

[114] S. O. Oti, “HIV and non communicable diseases: a case forhealth system building,” Current Opinion in HIV and AIDS, vol.8, pp. 65–69, 2013.

[115] S.M.Tollman,K.Kahn, B. Sartorius,M.A.Collinson, S. J. Clark,and M. L. Garenne, “Implications of mortality transition forprimary health care in rural South Africa: a population-basedsurveillance study,”The Lancet, vol. 372, no. 9642, pp. 893–901,2008.

[116] B. Janssens, W. Van Damme, B. Raleigh et al., “Offering inte-grated care for HIV/AIDS, diabetes and hypertension withinchronic disease clinics in Cambodia,” Bulletin of the WorldHealth Organization, vol. 85, no. 11, pp. 880–885, 2007.

[117] World Health Organization, “Innovative care for chronicconditions: building blocks for action: global report,” 2002,http://www.who.int/chp/knowledge/publications/iccc ch3.pdf.

[118] J. E. Epping-Jordan, S. D. Pruitt, R. Bengoa, and E. H. Wagner,“Improving the quality of health care for chronic conditions,”Quality and Safety in Health Care, vol. 13, no. 4, pp. 299–305,2004.

Hindawi Publishing CorporationInternational Journal of HypertensionVolume 2012, Article ID 584041, 7 pagesdoi:10.1155/2012/584041

Research Article

Gaps in Capacity in Primary Care in Low-ResourceSettings for Implementation of Essential NoncommunicableDisease Interventions

S. Mendis,1 Igbal Al Bashir,2 Lanka Dissanayake,3 Cherian Varghese,4

Ibtihal Fadhil,5 Esha Marhe,6 Boureima Sambo,7 Firdosi Mehta,3 Hind Elsayad,8

Idrisa Sow,9 Maltie Algoe,10 Herbert Tennakoon,11 Lai Die Truong,12 Le Thi Tuyet Lan,13

Dismond Huiuinato,14 Neelamni Hewageegana,15 Naiema A. W. Fahal,16 Goitom Mebrhatu,17

Gado Tshering,18 and Oleg Chestnov19

1Chronic Disease Prevention and Management, World Health Organization, Geneva, Switzerland2Public Health Institute, Ministry of Health, Khartoum, Sudan3World Health Organization, Colombo, Sri Lanka4WPRO, World Health Organization, Manila, Philippines5EMRO, World Health Organization, Cairo, Egypt6PAHO-WHO, Paramaribo, Suriname7AFRO, World Health Organization, Brazzaville, Democratic Republic of Congo8Ministry of Health, Damascus, Syria9World Health Organization, Asmara, Eritrea10Ministry of Health, Paramaribo, Suriname11World Health Organization, Thimphu, Bhutan12World Health Organization, Hanoi, Vietnam13General Hospital, Ho Chi Minh City, Vietnam14Ministry of Health, Cotonou, Benin15Ministry of Health, Colombo, Sri Lanka16NCD Directorate, Ministry of Health, Khartoum, Sudan17Ministry of Health, Asmara, Eritrea18Ministry of Health, Thimphu, Bhutan19World Health Organization, Geneva, Switzerland

Correspondence should be addressed to S. Mendis, [email protected]

Received 20 September 2012; Revised 23 October 2012; Accepted 24 October 2012

Academic Editor: Eoin O’Brien

Copyright © 2012 S. Mendis et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective. The objective was to evaluate the capacity of primary care (PC) facilities to implement basic interventions for preventionand management of major noncommunicable diseases (NCDs), including cardiovascular diseases and diabetes. Methods. A cross-sectional survey was done in eight low- and middle-income countries (Benin, Bhutan, Eritrea, Sri Lanka, Sudan, Suriname,Syria, and Vietnam) in 90 PC facilities randomly selected. The survey included questions on the availability of human resources,equipment, infrastructure, medicines, utilization of services, financing, medical information, and referral systems. Results andConclusions. Major deficits were identified in health financing, access to basic technologies and medicines, medical informationsystems, and the health workforce. The study has provided the foundation for strengthening PC to address noncommunicablediseases. There are important implications of the findings of this study for all low- and middle-income countries as capacity of PCis fundamental for equitable prevention and control of NCDs.


1. Introduction

Noncommunicable diseases (NCDs), cardiovascular disease,cancer, diabetes, and chronic respiratory diseases, cause thedeath of more people each year than all other causescombined. Of 57 million global deaths in 2008, 36 million—almost two-thirds—were due to NCDs, comprising mainlycardiovascular diseases, cancers, diabetes, and chronic lungdiseases [1]. The combined burden of these diseases is risingdisproportionately in low- and middle-income countries(LMIC). In 2008, for example, 29 million NCD deaths(nearly 80% of the global total) occurred in LMIC [1]. Aprimary health care approach is essential to address NCDseffectively and equitably [2, 3], and the need to strengthenprimary care (PC) has been recently highlighted in the polit-ical declaration of the United Nations high-level meeting forNCD prevention and control [4].

Implementing essential NCD interventions in PC [5, 6]has the potential to prevent NCD complications such as heartattacks, strokes, blindness, amputations, and renal disease,through early detection and treatment of people at high risk[7]. There are many cost-effective and high-impact interven-tions that are feasible to be delivered in PC in low-resourcesettings by physician as well as nonphysician health careproviders [8]. These include cardiovascular risk assessmentand management to prevent heart attacks and strokes usinghypertension and diabetes as entry points, detection, andfollowup of diabetes to prevent diabetes complications suchas chronic renal disease, smoking cessation counselling toprevent progression of chronic respiratory disease, amongothers [1, 7, 9]. A core set of these interventions have beenprioritized for countrywide scaling up by the World HealthOrganization based on their cost effectiveness, impact, andfeasibility of delivery in PC in low-resource settings [7,10]. Key prerequisites for delivery of such interventionsinclude fair financing systems, basic technologies, essentialmedicines, trained health personnel, medical information,and referral systems [6, 7, 11]. The objective of this studywas to evaluate the capacity of PC facilities to implementbasic interventions for prevention and management of majorNCDs.

2. Methods

In 2009/2011, Ministries of Health in eight LMIC (2 low-income countries: Benin, Eritrea; 4 low-middle-incomecountries: Sudan, Bhutan, Sri Lanka, Vietnam; 2 upper-middle-income countries: Suriname and Syria), worked withthe World Health Organization to conduct feasibility studiesfor scaling up delivery of NCD interventions in PC usingthe WHO package of essential NCD interventions (WHOPEN) [7]. Facility capacity assessments were done to assessthe feasibility of delivering these interventions in PC in thepublic sector, in defined administrative areas selected bythe Ministries of Health for strengthening NCD services. Tofacilitate supervision and logistics, the administrative regionsselected were within one-day drive from the Ministry ofHealth. For each area, a list of PC facilities was compiled,and 50% or more of the facilities were randomly selected.

The defined areas were Cotonou Ouidah, Kpomasse, Toriadministrative areas in Benin, Bumthang and Paro districtsin Bhutan, Asmara (Akria, Addis Alem, Godaif, Tsaeda-Christian, Semenawi Meerab, and Semenawi Mibrak sub-zones) in Eritrea, Badulla district in Sri Lanka, Sharg Elniland Elkamlin districts in Sudan, urban coastal, rural coastal,rural interior administrative areas in Suriname, Damascus(Kaa’a, Dowella, and Tadamun) and Lattakia (Sekentori,Alramel, Kaneed, and Hai Alaa’dein) in Syria, and Phunhuandistrict in Vietnam.

Surveys were conducted in 90 PC facilities, betweenJanuary 2009 and January 2011. A rapid assessment toolfor primary care facility capacity assessment for NCDs wasused to collect data from facilities [7]. The survey included33 questions to gather data on service utilization, infras-tructure, financing and administration, medical informationsystem, referral services, human resources, equipment, anddiagnostic tests and medicines [7, 10]. Information collectedon diagnostic tests and medicines was in relation to priorityinterventions [7, 10] for major NCDs; cardiovascular disease,diabetes, chronic respiratory disease (asthma and chronicobstructive airways disease), and cancer (palliative care). Allmedicines surveyed are in the WHO’s model formulary ofessential medicines [12]. The assessment focused on theavailability of 7 biochemical tests, 10 basic equipment, and27 medicines and medical information systems to implement14 basic NCD interventions [7]. Information was providedby a physician or a nurse in charge of each facility and wascomplemented by interviews with staff from health facilitiesand ministries of health and national health statistics. Weused version Excel MS 2003 for data entry and analysis andemployed descriptive statistical methods to compare individ-ual elements of the survey between different countries.

3. Results

Table 1 shows the countries in which the surveys were con-ducted, the World Bank income class of the countries,number of facilities surveyed, mean size of the populationserved by facilities, total number of patient visits per month,number of patient visits attributed to NCD, per capita expen-diture on health, and the percentage of private expenditureand out-of-pocket expenditure. The average populationcovered by a PC facility and the percentage of patient visitsto PC, attributed to NCDs, in the 8 countries varied widely.

3.1. Diagnostic Tests, Equipment, and Services. The availabil-ity of basic diagnostic tests (urine tests: albumin, glucose,ketones; blood tests: glucose, cholesterol, creatinine, andtroponin) is shown in Table 2. Essential urine and blood testswere not available in PC in some countries, and patients hadto be referred to a higher level facility or a private sectorinstitution for these tests.

All facilities had at least one functional sphygmomano-meter. Most of them were mercury and/or aneroid devices.Automatic devices were available in 10% of all facilities.Facilities that used aneroid sphygmomanometers were usingthem without ever calibrating them. Weighing scales wereavailable in almost all (99%) of the facilities and measuring


Ta

ble

1:C

har

acte

rist

ics

ofsu

rvey

edco

un

trie

san

dpr

imar

yca

refa

cilit

ies,

2009

/201

1.

Ch

arac

teri

stic

sof

prim

ary

care

faci

litie

sPa

rtic

ipat

ing

cou

ntr

ies

Ben

in(N=

12)

Eri

trea

(N=

6)Su

dan

(N=

12)

Syri

a(N=

14)

Bhu

tan

(N=

7)Sr

iLan

ka(N=

14)

Vie

tnam

(N=

15)

Suri

nam

e(N=

10)

Wor

ldB

ank

inco

me

clas

s∗Lo

win

com

eLo

win

com

eLo

wer

mid

dle

inco

me

Low

erm

iddl

ein

com

eLo

wer

mid

dle

inco

me

Low

erm

iddl

ein

com

eLo

wer

mid

dle

inco

me

Upp

erm

iddl

ein

com

ePo

pula

tion

serv

edm

ean

(SD

)31

333

(119

02)

6466

7(2

9084

)13

083

(136

81)

3415

7(1

2167

)50

71(8

86)

3530

8(2

0010

)13

267

(413

1)13

150

(159

65)

Nu

mbe

rof

pati

ents

regi

ster

edp

erm

onth

mea

n(S

D)

398

(256

)11

90(4

66)

847

(569

)18

67(1

060)

725

(626

)23

43(1

388)

238

(107

)10

06(7

10)

Perc

enta

geof

NC

Dpa

tien

tsre

gist

ered

per

mon

th4%

11%

30%

11%

11%

24%

62%

69%

Tota

lexp

endi

ture

onh

ealt

has

%of

gros

sdo

mes

tic

prod

uct∗∗

(200

8)4.

13.

16.

93.

15.

54.

17.

27.

2

Per

capi

tato

tale

xpen

ditu

reon

hea

lth

(PP

Pin

t.$)∗∗

(200

8)61

1814

712

326

318

720

153

2

Per

capi

tago

vern

men

tex

pen

ditu

reon

hea

lth

(PP

Pin

t.$)∗∗

(200

8)32

849

4821

782

7725

8

Pri

vate

expe

ndi

ture

onh

ealt

has

a%

ofto

tale

xpen

ditu

reon

hea

lth

(200

8)48

.355

.166

.961

.217

.556

.361

.551

.5

Ou

t-of

-poc

ket

expe

ndi

ture

as%

ofpr

ivat

eex

pen

ditu

reon

hea

lth

(200

8)99

.910

091

.910

010

083

.391

.744

∗T

he

Wor

ldB

ank.

Cou

ntr

yan

dLe

ndi

ng

Gro

ups

byIn

com

e,h

ttp:

//da

ta.w

orld

ban

k.or

g/ab

out/

cou

ntr

y-cl

assi

fica

tion

s/co

un

try-

and-

len

din

g-gr

oups

.∗∗

Wor

ldH

ealt

hSt

atis

tics

2011

.Tab

le7,

Hea

lth

expe

ndi

ture

,htt

p://

ww

w.w

ho.

int/

wh

osis

/wh

osta

t/20

11/e

n/i

nde

x.h

tml.


Table 2: Percentage availability of basic diagnostic tests in primary care facilities in defined areas in eight countries, 2009/2011.

Urine and bloodtests

Benin(n = 12)

Eritrea(n = 6)

Sudan(n = 12)

Syria(n = 14)

Bhutan(n = 7)

Sri Lanka(n = 14)

Vietnam(n = 15)

Suriname(n = 10)

Urine albumin 100 67 92 64 100 46 0 70

Urine glucose 92 67 92 71 100 54 0 70

Urine ketones 42 33 58 79 0 0 0 40

Blood glucose 67 17 75 93 0 0 0 90

Blood cholesterol 25 0 33 14 0 8 0 20

Serum creatinine 33 0 58 0 0 8 0 10

Serum troponin 8 0 8 0 0 0 0 0

tapes in 63%. Ambu bags, oxygen masks, nebulizers, elec-trocardiographs, peak expiratory flow meters and pulseoximeters were available in 61%, 44%, 37%, 28%, 20%, and2% of PC facilities, respectively.

Counselling for smoking cessation, foot care, and oph-thalmoscopic examination of the eyes for patients withdiabetes were available in 88%, 42%, and 21% of all facilities.Intravenous infusions and intravenous injections could notbe administered in 25% and 6% of all facilities, respectively.

3.2. Access to Essential Medicines. The availability of medi-cines that are used for management of major NCDs is shownin Table 3. If the medicine was generally available in thefacility, even if it was not available on the day of the surveydue to shortage of stocks, it was considered as available. Insome countries, none of the surveyed PC facilities providedaccess to certain medicines. For example, glyceryl trinitrate,isosorbide dinitrate, insulin, glibenclamide, ipratropim bro-mide, and morphine injection was not available in any PCfacility in 4 countries.

None of the countries had all the selected essentialmedicines in all primary care facilities. Only in one countrywere glyceryl trinitrate, insulin, and beclometasone inhaleravailable in more than half the PC facilities. In 34% of PCfacilities, there were no stock cards or log books that kept anup-to-date account of available medicine stocks.

Table 4 provides information on the method of financingof PC services. Consultations, diagnostic tests, and medicineswere provided for free in three countries. However, diag-nostic tests and medicines were not regularly availablethroughout the year due to shortage of public sectorresources. In all other countries, only some facilities providedconsultations, diagnostic tests, and medicines free of charge.In some countries, these services were subsidized throughgovernment funds or social security assistance. In Vietnamand Suriname, people could use private insurance to coverthe services provided.

3.3. Health Workforce in Primary Care. There were physi-cians in all PC facilities in only two countries. In the othercountries, only some of the facilities were managed by phys-icians. There were no physicians in any of the PC facilitiesin some countries. They were managed by trained nursesand health assistants. In one country, there were no nurses

in PC facilities surveyed. In all other countries, more than75% of PC facilities were staffed by at least one nurse.Other categories of staff working in some of the facilitiesincluded medical assistants, associate nurses, pharmacistassistants, auxiliary health workers, and community healthworkers. Public health midwives, public health inspectorsand dispensers were working in PC facilities in Sri Lankaand Eritrea. Sudan has a category of staff called a “healthvisitor.” Staff dedicated to administration was available insome PC facilities in Eritrea, Suriname, and Syria. In allother facilities, administrative work including procurementand stock keeping of consumables, medicines, and financialadministration was done by medical or nursing staff. Provi-sion of care for NCD using multidisciplinary teams was notfeasible or affordable in any of the PC facilities.

3.4. Medical Records and Referral Facilities. There were nocomputer facilities for record keeping in any of the PCfacilities. In 85% of facilities, paper-based records were kept.In 58% of facilities, the information was entered into a dailyattendance register. The daily register provided a few itemsof information on each patient that attended the facility. Inthe other 42%, separate records were made for individualpatients, and in half of them the records were retrieved andused for follow-up visits. In no sites was any attempt madeto send reminders to people with diabetes or hypertensionto come for followup. Only in one country surveyed was anappointment system used in PC for followup of patients.There was no organized referral and back referral systemthat allowed tracking of progress of patients in any country.One-fifth of the facilities had an ambulance for emergencytransfers. The mean distance for referral for emergency carein the 8 countries ranged from 4–50 kilometres. The durationfor transfer ranged from 15 to 110 minutes.

4. Discussion

There is a scarcity of data regarding the PC capacity in LMICto respond to the needs of people with NCDs. Even thoughNCD interventions (such as diagnosis and treatment) areuniversal, effective delivery strategies to make them accessibleto people in the prevailing socioeconomic, cultural, andhealth system scenarios are different in LMICs compared tohigh-income countries. The results of this survey in eight


Table 3: Percentage availability of selected essential medicines in primary care facilities in defined areas in eight countries, 2009/2011.

Selected essential medicinesBenin

(n = 12)Eritrea(n = 6)

Sudan(n = 12)

Syria(n = 14)

Bhutan(n = 7)

Sri Lanka(n = 14)

Vietnam(n = 15)

Suriname(n = 10)

Atenolol 8.3 0.0 42.9 14.3 0.0 69.2 93.3 100.0

Enalapril 33.3 0.0 28.6 14.3 0.0 69.2 60.0 30.0

Amlodipine 58.3 0.0 50.0 0.0 0.0 69.2 86.7 80.0

Hydrochlorothiazide 75.0 100.0 35.7 14.3 85.7 69.2 40.0 90.0

Isosorbide dinitrate 0.0 0.0 0.0 21.4 0.0 69.2 60.0 90.0

Frusemide 83.3 50.0 85.7 92.9 14.3 69.2 86.7 100.0

Simvastatin or lovastatin 8.3 0.0 35.7 7.1 0.0 23.1 46.7 50.0

Insulin long acting 0.0 0.0 21.4 21.4 0.0 30.8 0.0 80.0

Insulin soluble 0.0 0.0 28.6 21.4 0.0 30.8 0.0 80.0

Metformin 25.0 0.0 42.9 14.3 0.0 69.2 53.3 100.0

Glibenclamide 41.7 0.0 71.4 21.4 14.3 69.2 33.3 100.0

Beclometasone inhaler 33.3 16.7 21.4 28.6 0.0 15.4 6.7 80.0

Prednisolone 0.0 0.0 42.9 7.1 0.0 69.2 93.3 90.0

Salbutamol inhaler 33.3 100.0 71.4 78.6 0.0 30.8 20.0 90.0

Salbutamol tablets 66.7 100.0 85.7 14.3 100.0 69.2 93.3 90.0

Ipratropium bromide 0.0 0.0 14.3 14.3 0.0 30.8 0.0 20.0

Aspirin 100.0 100.0 100.0 21.4 0.0 69.2 100.0 100.0

Paracetamol 100.0 100.0 92.9 0.0 100.0 69.2 100.0 100.0

Ibuprofen 83.3 100.0 100.0 0.0 100.0 69.2 73.3 80.0

Morphine (oral) 0.0 0.0 14.3 0.0 0.0 15.4 0.0 20.0

Morphine injection 8.3 0.0 14.3 0.0 0.0 38.5 0.0 20.0

Codeine 8.3 0.0 35.7 0.0 0.0 15.4 33.3 60.0

Glucose solution for injection 91.7 0.0 0.0 0.0 57.1 53.8 66.7 80.0

Sodium chloride infusion 91.7 100.0 92.9 35.7 0.0 53.8 100.0 60.0

Benzathine penicillin 50.0 100.0 92.9 57.1 30.8 0.0 60.0 100.0

LMICs show critical gaps in PC in four key areas. Theyinclude health financing, medicines and technologies, healthworkforce, and health information systems.

Patient-oriented and accountable health systems requirereimbursement at least for basic PC services. PC services werefree at the point of delivery only in three countries. To delivera minimum set of interventions for communicable diseasesand maternal and child health alone, a per capita expenditureof at least US$ 60 has been estimated to be necessary [13]. Ithas also been estimated that around 12% of GNP is requiredin low-income countries to meet the international healthdevelopment goals [14]. Based on these benchmarks, it isclear that public investment in health is inadequate to addressNCDs, in all countries surveyed. The shortfall in governmentinvestment is made up by private spending resulting in veryhigh out-of-pocket expenditure on health, ranging from 83%to 100%. To ensure equity, social protection strategies needto be introduced to move health financing systems towardsrisk-pooling and prepayment and away from out-of-pocket“fee for service” payment [11].

The results of this survey also showed major gaps inaccess to basic technologies and essential medicines. Ideally,PC facilities should be equipped with technologies andmedicines to deliver a wide range of NCD interventions

including NCD emergencies. However, public spending onhealth in many LMIC is inadequate to cover a comprehensiveset of NCD interventions in PC. In this context, a pragmaticapproach would be to prioritize available resources todeliver low-cost, high-impact NCD interventions that canbe delivered through a primary health care approach. WHOtools are available for selecting priority NCD interventionsin this manner and estimating the costs required for theirimplementation [7, 10, 15, 16].

The results of the survey also highlight the shortage ofhealth personnel and the need to train and empower nonphysician health workers to deliver certain essential NCDinterventions, for example, cardiovascular risk assessment,counselling for smoking cessation, and foot care for peoplewith diabetes. Previous studies have demonstrated the feasi-bility of this approach even in low-resource settings [8, 17].Continuing medical education programs, evidence-basedguidelines, audit systems to assess performance, policiesfor career development, and promotional prospects andincentives is required to enable the health workforce in PCto contribute better to prevention and control of NCDs[17, 18].

Obstacles to continuity of care that were identified alsoneed to be addressed to improve the effectiveness of NCD


Table 4: Financing of services and financing sources.

FinancingBenin

(n = 12)Eritrea(n = 6)

Sudan(n = 12)

Syria(n = 14)

Bhutan(n = 7)

Sri Lanka(n = 14)

Vietnam(n = 15)

Suriname(n = 10)

Facilities providing consultations for free (%) 42 100 50 100 100 69 27 100

Subsidized by central or local government (%) 0 100 50 100 100 69 20 100

Subsidized by social health insurance (%) 42 0 0 0 0 0 7 0

Facilities providing diagnostic tests for free (%) 42 100 50 100 100 69 13 100



Facilities providing medicines for free (%) 42 100 50 100 100 62 0 70



interventions. In this regard, individual medical recordsthat track the progress as well as referral/back referraland organized appointment/reminder systems which areimportant components of long-term care for NCDs need tobe made available in PC facilities.

Since inadequate financial resources is one of the rootproblems for the critical gaps identified, one of the firstremedial steps that could be taken is to improve the efficiencyof service delivery. This can be done through prioritizationof NCD interventions based on equity, safety, effectiveness,and cost [7, 11]. If these prioritized interventions aredelivered by a trained workforce, and scaled up to improvepopulation coverage, it will improve the chances of reversingthe progression of NCDs, preventing complications, andreducing health care budgets [17, 19, 20]. For example,results of blood sugar and blood cholesterol tests when takentogether with age, gender, smoking status, and systolic bloodpressure can predict the risk of a future heart attack or astroke, providing the opportunity for appropriate treatmentto prevent heart attacks and strokes [7, 15, 19].

Any scaling up efforts to address NCDs in low-resourcesettings need to invest resources to address the critical gapsin the health system that have been identified. In countrieswhere the survey was conducted, local projects are ongoingto investigate the feasibility of addressing the gaps identifiedwith the objective of using the lessons learned for nationalscaling up of NCD prevention and control.

5. Strengths and Limitations

The surveys were undertaken in collaboration with theministries of health to identify gaps for strengthening PC forprevention and control of NCDs. This was the strength ofthe study as it provided baseline data to monitor progress ofNCD programs implemented in primary care. The study hasseveral limitations. Surveys were not representative nationalsurveys but subnational surveys which were conducted inselected suburban areas and may have overestimated thecapacity of PC facilities in rural areas. Further, to assessavailability of services we relied on interview responses ofmanagers. The validity, reliability, and comparability of theseresponses are unknown. It was not possible to rectify theselimitations due to lack of resources and logistic difficulties.

These preliminary results help to flag the critical gaps andhighlight the need for including indicators for monitoringhealth system capacity in the global monitoring of pre-vention and control of NCDs and collating data throughnationally representative standardized surveys.

6. Conclusions

Prevention, early detection, diagnosis, and management ofNCDs are compromised due to critical health system gapsat PC level. They include deficiencies in equitable healthfinancing, access to medicines and technologies, reliablehealth information and referral systems, and the healthworkforce. These findings support the growing consensusthat health system strengthening, particularly at PC level isa prerequisite for scaling up prevention and control of NCDsin resource-constrained settings.

Disclaimer

The views expressed in this paper are those of the authorsand not of WHO.

Acknowledgments

The staffs of Ministries of Health, WHO Country Offices andPHC facilities are thanked for their support in organizing thesurveys. In addition, the following individuals are acknowl-edged for their contribution to this project: WHO, HQ: J.Dangou, J. Hospedales, J. Leowski (Late), R. Martinez, G.Roglic, R. Garg, and N. Nair; Benin: Country Representative,World Health Organization, Bhutan: Hon. Ministers ofHealth Zangley Dupka, T. Waangdi, and G. Dorji; Eritrea:Hon. A. Nurhussien, Hon. (Late) S. Meky, B. Ghebretinsae,A. Kosia, Y. Ghebrat, A. T. Fessehaye, and W. Mesfin; SriLanka: Hon. N. S. De Silva, A. Kahandaliyanage, and P. D.K. Adhikari; Sudan: Z. Ibrahim Swar, S. Mohamed Alfadil,and A. Altahir Ahmed; Suriname: A. Somai, G. Eijkemans(Country Representative PAHO/WHO), E. van Eer, M.Sardjoe, E. Berggraaf, and J. Goedschalk; Syria: I. Betelmal,A. Jaber, M. Khadra, Y. Mohammed, A. Al-Dahwi, and M.Albittar; Vietnam: L. thi Thanh, N. thi Le Thuy, T. thi K.Thu,and N. N. Vinh I.


References

[1] World Health Organization, “Global status report on non-communicable diseases,” Tech. Rep., World Health Organiza-tion, Geneva, Switzerland, 2010.

[2] World Health Organization, “The global strategy for preven-tion and control of noncommunicable diseases,” Tech. Rep.Resolution WHA 53. 14, World Health Organization, Geneva,Switzerland, 2000.

[3] World Health Organization, “2008—2013 action plan for theglobal strategy for prevention and control of noncommunica-ble diseases,” Tech. Rep. Resolution WHA61.14., World HealthOrganization, Geneva, Switzerland.

[4] “Political declaration of the High-level Meeting of the GeneralAssembly on the Prevention and Control of Noncommunica-ble Diseases,” 66th Session of the General Assembly, agendaitem 117. A/66/L. 1, 2011.

[5] World Health Organization, Declaration of Alma-Ata, WHO,1978, http://www.who.int/publications/almaata declarationen.pdf.

[6] World Health Organization, “Primary health care—now morethan ever,” World Health Report, World Health Organization,Geneva, Switzerland, 2008.

[7] World Health Organization, Package of Essential Noncom-municable Disease Interventions for Primary Health Care inLow-Resource Settings, World Health Organization, Geneva,Switzerland, 2010.

[8] D. O. Abegunde, B. Shengelia, A. Luyten et al., “Can non-physician health-care workers assess and manage cardiovascu-lar risk in primary care?” Bulletin of the World Health Organi-zation, vol. 85, no. 6, pp. 432–440, 2007.

[9] World Health Organization, Prevention of Cardiovascular Dis-ease: Guidelines for Assessment and Management of Cardiovas-cular Risk, World Health Organization, Geneva, Switzerland,2007.

[10] World Health Organization, Scaling Up Action against Non-communicable Diseases, World Health Organization, Geneva,Switzerland, 2011.

[11] World Health Organization, The World Health Report, HealthSystems Financing: The Path To Universal Coverage, WorldHealth Organization, Geneva, Switzerland, 2010.

[12] WHO Model formulary, 2008, http://www.who.int/selectionmedicines/list/WMF2008.pdf.

[13] World Health Organization, “Report of the Commissionon Macroeconomics and Health: investing in Health forEconomic Development (WHO-CMH),” Tech. Rep., WorldHealth Organization, Geneva, Switzerland, 2001.

[14] “Public spending on health care and the poor,” InternationalMonetary Fund study, 2001.

[15] World Health Organization, “Prevention of cardiovasculardisease: pocket guidelines for assessment and managementof cardiovascular risk,” Geneva, World Health Organization,Geneva, Switzerland, 2008.

[16] “World Health Organization Guidelines for Primary HealthCare in Resource Constrained Settings,” World Health Orga-nization, 2012.

[17] S. Mendis, S. C. Johnston, W. Fan, O. Oladapo, A. Cameron,and M. F. Faramawi, “Cardiovascular risk management andits impact on hypertension control in primary care in low-resource settings: a cluster-randomized trial,” Bulletin of theWorld Health Organization, vol. 88, no. 6, pp. 412–419, 2010.

[18] S. Lewin, J. N. Lavis, A. D. Oxman et al., “Supporting thedelivery of cost-effective interventions in primary health-care systems in low-income and middle-income countries: an

overview of systematic reviews,” The Lancet, vol. 372, no. 9642,pp. 928–939, 2008.

[19] S. Mendis, D. Abegunde, S. Yusuf et al., “WHO study onprevention of recurrences of myocardial infarction and strokE(WHO-PREMISE),” Bulletin of the World Health Organization,vol. 83, no. 11, pp. 820–828, 2005.

[20] World Health Organization, “Prevention of recurrent heartattacks and strokes in low and middle income populations:evidence based recommendations for policy-makers andhealth professionals,” World Health Organization, Geneva,Switzerland, 2003.


Clinical Study

Prevalence of Hypertension and Diabetes andCoexistence of Chronic Kidney Disease and Cardiovascular Riskin the Population of the Republic of Moldova

Igor Codreanu,1 Vera Sali,1 Sergiu Gaibu,1 Luminita Suveica,2 Sergiu Popa,1

Norberto Perico,3 Bogdan Ene-Iordache,3 Sergio Carminati,3

John Feehally,4 and Giuseppe Remuzzi3

1 Republican Clinic Hospital, Chisinau, Moldova2 Municipal Council Health Department, Chisinau, Moldova3 Clinical Research Center for Rare Diseases “Aldo e Cele Dacco” and Centro Anna Maria Astori,Science and Technology Park Kilometro Rosso, Mario Negri Institute for Pharmacological Research, 24126 Bergamo, Italy

4 The John Walls Renal Unit, Leicester General Hospital, Leicester LE5 4PW, UK

Correspondence should be addressed to Giuseppe Remuzzi, [email protected]

Received 17 September 2012; Accepted 24 October 2012

Academic Editor: Yackoob Kassim Seedat

Copyright © 2012 Igor Codreanu et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In 2005, the International Society of Nephrology (ISN) established the Global Outreach Program (GO) aimed at building acapacity for detecting and managing chronic kidney disease and its complications in low- and middle-income countries. Herewe report data from the 2006-2007 screening program (1025 subjects from the general population) in the Republic of Moldovaaimed to determine the prevalence of hypertension, diabetes, and their coexistence with microalbuminuria. The likelihood of aserious cardiovascular (CV) event was also estimated. Hypertension and diabetes were very common among screened subjects.The prevalence of microalbuminuria was 16.9% and that of estimated GFR <60 ml/min/1.73 m2 (decreased renal function) was9.4%. Male gender was associated with an increased prevalence of hypertension and microalbuminuria. Hypertension and diabetesclustered in subjects with microalbuminuria and renal dysfunction. Risk factors such as preobesity/obesity, physical inactivityand smoking were relatively common, even in younger participants. The prevalence of subjects with predicted 10-year CV risk≥10% was 10.0%. In conclusion, in the Republic of Moldova patients with hypertension and diabetes should be screened for thecoexistence of renal abnormalities, with the intention of developing disease-specific health-care interventions with the primarygoal to reduce CV morbidity and mortality and prevent renal disease progression to end stage renal disease.

1. Introduction

The growing global burden of noncommunicable chronicdiseases (NCDs) worldwide has been disregarded untilrecently by policy makers, major aid donors, and academics.However, NCDs are the leading cause of death in the world[1–3]. In 2008, there were 57 million deaths globally of which63% were due to NCDs. Cardiovascular disease (includinghypertension), diabetes, cancer, and chronic respiratorydisease are the four NCDs prioritized in the Global NCDAction Plan endorsed by the World Health Assembly in 2012because they share major behavioral risk factors amenable

to public-health action and are the major contributors tothe global NCD burden. There is also evidence that chronickidney disease (CKD) is a key determinant of the poorhealth outcomes of hypertension and diabetes and oneof the strongest cardiovascular (CV) risk factors [4]. Inthe general population, glomerular filtration rate (GFR)lower than 60 mL/min/1.73 m2 and albuminuria—one ofthe earliest manifestation of CKD—are associated with anindependent risk of CV morbidity and mortality [5–7].Nevertheless, data on the prevalence of renal dysfunction andmicroalbuminuria from population screening programs arescarce, especially in low-income countries, where renal and


CV risk factors, such as hypertension, diabetes, and obesity,are increasing at an even higher rate than in industrializednations [8].

The Republic of Moldova remains the poorest countryin Europe, ranking 111 according to the Global HumanDevelopment Index [9], with CV disease as the main cause ofdeath [10, 11] and treatment options for patients with NCDare very limited, especially in rural areas. Renal replacementtherapy (RRT) for end stage renal disease (ESRD) cannotbe offered to all patients due to the shortage of resources.Since measurements of renal function and albuminuriaare easy and relatively inexpensive, detection programs forkidney disease and its associated risk factors seem to offer avaluable opportunity to establish early prevention strategies,particularly at the primary-care level.

In 2005, the International Society of Nephrology (ISN)established the Global Outreach Program (GO) (formerlycalled the Commission on Global Advancement of Nephrol-ogy (COMGAN)) aimed at building global capacity fordetecting and managing CKD in low- and middle-incomenations (http://www.theisn.org/). In 2007, the ISN fundedthe establishment of an electronic database (Kidney DiseaseData Center (KDDC)) to support the collection and analysisof data obtained through ISN-sponsored prevention pro-grams. This program has been developed in the Republicof Moldova for general population screening, providinga unique opportunity to assess the prevalence of renaldysfunction and microalbuminuria in two representativeurban areas of the country.

In the present study we analyzed data from the 2006-2007 screening program in Moldova with the aim of deter-mining the prevalence of hypertension, diabetes, and theircoexistence with renal dysfunction and microalbuminuria byusing data from the ISN KDDC. Moreover, we estimated thelikelihood of a serious CV event in the same population.

2. Methods

2.1. Study Population. This study is part of the screeningand intervention program Early Detection and InterventionProgram for Chronic Renal and Cardiovascular Disease inthe Republic of Moldova on the behalf of ISN GO intwo representative cities of the country. The screening wasconducted in the general population invited to attend totwo primary health care units in the capital Chisinau and inIaloveni. During the period from September 2006 to January2007, 1025 individuals aged 18 or more participated to thestudy (Chisinau: 553, Ialoveni: 472).

2.2. Data Collection. Data were collected prospectively usingan electronic database provided to the Moldova Coordinat-ing Center in Chisinau by the ISN KDDC based in Bergamo,Italy. Data quality was monitored by the bioinformatics teamof the Clinical Research Center for Rare Diseases “Aldoe Cele Dacco,” Bergamo, Italy. In the day of screening,the participants were enrolled after being informed aboutthe objectives of the survey and the screening procedure,as well as potential benefits of the study. Baseline data

obtained from each participant included age, sex, maritaland employment status, education level, smoking status,alcohol use, physical activity, diabetes mellitus status, andpersonal history of hypertension and kidney disease. Familyhistory of diabetes, hypertension, cardiovascular diseases,and kidney disease was also collected. Height and weightwere measured and used to calculate body mass index.Systolic and diastolic blood pressures were measured bytrained personnel using manual sphygmomanometers afterparticipants rested quietly for five minutes.

Fasting venous blood (creatinine, glucose, cholesterol,and hemoglobin) and spot urine (albumin, creatinine)specimens were provided by the participants accordingto local protocol. Individuals with microalbuminuria wereasked to proceed with a second confirmatory test a weekapart. Screening was carried out under research protocolapproved in advance by the relevant institutional reviewboard. All participants gave a written informed consent.

2.3. Definitions. Hypertension was classified according to theSeventh Report of the Joint National Committee on Prevention,Detection, Evaluation, and Treatment of High Blood Pressurescheme [12]. Participants were classified as having diabetesmellitus (DM) if they reported a history of or were currentlytreated for DM, or had a fasting blood glucose level≥126 mg/dL. Participants’ body mass index was classifiedaccording to the current World Health Organization (WHO)[13] scheme as follows: <18.49 kg/m2 (underweight), 18.5–24.9 kg/m2 (reference range), 25–29.9 kg/m2 (preobese),and ≥30 kg/m2 (obese). Microalbuminuria was defined asurinary albumin/creatinine (ACR) values of 30–300 mg/g.Subjects with ACR lower than 30 mg/g were defined asnormoalbuminuric, and those with more than 300 mg/gas macroalbuminuric. Urine albumin concentration wasdetermined by an ELISA method (UBI-MAGIWEL EnzymeImmunoassay) [14]. Serum creatinine was used to estimateglomerular filtration rate (GFR) using the 4-variable Mod-ification of Diet in Renal Disease (MDRD) Study equationin all participants [15]. Because the MDRD Study equationis less accurate at higher levels of true GFR, participants wereclassified regarding the presence or absence of estimated GFR(eGFR) <60 mL/min/1.73 m2 (termed “decreased eGFR”).

The likelihood of a serious CV adverse outcome (death,myocardial infarction, stroke, heart failure, or coronaryrevascularization) during the next 10 years was estimated byusing World Health Organization (WHO) charts.

2.4. Analytical Methods. Descriptive statistics were tabulatedusing count and percentage or mean, as appropriate. Missingvalues were not imputed and casewise deletion did not occur;therefore the total number of participants varied by variable.Outcome of interest included hypertension, diabetes, bodymass index, microalbuminuria, eGFR <60 mL/min/1.73 m2),and CV risk, as defined. According to the WHO charts, the10-year risk of fatal or nonfatal CV event considered thefollowing parameters: age (years), gender, smoking habit,SBP (mmHg), cholesterol (mg/dL), and presence/absence ofDM. An SAS version 9.1 code was constructed to generate


the 10-year CV risk class for each participant. Resultswere stratified by age, sex, and microalbuminuria. Statisticalanalyses were performed using Stata software, version 12.1(StataCorp, http://www.stata.com/).

3. Results

3.1. Participant Characteristics. Demographic and clinicalcharacteristics of the 1025 participants are listed in Table 1.

Mean age of participants was 48 years ranging from18 to 77 years, and most of them were women (73.3%).Levels of education were variable, with the highest fractionof subjects with >10 years of education. Participants reportedmainly working outside the home, but also a large rate ofunemployment. Prevalence of current smoking habit washigher than 13%, with 35% of men and 5% of womenbeing current smokers. Among current male smokers,microalbuminuria was detected in 17.6% of subjects andGFR <60 mL/min/1.73 m2 in 4.9%. Alcohol consumptionwas variable, but always higher in men than in women. Dailyconsumption of fruit and vegetables was common, whileno more than 35% of participants reported daily inactivitywith slight prevalence in women. Positive familiar history forhypertension and CV disease was relatively high. At physicalexamination mean BMI was in the preobese stage both inmen and women, whereas mean blood pressure levels werewithin the normal range for both genders.

3.2. Prevalence of Hypertension, Diabetes and Preobesity. Theprevalence of hypertension (assessed at the clinic visit) washigh with more than 50% of participants having elevated SBPor DPB or were receiving treatment for previously diagnosedhypertension. As expected, the prevalence of hypertensionwas the highest in participants who were male, and olderthan 40 years (Table 2). Overall 62.7% of hypertensive sub-jects were taking antihypertensive medication. Hypertensionwas in general well controlled. 16.1% of participants hadDM. No significant difference was found in the prevalenceof DM between female and male subjects (Table 2). Seventy-eight percent of diabetic subjects had hypertension. Theprevalence of DM progressively increased with BMI, and5.6% of the preobese and 7.8% of the obese were diabetic.Thirty-seven percent of participants were preobese (assessedby BMI), with a prevalence lower in female than male.

3.3. Prevalence of Microalbuminuria and eGFR<60 mL/min/1.73 m2. The prevalence of microalbuminuria(assessed at the clinic visit) was 16.9%, higher in participantsolder than 40 years (Table 3). Microalbuminuria wasmore common in male than female. The prevalence ofeGFR <60 mL/min/1.73 m2 was 8.2% (Table 3). Higherprevalence was found in participants who were male andolder than 40 years. The proportion of patients who hadboth microalbuminuria or macroalbuminuria and eGFR<60 mL/min/1.73 m2 was 2.2%.

3.4. Microalbuminuria in Hypertension and Diabetes. Weanalyzed the relationship between microalbuminuria and

hypertension or diabetes according to age groups andwhether eGFR was lower than 60 mL/min/1.73 m2 (Table 4).In nondiabetic hypertensive subjects the prevalence ofmicroalbuminuria was 19.0%. It was higher in participantswith hypertension older than 60 years who had decreasedeGFR (ACR 30–300 mg/g: 7.4%). Similarly, in diabetics theproportion of patients with microalbuminuria was 12.0%.In this cohort, the prevalence of microalbuminuria progres-sively increased with age independently of eGFR. Neverthe-less, microalbuminuria was more frequent in patients witheGFR <60 mL/min/1.73 m2 (7.4%) than in those with highereGFR (4.6%). Microalbuminuria was detected in 10.9%of subjects with coexistence of diabetes and hypertension(Table 4).

3.5. Distribution of Cardiovascular Risk. The prevalence ofparticipants with predicted 10-year cardiovascular (CV) risk≥10% was 10.0%. For predicted CV risk 10.1–20%, 20.1–30%, 30.1–40%, and >40.1%, the proportion of subjects was5.35%, 3.33%, 0.81%, and 0.81%, respectively.

4. Discussion

The present screening program of a representative cohort ofgeneral population in Moldova showed a very high preva-lence of hypertension. DM was also common among thescreened participants, together with hypertension clusteredin subjects with microalbuminuria, and renal dysfunction. Inaccordance with previously published studies, male genderwas associated with an increased prevalence of hypertension,microalbuminuria and reduced renal function [16–18]. Inaddition to disease requiring medical treatment, risk factorssuch a pre-obesity/obesity, inactivity, and smoking wererelatively prevalent in the population screened, even inyounger participants. A large proportion of the participantswere unemployed which would favor a sedentary lifestyleeventually contributing to the high prevalence of pre-obesityand ultimately of hypertension and DM.

Despite the prevalence of these medical and nonmedicalrisk factors, microalbuminuria was present in 10.9% ofsubjects with coexistent DM and hypertension. Raised bloodpressure is a key NCD risk factor, and its prevalence, likethat of diabetes, is projected to increase sharply over thenext few decades, especially in low-income countries [19].Therefore we speculate that—because the epidemic of NCDis still becoming established in the Republic of Moldova—thefull impact of these risk factors has not yet been fully realized,and the prevalence of microalbuminuria and possibly CKD(defined as eGFR <60 mL/min/1.73 m2) are likely to increasesubstantially during the coming decades, in parallel withCV disease. This highlights the importance of preventionbecause most residents in this country cannot afford renalreplacement therapies and coronary revascularization proce-dures.

The prevalence of microalbuminuria found in thepresent study is higher than that reported by other ISN-sponsored screening programs in indigent residents ofGuadalajara, Mexico [20], in Nepal [21], and Kinshasa,


Table 1: Demographics and clinical characteristics of participants in the screening program.

Overall (n = 1025) Women (n = 737) Men (n = 288)

Age (years) 48.8± 14.6 48.7± 14.5 50.0± 14.8

Education (years) 944 673 271

>10 343 (36.3) 231 (34.3) 112 (41.3)

6–10 234 (24.7) 166 (24.7) 68 (25.1)

1–5 312 (33.0) 232 (34.5) 80 (29.5)

None 55 (5.8) 44 (6.5) 11 (4.1)

Work 927 657 270

Physical labor 283 (30.5) 172 (26.2) 111 (41.1)

Office work 210 (22.6) 157 (23.9) 53 (19.6)

House work 83 (22.6) 72 (11.0) 11 (4.1)

Unemployed 351 (37.8) 256 (39.0) 95 (35.2)

Fruit/Vegetable intake 1018 732 286

1 x/day 545 (53.5) 420 (57.4) 125 (43.7)

3–5 x/day 355 (34.8) 227 (31.0) 128 (44.8)

1 x/week 101 (9.9) 73 (10.0) 28 (9.8)

None 17 (1.6) 12 (1.6) 5 (1.7)

Smoking 1021 734 287

Current 139 (13.6) 37 (5.0) 102 (35.5)

Former 33 (3.2) 5 (0.7) 28 (9.8)

None 849 (83.2) 692 (94.3) 157 (54.7)

Alcohol 1021 735 286

1 x/day 21 (2.1) 7 (1.0) 14 (4.9)

1 x/week 148 (14.5) 61 (8.3) 87 (30.4)

1 x/month 292 (28.6) 208 (28.3) 84 (29.4)

None 560 (54.8) 459 (62.4) 101 (35.3)

Physical activity (min/d) 1007 727 280

>60 372 (36.9) 269 (37.0) 103 (36.8)

30–60 134 (13.3) 82 (11.3) 52 (18.6)

<30 120 (11.9) 88 (12.1) 32 (11.4)

None 381 (37.8) 288 (39.6) 93 (33.2)

Family history

CKD 209 (21.3) 171 (24.2) 38 (13.9)

HTN 498 (50.2) 373 (52.1) 125 (45.3)

DM 157 (16.1) 121 (17.2) 36 (13.1)

Patient’s history

CKD 384 (38.1) 313 (43.2) 71 (25.2)

HTN 480 (47.5) 341 (46.8) 139 (49.5)

DM 125 (12.5) 86 (12.0) 39 (13.9)

MI/CVD 253 (25.2) 186 (25.8) 67 (23.8)

Physical examination

BMI (kg/m2)1005 724 281

27.72± 5.35 27.9± 6.0 27.4± 4.7

<18.5 61 (6.07%) 49 (6.8) 12 (4.3)

18.5–24.9 254 (25.27%) 177 (24.4) 78 (27.8)

25–29.9 369 (36.72%) 257 (35.5) 111 (39.5)

>30 321 (31.94%) 242 (33.4) 79 (28.1)

Blood pressure (mm Hg)

SBP 130.2± 21.3 129.1± 22.2 133.1± 19.3

DBP 83.1± 11.3 82.5± 12.2 85.0± 10.3


Table 1: Continued.

Overall (n = 1025) Women (n = 737) Men (n = 288)

Laboratory parameters

A/C ratio (mg/g) 20.8± 22.1 20.3± 19.8 22.1± 26.9

eGFR (mL/min/1.73 m2) 84.2± 21.3 79.1± 16.8 97.9± 25.6

Data are a number of screened subjects and percent (%) if not otherwise specified. Values for Age, BMI, SBP, DBP, A/C ratio, and eGFR are mean ± SD.CKD: chronic kidney disease; HTN: hypertension; DM: diabetes mellitus; MI/CVD: myocardial infarction/cardiovascular disease; BMI: body mass index;SBP: systolic blood pressure; DBP: diastolic blood pressure; A/C: urinary albumin/creatinine ratio; eGFR: estimated glomerular filtration rate.

Table 2: Prevalence of hypertension and diabetes in the Moldova population aged ≥18 years.

Subjects (n) Hypertension∗ Subjects (n) Diabetes◦

All 991 520 (52.4) 959 155 (16.1)

Age (years)

18–39 41 (7.9) 14 (9.0)

40–59 253 (48.8) 69 (44.5)

≥60 224 (43.2) 72 (45.4)

Women 716 369 (51.5) 695 105 (15.1)

Age (years)

18–39 28 (7.6) 8 (7.6)

40–59 182 (49.4) 45 (42.8)

≥60 158 (42.9) 52 (49.5)

Men 275 151 (54.9) 264 50 (18.9)

Age (years)

18–39 13 (8.6) 6 (12.0)

40–59 71 (47.3) 24 (48.0)

≥60 66 (44.0) 20 (40.0)

Data are a number of screened subjects and percent (%) if not otherwise specified. ∗Hypertension is defined as participants with SBP >140 mm Hg or DBP>90 mm Hg, or receiving treatment for previously diagnosed hypertension. ◦Diabetes is defined as participants reporting a history of, or currently treated fordiabetes mellitus, or with fasting blood glucose level ≥126 mg/dL.

Table 3: Prevalence of microalbuminuria and decreased GFR.

Subjects ACR∗ Subjects eGFR◦

(n) 30–300 mg/g (n) <60 mL/min/1.73 m2

All 978 166 (16.9) 973 92 (9.4)

Age (years)

18–39 43 (25.9) 5 (2.0)

40–59 68 (40.9) 28 (6.1)

≥60 54 (32.5) 58 (21.9)

Women 702 108 (15.3) 708 78 (11.0)

Age (years)

18–39 31 (28.7) 4 (5.1)

40–59 41 (37.9) 24 (30.7)

≥60 36 (33.3) 50 (64.1)

Men 276 59 (21.3) 265 14 (5.2)

Age (years)

18–39 12 (20.3) 1 (7.1)

40–59 27 (45.7) 4 (28.5)

≥60 18 (30.5) 9 (64.2)

Data are a number of screened subjects and percent (%) if not otherwise specified. ACR: urinary albumin/creatinine ratio. eGFR: estimated glomerularfiltration rate. Microalbuminuria: ACR 30–300 mg/g; decreased GFR: eGFR <60 mL/min/1.73 m2.


Table 4: Prevalence of microalbuminuria in participants withhypertension or DM according to age groups and level of renalfunction.

ACR (30–300 mg/g)∗

Age (years) 18–39 40–59 ≥60 All ages

Hypertension

eGFR (mL/min/1.73 m2)

<60 1 (1.1) 4 (4.3) 7 (7.4) 12 (12.8)

≥60 8 (0.9) 25 (2.9) 20 (2.3) 53 (6.2)

Diabetes


<60 0 (0.0) 3 (3.2) 4 (4.3) 7 (7.4)

≥60 8 (0.9) 14 (1.6) 17 (2.0) 39 (4.6)

Diabetes + hypertension


<60 0 (0.0) 3 (3.3) 4 (4.3) 7 (7.6)

≥60 2 (0.2) 12 (1.4) 15 (1.7) 29 (3.3)

Data are a number of screened subjects and percent (%) if not otherwisespecified. ACR: urinary albumin/creatinine ratio. eGFR: estimated glomeru-lar filtration rate. Microalbuminuria: ACR 30–300 mg/dL. ∗Hypertensionis defined as participants with SBP >140 mm Hg or DBP >90 mm Hg,or receiving treatment for previously diagnosed hypertension. ◦Diabetesis defined as participants reporting a history of, or currently treated fordiabetes mellitus, or with fasting blood glucose level ≥126 mg/dL.

Democratic Republic of Congo [22]. However this highlightsthe generalizability of this approach for case detection indiverse settings around the world. For example, the sameapproach has been adopted by the Prevention of Renaland Vascular ENd-stage Disease (PREVEND) study, a largeEuropean screening program [23].

About 10% of the subjects in the screened populationhad an estimated 10% or higher risk of developing a fatalor nonfatal CV event in the following 10 years. Thereis evidence that the increased cardiovascular risk in CKDpatients does not just coexist with hypertension or DM.Indeed, an independent and progressive association betweenGFR and the risk of CV events and deaths has been foundin a community-based study in more than 1 million adultsubjects in the USA [24]. Similarly, a recent study in morethan 6000 people followed on average 7 years has shownthat the risk of cardiovascular death was increased 46% insubjects with a mild-to-moderate reduction in GFR, inde-pendent of conventional risk factors such as hypertensionand diabetes [25]. Evidence is also available that the risk ofmortality is better correlated with proteinuria/albuminuriathan with GFR alone [6, 26–28]. A large population-basedstudy of more than 1 million people from Alberta, Canada,demonstrated that the presence of proteinuria was associatedwith marked increase in the risk of all-cause mortality andthe risk of kidney failure, independent of GFR and at all levelsof baseline kidney function [29]. The association betweenproteinuria and CV mortality independent of hypertension,DM, and GFR has recently been demonstrated in a meta-analysis of 22 studies [7] including participants with awide age range from around the world. The independentrisk associated with albuminuria for all-cause mortality,

CV mortality, and progression to ESRD was confirmed inover 1.1 million people with proteinuria identified only bydetection of “trace” or greater on dipstick urinalysis, aswell as in over 100,000 who had an albumin creatinineratio (ACR) of 10 mg/g or more [7]. Thus, considering thehigh prevalence of microalbuminuria and renal dysfunctionin the present screening in the Republic of Moldova, thepredicted CV risk at 10 years was probably underestimated.Long term outcome analysis of the present screened cohortwill clarify whether the inclusion of albuminuria and/orreduced GFR among the variables considered in algorithmsfor the prediction of individual CV risk will improve theperformance of current WHO prediction charts.

Evidence is also emerging that CKD and CV diseaseshave a major impact on macroeconomic development dueto diminished labor supply related to premature death anddisability in people of working age. According to WHO,these conditions decrease the potential annual growth ratein gross domestic product by 1–5% in low-income countriesexperiencing a rapid economic growth [30]. Importantly,data from large trials have consistently shown that offpatentdrugs such ACE inhibitors can reduce albuminuria andprevent GFR decline and CV events [31]. Thus, preventionprogram should identify subjects whose renal abnormalitiescan be treated early at low cost, with the primary goal toreduce CV mortality and morbidity, which, in turn, maytranslate into an economical benefit.

Screening the general population for CKD by measuringalbuminuria and/or serum creatinine has been advocated toidentify and treat those at risk for progressive renal disease,arguing that most persons with albuminuria and/or reducedGFR are asymptomatic; however, it is so far consideredpremature to recommend in both industrialized and low-and middle-income countries. On the other hand, screeningin people at increased risk of CKD (so called “selectivescreening”) such as those with hypertension and/or DM, inwhom early intervention can slow down the deterioration ofrenal function, has received more support [32]. Further stud-ies, however, are warranted before definite recommendationsfor general population or selective screening for CKD canbe provided. Difficulties in identifying subjects at increasedrisk of CKD in low-income countries should be considered.Therefore, in this setting, a prescreening phase includinghistory, blood pressure, and anthropometric values mightallow the identification of patients in whom screening withblood and urine testing could be most cost effective. Thereare also data from low-income countries that a significantpercentage of people younger than 60 years without previoushistory of hypertension and diabetes has microalbumin-uria/proteinuria [21]. Concerns about general populationscreenings include not only the cost of the screening itselfbut, more importantly, the risk and the cost of treating falsepositive subjects with no other modifiable risk factors. Thus,the first positive test should be always repeated and onlythose with confirmed positivity should be treated [33] as wasdone with the screening in the Republic of Moldova. Whendebating the issue of screening for NCDs, the perspective ofthe low- and middle-income countries should be consideredas well as that of the industrialized nations. And, there is not


a unique blueprint of screening strategy even among low-income countries, so that the approaches should be adaptedto the conditions and socioeconomic status of each nation[34].

Our study has some limitations: the study cohortincludes more than double women than men; results fromthis screening cannot be taken to infer the absolute or relativeprevalence of hypertension, DM, and renal abnormalitiesin the Republic of Moldova, since all subjects were referredto two centers of the country. However, in considerationof the limited availability of local resources and relativelylow population of the country, current data seem reasonablyreliable which is supported by the fact that, inline with theavailable evidence, the prevalence of microalbuminuria washigher in subjects with hypertension or DM.

5. Conclusion

We found that hypertension, DM, microalbuminuria, andimpaired kidney function are common within the generalpopulation of the Republic of Moldova. Thus patients withhypertension or DM should be screened for coexistence ofrenal abnormalities. Overall the present data demonstratethe feasibility of early detection of CKD and associated riskfactors in low-income countries like Moldova. Top priorityfor the prevention of NCD including CKD must focuson effective methods to facilitate physical activity, controltobacco use, reduce harmful use of alcohol, and promote ahealthy diet. In addition, individual disease-specific health-care interventions are also required to address those withhypertension, DM, CKD, or CV disease or at a high risk ofdeveloping these noncommunicable diseases.

Acknowledgments

This study was funded by a Grant from the InternationalSociety of Nephrology (ISN), through the Call for PreventionPrograms on NCDs in low- and middle-income countries ofthe ISN GO Research and Prevention Committee.

References

[1] World Health Organization, Preventing Chronic Diseases:A Vital Investment, World Health Organization, Geneva,Switzerland, 2005.

[2] Q. L. Zhang and D. Rothenbacher, “Prevalence of chronic kid-ney disease in population-based studies: systematic review,”BMC Public Health, vol. 8, article 117, 2008.

[3] M. El Nahas, R. Barsoum, G. Eknoyan et al., “The globalchallenge of chronic kidney disease,” Kidney International, vol.68, no. 6, pp. 2918–2929, 2005.

[4] W. G. Couser, G. Remuzzi, S. Mendis, and M. Tonelli, “Thecontribution of chronic kidney disease to the global burden ofmajor noncommunicable diseases,” Kidney International, vol.80, no. 12, pp. 1258–1270, 2011.

[5] C. Meisinger, A. Doring, and H. Lowel, “Chronic kidneydisease and risk of incident myocardial infarction and all-cause and cardiovascular disease mortality in middle-agedmen and women from the general population,” EuropeanHeart Journal, vol. 27, no. 10, pp. 1245–1250, 2006.

[6] H. L. Hillege, V. Fidler, G. F. H. Diercks et al., “Urinary albu-min excretion predicts cardiovascular and noncardiovascularmortality in general population,” Circulation, vol. 106, no. 14,pp. 1777–1782, 2002.

[7] K. Matsushita, M. van der Velde, B. C. Astor et al., “Associationof estimated glomerular filtration rate and albuminuria withall-cause and cardiovascular mortality in general populationcohorts: a collaborative meta-analysis,” The Lancet, vol. 375,no. 9731, pp. 2073–2081, 2010.

[8] S. Wild, G. Roglic, A. Green, R. Sicree, and H. King, “Globalprevalence of diabetes: estimates for the year 2000 andprojections for 2030,” Diabetes Care, vol. 27, no. 5, pp. 1047–1053, 2004.

[9] United Nations Development Programme, National HumanDevelopment Report, Chisinau, 2011.

[10] Highlights on health in the Republic of Moldova 2005, WhoRegional Office for Europe, http://www.EURO.WHO.INT/DATA/ASSETS/PDF FILE/0003/103566/E88552.pdf.

[11] L. MacLehose, “Health care systems in transition: Republic ofMoldova,” in European Observatory on Health Care Systems,M. McKee, Ed., vol. 4, Copenhagen, Denmark, 2002.

[12] A. V. Chobanian, G. L. Bakris, H. R. Black et al., “Theseventh report of the joint national committee on prevention,detection, evaluation, and treatment of high blood pressure:the JNC 7 Report,” Journal of the American Medical Association,vol. 289, no. 19, pp. 2560–2572, 2003.

[13] World Health Organization, “Obesity: preventing and manag-ing the global epidemic,” Technical Report 894, World HealthOrganization, Geneva, Switzerland, 2000.

[14] B. A. Fielding, D. A. Price, and C. A. Houlton, “Enzyme im-munoassay for urinary albumin,” Clinical Chemistry, vol. 29,no. 2, pp. 355–357, 1983.

[15] A. S. Levey, J. P. Bosch, J. B. Lewis, T. Greene, N. Rogers, andD. Roth, “A more accurate method to estimate glomerularfiltration rate from serum creatinine: a new predictionequation,” Annals of Internal Medicine, vol. 130, no. 6, pp. 461–470, 1999.

[16] I. Guessous, W. McClellan, S. Vupputuri, and H. Wasse, “Lowdocumentation of chronic kidney disease among high-riskpatients in a managed care population: a retrospective cohortstudy,” BMC Nephrology, vol. 10, no. 1, article 25, 2009.

[17] B. O. Eriksen and O. C. Ingebretsen, “The progression of chro-nic kidney disease: a 10-year population-based study of theeffects of gender and age,” Kidney International, vol. 69, no.2, pp. 375–382, 2006.

[18] C. Y. Hsu, C. Iribarren, C. E. McCulloch, J. Darbinian, and A.S. Go, “Risk factors for end-stage renal disease: 25-year follow-up,” Archives of Internal Medicine, vol. 169, no. 4, pp. 342–350,2009.

[19] P. M. Kearney, M. Whelton, K. Reynolds, P. Muntner, P. K.Whelton, and J. He, “Global burden of hypertension: analysisof worldwide data,” The Lancet, vol. 365, no. 9455, pp. 217–223, 2005.

[20] J. A. Gutierrez-Padilla, M. Mendoza-Garcia, S. Plascencia-Perez et al., “Screening for CKD and cardiovascular diseaserisk factors using mobile clinics in Jalisco, Mexico,” AmericanJournal of Kidney Diseases, vol. 55, no. 3, pp. 474–484, 2010.

[21] P. Cravedi, S. Sharma, R. Flores Bravo et al., “Preventing renaland cardiovascular risk by renal function assessment: insightsfrom a cross-sectional study in low-income countries and theUS,” BMJ Open, vol. 2, no. 5, Article ID e001357, 2012.


[22] E. K. Sumaili, J. M. Krzesinski, C. V. Zinga et al., “Prevalenceof chronic kidney disease in Kinshasa: results of a pilot studyfrom the Democratic Republic of Congo,” Nephrology DialysisTransplantation, vol. 24, no. 1, pp. 117–122, 2009.

[23] R. T. Gansevoort, J. C. Verhave, H. L. Hillege et al., “Thevalidity of screening based on spot morning urine samplesto detect subjects with microalbuminuria in the generalpopulation,” Kidney International, Supplement, vol. 67, no. 94,pp. S-28–S-35, 2005.

[24] A. S. Go, G. M. Chertow, D. Fan, C. E. McCulloch, and C. Y.Hsu, “Chronic kidney disease and the risks of death, cardi-ovascular events, and hospitalization,” New England Journal ofMedicine, vol. 351, no. 13, pp. 1296–1370, 2004.

[25] C. S. Fox, P. Muntner, A. Y. Chen et al., “Use of evidence-based therapies in short-term outcomes of ST-segment ele-vation myocardial infarction and non-ST-segment elevationmyocardial infarction in patients with chronic kidney disease:a report from the national cardiovascular data acute coronarytreatment and intervention outcomes network registry,” Cir-culation, vol. 121, no. 3, pp. 357–365, 2010.

[26] M. Tonelli, N. Wiebe, B. Culleton et al., “Chronic kidneydisease and mortality risk: a systematic review,” Journal of theAmerican Society of Nephrology, vol. 17, no. 7, pp. 2034–2047,2006.

[27] S. J. Barbour, L. Er, O. Djurdjev, M. Karim, and A. Levin,“Differences in progression of CKD and mortality amongstCaucasian, Oriental Asian and South Asian CKD patients,”Nephrology, Dialysis, Transplantation, vol. 25, no. 11, pp. 3663–3672, 2010.

[28] B. C. Astor, S. I. Hallan, E. R. Miller, E. Yeung, and J. Coresh,“Glomerular filtration rate, albuminuria, and risk of car-diovascular and all-cause mortality in the US population,”American Journal of Epidemiology, vol. 167, no. 10, pp. 1226–1234, 2008.

[29] B. R. Hemmelgarn, B. J. Manns, A. Lloyd et al., “Relationbetween kidney function, proteinuria, and adverse outcomes,”Journal of the American Medical Association, vol. 303, no. 5, pp.423–429, 2010.

[30] WHO, Action Plan For the Global Strategy for the Preventionand Control of Noncommunicable Diseases: Prevent and ControlCardiovascular Diseases, Cancer, Chronic Respiratory Diseasesand Diabetes, WHO, Geneva, Switzerland, 2008.

[31] P. Ruggenenti and G. Remuzzi, “Time to abandon microalbu-minuria?” Kidney International, vol. 70, no. 7, pp. 1214–1222,2006.

[32] A. E. Raffle and J. A. M. Gray, “What screening is and is not,” inScreening: Evidence and Practice, Oxford University Press, NewYork, NY, USA, 1st edition, 2007.

[33] M. J. Bottomley, A. Kalachik, C. Mevada, M. O. Brook,T. James, and P. N. Harden, “Single estimated glomerularfiltration rate and albuminuria measurement substantiallyoverestimates prevalence of chronic kidney disease,” Nephron,vol. 117, no. 4, pp. c348–c352, 2011.

[34] N. Chen, C. C. Hsu, K. Yamagata, and R. Langham, “Challeng-ing chronic kidney disease: experience from chronic kidneydisease prevention programs in Shanghai, Japan, Taiwan andAustralia,” Nephrology, vol. 15, supplement 2, pp. 31–36, 2010.


Review Article

Diabetes and Coronary Heart Disease: A Risk Factor forthe Global Epidemic

Maguy Chiha,1 Mario Njeim,2 and Edgar G. Chedrawy3

1 Division of Endocrinology, Department of Medicine, Loyola University Medical Center, 2160 South First Avenue,Fahey Bldg, Maywood, IL 60153, USA

2 Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Hospital, 2799 West Grand Boulevard,Detroit, MI 48202, USA

3 Cardiovascular and Thoracic Surgery, University of Illinois at Chicago and Vanguard Weiss Memorial Hospital,4646 North Marine Drive, Chicago, IL 60640, USA

Correspondence should be addressed to Edgar G. Chedrawy, [email protected]

Received 22 June 2012; Accepted 8 September 2012

Academic Editor: Eoin O’Brien

Copyright © 2012 Maguy Chiha et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cardiovascular disease remains a leading cause of death in the United States and the world. In this we will paper focus on type2 diabetes mellitus as a risk factor for coronary heart disease, review the mechanisms of atherogenesis in diabetics, the impactof hypertension and the treatment goals in diabetics, the guidelines for screening, and review the epidemiologic consequences ofdiabetes and heart disease on a global scale. The underlying premise to consider diabetes a cardiovascular disease equivalent willbe explored as well as the recommendations for screening and cardiac testing for asymptomatic diabetic patients.

1. Introduction

Cardiovascular disease is currently responsible for 30% of alldeaths worldwide with most of the burden now occurring indeveloping countries [1]. After a peak around 1968, deathfrom coronary heart disease (CHD) has declined signifi-cantly in the United States [2]. Based on a statistical mortalitymodel previously validated in Europe, New Zealand, andChina [3–6], Ford et al. estimated that 47% of the decreasein mortality from coronary heart disease in the United Statesbetween 1980 and 2000 was attributed to advances in medicaltherapies including treatment of acute coronary syndromesand heart failure. Approximately 44% of the reduction wassecondary to a decline in cardiovascular risk factors includinghypercholesterolemia, hypertension, smoking, and physicalinactivity. This improvement was partially counterweightedby an increase in the prevalence of diabetes and body massindex [7]. In contrast to the United States, the cardiovasculardisease epidemic continues to rapidly evolve on a globallevel and is currently responsible for twice as many deathin developing compared to developed countries [1]. In low-and middle-income countries, cardiovascular risk factors

especially smoking and obesity continue to increase inprevalence and affect a larger proportion of younger patients[8]. Cardiovascular mortality has been reported 1.5 to 2times higher among the working population in India, SouthAfrica, and Brazil compared to the United States [8].

Diabetes mellitus is associated with an increased riskof cardiovascular death and a higher incidence of cardio-vascular diseases including coronary artery diseases (CAD),congestive heart failure (CHF) [9], and atrial fibrillation[10]. The mechanisms underlying the association betweenglucose homeostasis and each of myocardial dysfunctionand atrial fibrillation remain mostly speculative. In contrastthe relationship between abnormal glucose homeostasis andcoronary artery disease has been the center of extensivebasic science, epidemiological, and therapeutic researchstudies.

In this paper we will focus on type 2 diabetes mellitus as arisk factor for CAD, review the mechanisms of atherogenesisin diabetes, the impact of hypertension on the treatmentgoals in diabetes, the guidelines for CAD screening, andreview the epidemiologic consequences of diabetes and heartdisease on a global scale.


2. Prevalence of Cardiac Diseaseamong Diabetics

Diabetes mellitus has been well described as a cardiovascularrisk factor in developed countries. In the Framingham study,the incidence of cardiovascular disease among diabetic menwas twice that among nondiabetic men, and similarly wasthree times more elevated in diabetic women compared tonondiabetic women [11]. In the Copenhagen City heartStudy, the relative risk of incident myocardial infarction was2 to 3 fold increased in diabetics compared to nondiabetics,independent of the presence of other known cardiovascularrisk factors (such as hypertension) [12]. In a recent meta-analysis by Berry et al. reviewing the lifetime risks ofcardiovascular disease, 18 studies involving 257,384 menand women were reviewed. Patients were stratified by bloodpressure, cholesterol level, smoking status, and diabetesstatus and by age group as well as gender and race. Significantdifferences were noted in the lifetime risk of cardiovasculardisease, with substantially lower risk of fatal and nonfatalcardiovascular disease among participants with no riskfactors. The trend was observed in both genders, across allage groups as well as among all races [13]. Furthermorethe differential impact of diabetes on coronary artery diseasemortality in men and women has been the subject of multiplestudies; Lee et al. reported the relative risk of coronary heartdisease mortality to be 2.5 in women, compared to 1.85 inmen [14]. Even modest elevations in blood glucose, withouta diagnosis of diabetes, have been linked to increased riskfor development of CAD independent of other recognizedrisk factors when reviewed in a population of predominantlymale, nondiabetic veterans [15].

2.1. Diabetes in the Developing Countries. Our currentknowledge about the epidemiology of diabetes mellitus andits association with cardiovascular disease is mainly derivedfrom studies done in populations of European origin. Thereis however increasing data available from other ethnic groupsand emerging countries suggesting a substantial contributionof diabetes to the worldwide epidemics of cardiovasculardisease. King et al. used a global database from the WorldHealth Organization in addition to demographic projectionsfrom the United Nations to generate numerical estimatesfor the prevalence of diabetes in all countries of the world.The authors reported that the prevalence of diabetes mellitusis lower in developing than in developed countries andestimated that it will remain so in 2025. On the other hand,62% of the diabetic patients worldwide resided in emergentnations in 1995 and this proportion is estimated to reach75% by 2025 [16]. The INTERHEART study was a case-control study including patients from 52 different countriesrepresenting all inhabited continents. It was designed toassess if the association between acute myocardial infarctionand various risk factors including diabetes mellitus varies bygeographic region, ethnic origin, sex, or age. Diabetes wasone of 9 risk factors that were significantly related to acutemyocardial infarction in all age groups, genders and regionsof the world. After adjustment for all other risk factors,the population attributable risk for diabetes alone was 9.9%

in the overall study population. Despite variations acrossdifferent subpopulations in the prevalence for diabetes, theodds ratio for this risk factor was qualitatively similar in allregions of the world and all ethnic groups [17].

3. Pathogenesis of CAD in Diabetes

There is a consensus in the literature about an increasedprevalence of coronary plaques in diabetic hearts, with suchplaques bearing a higher propensity for rupture. In a study bySilva et al., the coronary angiography and angioscopy find-ings of 55 consecutive patients admitted with unstable angina(31% of which were diabetic) were reviewed. The plaquewas ulcerated in 94% of the diabetic patients, versus in only60% of the nondiabetic patients, and thrombi were found in94% of diabetic patients versus 55% of nondiabetics [18].Similarly, in a postmortem study of coronary atherectomyspecimens from 47 diabetic and 48 non diabetic patients,Moreno et al. noted a larger lipid content and increasedmacrophage infiltration and thrombosis in the atheromasof diabetic patients [19]. Multiple mechanisms appear tobe involved, including endothelial dysfunction, hypercoag-ulability, and platelet dysfunction [20], with hyperglycemiabeing the common trigger.

Hyperglycemia results in multiple biochemical changes,a few of which we will list: an increase in the reductionof nicotinamide adenine dinucleotide (NAD+) to NADHis thought but not proven yet to be a cellular oxida-tive stressor; an increase in the production of uridinediphosphate (UDP) N-acetyl glucosamine is thought toalter cellular enzymatic function. Very importantly, theglycosylation of proteins in the arterial wall is thought tocontribute to diabetic atherosclerosis. The nonenzymaticreaction between glucose and arterial wall proteins resultsin the formation of advanced glycation end products(AGE), process that is enhanced in hyperglycemia. AGEs arethought to directly interfere with endothelial cell functionand accelerate atherosclerosis. Additionally, hyperglycemiaincreases the formation of reactive oxygen species (ROS);these ROS inhibit endothelial production of nitric oxide, apotent vasodilator and regulator of platelet activation [21].Furthermore, those ROS prevent the migration of vascularsmooth muscle cells into the intimal plaques, a step necessaryto the stabilization of coronary plaques. Such plaques thencarry an increased risk of rupture, as is known of diabeticcoronary plaques [22].

In the event of a plaque rupture, the increased thrombo-genesis and platelet dysfunction present in diabetes worsenthe clinical consequences of plaque rupture. Circulatingglucose molecules freely enter platelets, raising intracellularglucose concentration and leading to activation of proteinkinase C, decrease platelet derived NO, and increasedexpression of glycoprotein Ib (GpIb), a platelet aggregationmediator [20]. This might further explain the enhancedthrombosis in diabetics. In an elegant experimental design,Shechter et al. were able to demonstrate the role of glucose asan independent predictor of platelet dependent thrombosis[23]. Furthermore, insulin has been found to increaseserum concentrations of Plasminogen Activator Inhibitor


type I (PAI-1) [24] which has been shown to correlate withimpaired fibrinolysis [25].

4. Hypertension in Diabetes

Hypertension is often found at the time of diagnosis of type2 diabetes even in the absence of microalbuminuria [26].It is postulated that hyperinsulinemia, arterial stiffness aswell as extracellular fluid volume expansion all play a role.Indeed hyperinsulinemia is linked to weight gain, as wellas increased sympathetic activation [27]. Additionally, whenhyperglycemia is mild, it results in increased glucose filtra-tion and subsequent reabsorption at the glomerulus, drivingsodium reabsorption with it and causing extracellular fluidvolume expansion.

Treatment of hypertension in diabetes is essential toprevent development of renal disease, retinopathy as wellas cardiovascular disease. In the UKPDS trial that lookedat patients with type 2 diabetes, achieving lower bloodpressure with captopril or atenolol versus placebo resultedin a 24% reduction in diabetes-related end points includingmicrovascular disease, diabetes related deaths, stroke, as wellas retinopathy. The achieved blood pressure in the treatmentarm was 144/82 mm Hg, compared to 154/87 mm Hg; thesebenefits required continued control of blood pressure.Indeed upon eight years of followup, the greater reductionof blood pressure that was achieved in the treatment armdisappeared and the reduction in clinical end points was notsustained [28].

In the ADVANCE trial, the effect of intensive bloodpressure control on cardiovascular disease in patients withlong standing type 2 diabetes at high risk for vascular diseasewas studied. A combination of perindopril-indapamide wascompared to placebo. After more than four years of treat-ment, a lower rate of major macrovascular and microvascularevents as well as a lower risk of cardiovascular mortality werenoted. The mean blood pressure achieved in the treatmentarm was 134.5/74 mm Hg, compared to 140/76 mm Hg in theplacebo arm [29].

Major guidelines therefore recommend a goal bloodpressure of less than 130/80 in diabetic patients [30–32].The benefits of lower blood pressure goal have not beenestablished. In the blood pressure arm of the ACCORDtrial, patients with type 2 diabetes and cardiovascular disease(or two additional risk factors for cardiovascular disease)were randomly assigned to either intensive therapy (goalsystolic blood pressure less than 120 mm Hg) or standardtherapy (goal systolic blood pressure less than 140 mm Hg).The goals were reached with a mean systolic blood pressureof 119.3 mm Hg in the intensive arm and 133.5 mm Hg inthe standard arm. After 4.7 years, there was no differencein the annual rate of the primary composite outcome ofnonfatal myocardial infarction, nonfatal stroke, or deathfrom cardiovascular causes between groups. There was nodifference in the annual all-cause mortality or death fromcardiovascular disease. The annual rates of total and nonfatalstroke was significantly lower in the intensive treatment arm,but serious adverse events attributable to antihypertensivedrugs occurred more significantly in the intensive group.

Therefore there is no recommendation to achieve a systolicblood pressure of less than 120 mm Hg [33]. Similar resultswere noted in the SANDS trial which looked at progressionof atherosclerosis and left ventricular hypertrophy as well asclinical cardiovascular events in American Indian patientswith type 2 diabetes treated to a goal blood pressure ofeither less than 120/75 mm Hg or less than 115/70 mm Hg.Tight blood pressure control resulted in reduction in theprogression of atherosclerosis and left ventricular mass indexbut no decline in clinical cardiovascular outcomes. Moreadverse events related to antihypertensive drugs were notedin the intensive therapy arm [34].

4.1. Diabetes as a Cardiovascular Disease (CVD) Equivalentand a Poor Prognostic Factor in Acute Coronary Syndromes.Most guideline documents recommend treating cardiovas-cular risk factors in diabetic patients as aggressively as inpatients with established coronary artery disease. In 2002, theNational Cholesterol Education Program report designateddiabetes as a coronary heart disease equivalent. The reportexplained that a more intensive prevention strategy isjustified in diabetic patients because of their high risk ofnew CAD within 10 years, and because of the high deathrate observed in diabetics who experience a MI [35]. In thefollowing section we will briefly highlight and discuss theevidence behind these 2 observations.

Diabetic patients have twice the risk of myocardialinfarction (MI) and stroke of that of the general population[36]. In their cross-sectional study, Haffner et al. identifiedindividuals between age 45 and 64 from the Finnish SocialInstitution’s register and compared the outcomes of type 2diabetic patients with those of nondiabetic control subjects.During a seven-year followup and after adjustment forother cardiovascular risk factors, the risk of myocardialinfarction and the mortality from coronary heart diseasewere similar in diabetics without prior myocardial infarctionand nondiabetics with prior myocardial infarction [37]. Thisobservation, derived from a group of middle-aged and olderindividuals, has been integrated into clinical practice andserved as a premise to consider diabetes a CVD equivalent.Nonetheless, age remains an important factor to take intoaccount when assessing the risk of diabetic patients. In alarge population-based retrospective cohort study, Boothet al. reported that diabetes seems to account for a riskequivalent to ageing 15 years. However, younger diabetics(age 40 or younger) do not appear to be at high risk ofCVD [38]. A number of comprehensive risk assessment toolstaking into account patients’ age and risk factors profileare recognized by major scientific societies and have beenvalidated in numerous clinical trials. Such tools are availableonline and include the Framingham risk calculator [39],the UK Prospective Diabetes Study risk engine [40] and theADA’s Diabetes Personal Health Decisions [41].

Diabetic patients are also known to have worse outcomesafter an acute coronary syndrome when compared with thegeneral population. Diabetes was an independent mortalityrisk factor in patients receiving thrombolytic therapy forST elevation MI in both the GUSTO-I [42] and GISSI-2trials [43]. Insulin treated patients had the worse outcomes


in both trials and diabetes carried a higher adverse impactin women compared to men in the GISSI-2 trial. Newlydiagnosed diabetes mellitus at time of presentation withan acute MI was also associated with poorer long-termoutcomes in the VALIANT trial [44]. Data from a meta-analysis of 19 trials comparing primary PCI and fibrinolysisin ST elevation MI showed that diabetic patients had ahigher mortality reduction with PCI but continued to haveworse outcomes than nondiabetics [45]. Similar observationsfrom the VALIANT trial [44] and the OASIS registry [46]demonstrated that diabetics presenting with a non STelevation MI (NSTEMI) or unstable angina had worse long-term outcomes compared to nondiabetics. OASIS showedone more time a more ominous impact of diabetes on femalepatients compared to their male counterparts.

4.2. Cardiac Testing in Asymptomatic Patients with DiabetesMellitus. In addition to the higher incidence of clinicallysignificant cardiovascular events, type 2 diabetes is alsoassociated with a higher rate of subclinical CAD. Non-hemodynamically significant coronary lesions can remainlatent before resulting in myocardial ischemia. More impor-tantly diabetic autonomic neuropathy can impair ischemiaawareness and has been associated with an increased riskof cardiovascular mortality [47]. Noninvasive computedtomography (using coronary artery calcium (CAC) scoringor angiography) is now capable of detecting asymptomaticCAD even before the onset of silent ischemic electrocar-diographic changes and coronary perfusion defects duringstress testing. In a prospective study of 510 asymptomaticpatients with uncomplicated type 2 diabetes, significant CAC(a reliable marker of atherosclerosis) was seen in 46.3% of thepatients. The extent of CAC was a strong predictor of silentischemia by radionuclide myocardial perfusion imaging andshort-term cardiovascular events [48]. The DIAD trial ran-domized 1123 asymptomatic type 2 diabetics to adenosinestress radionuclide myocardial perfusion imaging or noscreening. Stress imaging identified silent ischemia in 22%of the screened patients [49]. A retrospective observationalstudy of 1899 asymptomatic patients with type 2 diabetesshowed that stratifying the patients according to the numberof additional CVD risk factors they have did not affect theirlikelihood of having an abnormal myocardial perfusion testand significant coronary artery disease. However patientswith 2 or more additional risk factors had a higher likelihoodof having more severe CAD with unfavorable angiographicanatomy not amenable to complete percutaneous or surgicalrevascularization [50].

Based on the above findings, clinicians might feelcompelled to screen asymptomatic diabetics in an attemptto detect early stages of CAD and implement appropriatetherapies. Such an enthusiasm should be tempered by thefact that intensive medical therapy is indicated for alldiabetic patients at high risk for CVD which makes screeningresults unlikely to change management. In addition diag-nostic testing can be expensive and can potentially leadto unnecessary procedures and complications. Furthermorethe hypothesis that asymptomatic diabetic patients benefitfrom revascularization remains unproven. The BARI 2D trial

randomized 2368 patients with both type 2 diabetes andstable CAD (defined as ≥50% stenosis of a major epicardialcoronary artery associated with a positive stess test or ≥70%stenosis of a major epicardial coronary artery and classicangina) to receive prompt revascularization with intensivemedical therapy or intensive medical therapy alone. Therewas no significant difference in death or serious adversecardiovascular events between both groups [51]. Additionaldata supporting the futility of screening asymptomaticpatients came from the DIAD trial where no significantdifference in cardiac death or nonfatal MI was seen betweenthe screening and no-screening groups at a mean followup of4.8 years [52].

Major society guidelines have made the following rec-ommendations about screening for asymptomatic CAD indiabetic patients.

(i) The 2002 ACC/AHA guidelines update for exercisetesting stated that asymptomatic diabetic patientshave an increased likelihood of CVD if they haveat least one of the following factors: age older than35, type 2 diabetes greater than 10 years’ duration,any additional atherosclerotic risk factor for CAD,presence of microvascular disease, peripheral vascu-lar disease or autonomic neuropathy. The guidelinesrecommend exercise testing if an individual meetingthe above criteria is planning to begin a moderate- tohigh-intensity exercise (class IIa; level of evidence: C)[53].

(ii) The 2010 ACCF/AHA guidelines for assessment ofcardiovascular risk in asymptomatic adults give aclass IIa recommendation for measurement of CACfor cardiovascular risk assessment in asymptomaticadults with diabetes who are 40 years of age and older(level of evidence: B). The authors acknowledge thatthere is no evidence supporting that this imaging testis useful in motivating patients to better adhere toprimary prevention measures. The same guidelinesgive a weak class IIb (level of evidence: C) recommen-dation to consider stress MPI for advanced cardio-vascular risk assessment in asymptomatic adults withdiabetes or in patients who have a CAC score of 400or greater [54].

(iii) In a recent 2012 position statement on standardsof medical care in diabetes, the American DiabetesAssociation (ADA) does not recommend screeningfor CAD in asymptomatic patients because it doesnot improve outcomes as long as CVD risk factorsare treated (level of evidence: A). The guidelinesacknowledge that newer noninvasive CT modalitiescan identify asymptomatic diabetic patients with ahigher CAD burden and a higher risk of futurecardiac events. However they consider that the role ofthese tests beyond risk stratification is unclear with acontroversial balance of benefit, cost, and risks [55].

4.3. Epidemiologic Consequences of Diabetes and Heart Diseaseon a Global Scale. The number of people with diabetes is


increasing due to population growth, aging, urbanization,and increasing prevalence of obesity and physical inactivity[16, 56, 57]. Quantifying the prevalence of diabetes andthe number of people affected by diabetes, now and in thefuture, is important to allow rational planning and allocationof resources. The prevalence of diabetes for all age-groupsworldwide was found to be 2.8% in 2000, 6.4% in 2010,and (estimated to be) 7.7% in 2030! The total number ofpeople with diabetes is projected to rise from 171 million in2000, to 285 million in 2010 to 440 million in 2030 [58].The prevalence of diabetes is higher in men than women,but there are more women with diabetes than men. Theurban population in developing countries is projected todouble between 2000 and 2030. Between 2010 and 2030,there will be a 69% increase in numbers of adults withdiabetes in developing countries and a 20% increase indeveloped countries [58]. The public health epidemic ofdiabetes will certainly affect the growth of these emergingeconomies. As the prevalence of diabetes increases so willthe need for healthcare services (primary, secondary, andtertiary) in these developing countries. Unfortunately, dataabout the use of effective secondary prevention medicationsin patients with known cardiovascular disease reflects theimportance of this challenge. The Prospective Urban RuralEpidemiological (PURE) study which enrolled between 2003and 2009 patients with cardiovascular disease from 17countries with variable levels of income showed that the useof appropriate drugs (antiplatelet drugs, ACE inhibitors orARBs, or statins) was universally low and decreased in linewith reduction of country economic level. The percentageof patients receiving no drugs was 11.2% in high-incomecountries, 45.1% in upper middle-income countries, 69.3%in lower middle-income countries, and 80.2% in low-incomecountries [59]. Moreover access to cardiac revascularizationincluding cardiac surgery and catheter-based techniquesremains disproportionate in different parts of the worldeven within Europe and North America [60]. This hasled major scientific societies to develop appropriatenessand necessity criteria that can guide decision-making andidentify the overuse and underuse of revascularizationprocedures. Historically, coronary artery bypass grafting(CABG) is the established method of revascularization inpatients with diabetes and multivessel coronary disease, butwith advances in percutaneous coronary intervention (PCI),there is uncertainty whether CABG remains the preferredmethod of revascularization. Kapur et al. studied a total of510 diabetic patients with multivessel or complex single-vessel coronary disease from 24 centers and randomizedthe patients to PCI plus stenting (and routine abciximab)or CABG [61]. The primary outcome was a composite ofall-cause mortality, myocardial infarction (MI), and stroke,and the main secondary outcome included the addition ofrepeat revascularization to the primary outcome events. At1 year of followup, the composite rate of death, MI, andstroke was 10.5% in the CABG group and 13.0% in thePCI group (hazard ratio (HR): 1.25, 95% confidence interval(CI): 0.75 to 2.09; P = 0.39), all-cause mortality rates were3.2% and 3.2%, and the rates of death, MI, stroke, or repeatrevascularization were 11.3% and 19.3% (HR: 1.77, 95%

CI: 1.11 to 2.82; P = 0.02), respectively [46]. Regardlessof the revascularization approach (PCI versus CABG), theoverall increase in prevalence will lead to an increaseddemand of (tertiary) services for patients who suffer fromdiabetes and its most fatal complication (cardiovasculardisease). The result will be an increased burden on theemerging economies of these developing countries.

5. Conclusion

Diabetes mellitus is associated with an increased risk of car-diovascular death and a higher incidence of cardiovasculardiseases including coronary artery disease. The substantialrise in prevalence of diabetes will ultimately lead to a hugeincrease in the demand for primary, secondary, and tertiaryhealthcare services globally. The need for appropriate screen-ing and cardiac testing is crucial to help better manage theend result (cardiovascular disease) of this global epidemic.

Acknowledgment

The authors would like to acknowledge the Research OpenAccess Publishing (ROAAP) Fund of the University of Illinoisat Chicago for financial support towards the open accesspublishing fee for this paper.

References

[1] T. A. Gaziano, “Cardiovascular disease in the developing worldand its cost-effective management,” Circulation, vol. 112, no.23, pp. 3547–3553, 2005.

[2] W. Rosamond, K. Flegal, G. Friday et al., “Heart disease andstroke statistics—2007 update: a report from the AmericanHeart Association Statistics Committee and Stroke StatisticsSubcommittee,” Circulation, vol. 115, no. 5, pp. e69–e171,2007.

[3] S. Capewell, C. E. Morrison, and J. J. McMurray, “Contri-bution of modern cardiovascular treatment and risk factorchanges to the decline in coronary heart disease mortality inScotland between 1975 and 1994,” Heart, vol. 81, no. 4, pp.380–386, 1999.

[4] B. Unal, J. A. Critchley, and S. Capewell, “Modelling thedecline in coronary heart disease deaths in England and Wales,1981–2000: comparing contributions from primary preven-tion and secondary prevention,” British Medical Journal, vol.331, no. 7517, pp. 614–617, 2005.

[5] S. Capewell, R. Beaglehole, M. Seddon, and J. McMurray,“Explanation for the decline in coronary heart disease mortal-ity rates in Auckland, New Zealand, between 1982 and 1993,”Circulation, vol. 102, no. 13, pp. 1511–1516, 2000.

[6] J. Critchley, J. Liu, D. Zhao, W. Wei, and S. Capewell,“Explaining the increase in coronary heart disease mortalityin Beijing between 1984 and 1999,” Circulation, vol. 110, no.10, pp. 1236–1244, 2004.

[7] E. S. Ford, U. A. Ajani, J. B. Croft et al., “Explaining thedecrease in U.S. deaths from coronary disease, 1980–2000,”The New England Journal of Medicine, vol. 356, no. 23, pp.2388–2398, 2007.

[8] V. Fuster, J. Voute, M. Hunn, and S. C. Smith, “Low priorityof cardiovascular and chronic diseases on the global health


agenda: a cause for concern,” Circulation, vol. 116, no. 17, pp.1966–1970, 2007.

[9] M. K. Poulsen, J. E. Henriksen, J. Dahl et al., “Left ventriculardiastolic function in type 2 diabetes mellitus prevalence andassociation with myocardial and vascular disease,” Circulation:Cardiovascular Imaging, vol. 3, no. 1, pp. 24–31, 2010.

[10] R. R. Huxley, K. B. Filion, S. Konety, and A. Alonso, “Meta-analysis of cohort and case-control studies of type 2 diabetesmellitus and risk of atrial fibrillation,” American Journal ofCardiology, vol. 108, no. 1, pp. 56–62, 2011.

[11] W. B. Kannel and D. L. McGee, “Diabetes and cardiovascularrisk factors: the framingham study,” Circulation, vol. 59, no. 1,pp. 8–13, 1979.

[12] P. Schnohr, P. Lange, H. Scharling, and J. Skov Jensen,“Long-term physical activity in leisure time and mortalityfrom coronary heart disease, stroke, respiratory diseases, andcancer. The Copenhagen City Heart Study,” European Journalof Cardiovascular Prevention and Rehabilitation, vol. 13, no. 2,pp. 173–179, 2006.

[13] J. D. Berry, A. Dyer, X. Cai et al., “Lifetime risks ofcardiovascular disease,” The New England Journal of Medicine,vol. 366, no. 4, pp. 321–329, 2012.

[14] W. L. Lee, A. M. Cheung, D. Cape, and B. Zinman, “Impactof diabetes on coronary artery disease in women and men: ameta- analysis of prospective studies,” Diabetes Care, vol. 23,no. 7, pp. 962–968, 2000.

[15] C. Nielson, T. Lange, and N. Hadjokas, “Blood glucose andcoronary artery disease in nondiabetic patients,” DiabetesCare, vol. 29, no. 5, pp. 998–1001, 2006.

[16] H. King, R. E. Aubert, and W. H. Herman, “Global burdenof diabetes, 1995–2025: prevalence, numerical estimates, andprojections,” Diabetes Care, vol. 21, no. 9, pp. 1414–1431,1998.

[17] P. S. Yusuf, S. Hawken, S. Ounpuu et al., “Effect of potentiallymodifiable risk factors associated with myocardial infarctionin 52 countries (the INTERHEART study): case-controlstudy,” The Lancet, vol. 364, no. 9438, pp. 937–952, 2004.

[18] J. A. Silva, A. Eseobar, T. J. Collins, S. R. Ramee, and C. J.White, “Unstable angina: a comparison of angioscopic find-ings between diabetic and nondiabetic patients,” Circulation,vol. 92, no. 7, pp. 1731–1736, 1995.

[19] P. R. Moreno, A. M. Murcia, I. F. Palacios et al., “Coronarycomposition and macrophage infiltration in atherectomyspecimens from patients with diabetes mellitus,” Circulation,vol. 102, no. 18, pp. 2180–2184, 2000.

[20] J. A. Beckman, M. A. Creager, and P. Libby, “Diabetes andatherosclerosis epidemiology, pathophysiology, and manage-ment,” Journal of the American Medical Association, vol. 287,no. 19, pp. 2570–2581, 2002.

[21] A. D’Souza, M. Hussain, F. C. Howarth, N. M. Woods, K.Bidasee, and J. Singh, “Pathogenesis and pathophysiology ofaccelerated atherosclerosis in the diabetic heart,” Molecularand Cellular Biochemistry, vol. 331, no. 1-2, pp. 89–116, 2009.

[22] P. R. Moreno, K. R. Purushothaman, V. Fuster et al., “Plaqueneovascularization is increased in ruptured atheroscleroticlesions of human aorta: implications for plaque vulnerability,”Circulation, vol. 110, no. 14, pp. 2032–2038, 2004.

[23] M. Shechter, C. N. Bairey Merz, M. J. Paul-Labrador, and S.Kaul, “Blood glucose and platelet-dependent thrombosis inpatients with coronary artery disease,” Journal of the AmericanCollege of Cardiology, vol. 35, no. 2, pp. 300–307, 2000.

[24] D. J. Schneider and B. E. Sobel, “Augmentation of synthesis ofplasminogen activator inhibitor type 1 by insulin and insulin-like growth factor type I: implications for vascular disease in

hyperinsulinemic states,” Proceedings of the National Academyof Sciences of the United States of America, vol. 88, no. 22, pp.9959–9963, 1991.

[25] J. B. McGill, D. J. Schneider, C. L. Arfken, C. L. Lucore, andB. E. Sobel, “Factors responsible for impaired fibrinolysis inobese subjects and NIDDM patients,” Diabetes, vol. 43, no. 1,pp. 104–109, 1994.

[26] “Hypertension in Diabetes Study (HDS): I. Prevalence ofhypertension in newly presenting type 2 diabetic patientsand the association with risk factors for cardiovascular anddiabetic complications,” Journal of Hypertension, vol. 11, no.3, pp. 309–317, 1993.

[27] M. S. Muntzel, E. A. Anderson, A. K. Johnson, and A. L. Mark,“Mechanisms of insulin action on sympathetic nerve activity,”Clinical and Experimental Hypertension, vol. 17, no. 1-2, pp.39–50, 1995.

[28] “Tight blood pressure control and risk of macrovascular andmicrovascular complications in type 2 diabetes: UKPDS 38,”British Medical Journal, vol. 317, no. 7160, pp. 703–713, 1998.

[29] A. Patel, “Effects of a fixed combination of perindopril andindapamide on macrovascular and microvascular outcomes inpatients with type 2 diabetes mellitus (the ADVANCE trial): arandomised controlled trial,” The Lancet, vol. 370, no. 9590,pp. 829–840, 2007.

[30] “Executive summary: standards of medical care in diabetes—2010,” Diabetes Care, vol. 33, supplement 1, pp. S4–S10, 2010.

[31] A. V. Chobanian, G. L. Bakris, H. R. Black et al., “Theseventh report of the joint national committee on prevention,detection, evaluation, and treatment of high blood pressure:the JNC 7 report,” Journal of the American Medical Association,vol. 289, no. 19, pp. 2560–2572, 2003.

[32] G. L. Bakris, M. Williams, L. Dworkin et al., “Preserving renalfunction in adults with hypertension and diabetes: a consensusapproach,” American Journal of Kidney Diseases, vol. 36, no. 3,pp. 646–661, 2000.

[33] R. Pop-Busui, G. W. Evans, H. C. Gerstein et al., “Effects ofcardiac autonomic dysfunction on mortality risk in the Actionto Control Cardiovascular Risk in Diabetes (ACCORD) trial,”Diabetes Care, vol. 33, no. 7, pp. 1578–1584, 2010.

[34] B. V. Howard, M. J. Roman, R. B. Devereux et al., “Effectof lower targets for blood pressure and LDL cholesterol onatherosclerosis in diabetes: the SANDS randomized trial,”Journal of the American Medical Association, vol. 299, no. 14,pp. 1678–1689, 2008.

[35] “Third Report of the National Cholesterol Education Program(NCEP) expert panel on detection, evaluation, and treatmentof high blood cholesterol in adults (Adult Treatment PanelIII) final report,” Circulation, vol. 106, no. 25, pp. 3143–3421,2002.

[36] T. A. Pearson, S. N. Blair, S. R. Daniels et al., “AHA guidelinesfor primary prevention of cardiovascular disease and stroke:2002 update: consensus panel guide to comprehensive riskreduction for adult patients without coronary or otheratherosclerotic vascular diseases,” Circulation, vol. 106, no. 3,pp. 388–391, 2002.

[37] S. M. Haffner, S. Lehto, T. Ronnemaa, K. Pyorala, and M.Laakso, “Mortality from coronary heart disease in subjectswith type 2 diabetes and in nondiabetic subjects with andwithout prior myocardial infarction,” The New England Jour-nal of Medicine, vol. 339, no. 4, pp. 229–234, 1998.

[38] G. L. Booth, M. K. Kapral, K. Fung, and J. V. Tu, “Rela-tion between age and cardiovascular disease in men and


women with diabetes compared with non-diabetic people:a population-based retrospective cohort study,” The Lancet,vol. 368, no. 9529, pp. 29–36, 2006.

[39] P. W. F. Wilson, R. B. D’Agostino, D. Levy, A. M. Belanger, H.Silbershatz, and W. B. Kannel, “Prediction of coronary heartdisease using risk factor categories,” Circulation, vol. 97, no.18, pp. 1837–1847, 1998.

[40] R. J. Stevens, V. Kothari, A. I. Adler, I. M. Stratton, and R.R. Holman, “The UKPDS risk engine: a model for the riskof coronary heart disease in type II diabetes (UKPDS 56),”Clinical Science, vol. 101, no. 6, pp. 671–679, 2001.

[41] D. M. Eddy and L. Schlessinger, “Archimedes: a trial-validatedmodel of diabetes,” Diabetes Care, vol. 26, no. 11, pp. 3093–3101, 2003.

[42] K. H. Mak, D. J. Moliterno, C. B. Granger et al., “Influence ofdiabetes mellitus on clinical outcome in the thrombolytic eraof acute myocardial infarction. GUSTO-I Investigators. Globalutilization of streptokinase and tissue plasminogen activatorfor occluded coronary arteries,” Journal of the American Collegeof Cardiology, vol. 30, no. 1, pp. 171–179, 1997.

[43] G. Zuanetti, R. Latini, A. P. Maggioni, L. Santoro, and M.G. Franzosi, “Influence of diabetes on mortality in acutemyocardial infarction: data from the GISSI-2 study,” Journalof the American College of Cardiology, vol. 22, no. 7, pp. 1788–1794, 1993.

[44] D. Aguilar, S. D. Solomon, L. Koøber et al., “Newly diagnosedand previously known diabetes mellitus and 1-year outcomesof acute myocardial infarction: The Valsartan in acute myocar-dial infarction (VALIANT) trial,” Circulation, vol. 110, no. 12,pp. 1572–1578, 2004.

[45] J. R. Timmer, J. P. Ottervanger, M. J. de Boer et al., “Primarypercutaneous coronary intervention compared with fibrinoly-sis for myocardial infarction in diabetes mellitus: results fromthe primary coronary angioplasty vs thrombolysis-2 trial,”Archives of Internal Medicine, vol. 167, no. 13, pp. 1353–1359,2007.

[46] K. Malmberg, S. Yusuf, H. C. Gerstein et al., “Impact ofdiabetes on long-term prognosis in patients with unstableangina and non-Q-wave myocardial infarction: results ofthe OASIS (Organization to Assess Strategies for IschemicSyndromes) registry,” Circulation, vol. 102, no. 9, pp. 1014–1019, 2000.

[47] A. I. Vinik, R. E. Maser, B. D. Mitchell, and R. Freeman,“Diabetic autonomic neuropathy,” Diabetes Care, vol. 26, no.5, pp. 1553–1579, 2003.

[48] D. V. Anand, E. Lim, D. Hopkins et al., “Risk stratificationin uncomplicated type 2 diabetes: prospective evaluation ofthe combined use of coronary artery calcium imaging andselective myocardial perfusion scintigraphy,” European HeartJournal, vol. 27, no. 6, pp. 713–721, 2006.

[49] F. J. T. Wackers, L. H. Young, S. E. Inzucchi et al., “Detection ofsilent myocardial ischemia in asymptomatic diabetic subjects:the DIAD study,” Diabetes Care, vol. 27, no. 8, pp. 1954–1961,2004.

[50] R. Scognamiglio, C. Negut, A. Ramondo, A. Tiengo, and A.Avogaro, “Detection of coronary artery disease in asymp-tomatic patients with type 2 diabetes mellitus,” Journal of theAmerican College of Cardiology, vol. 47, no. 1, pp. 65–71, 2006.

[51] R. L. Frye, P. August, M. M. Brooks et al., “A randomized trialof therapies for type 2 diabetes and coronary artery disease,”The New England Journal of Medicine, vol. 360, no. 24, pp.2503–2515, 2009.

[52] L. H. Young, F. J. T. Wackers, D. A. Chyun et al., “Cardiacoutcomes after screening for asymptomatic coronary artery

disease in patients with type 2 diabetes the DIAD study: arandomized controlled trial,” Journal of the American MedicalAssociation, vol. 301, no. 15, pp. 1547–1555, 2009.

[53] R. J. Gibbons, G. J. Balady, J. T. Bricker et al., “ACC/AHA2002 guideline update for exercise testing: summary article. Areport of the American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines (Committee toupdate the 1997 exercise testing guidelines),” Journal of theAmerican College of Cardiology, vol. 40, no. 8, pp. 1531–1540,2002.

[54] P. Greenland, J. S. Alpert, G. A. Beller et al., “2010 ACCF/AHAguideline for assessment of cardiovascular risk in asymp-tomatic adults: a report of the american college of cardiologyfoundation/american heart association task force on practiceguidelines,” Circulation, vol. 122, no. 25, pp. e584–e636, 2010.

[55] “Standards of medical care in diabetes—2012,” Diabetes Care,vol. 35, supplement 1, pp. S11–S63, 2012.

[56] S. Wild, G. Roglic, A. Green, R. Sicree, and H. King, “Globalprevalence of diabetes: estimates for the year 2000 andprojections for 2030,” Diabetes Care, vol. 27, no. 5, pp. 1047–1053, 2004.

[57] H. King and M. Rewers, “Global estimates for prevalence ofdiabetes mellitus and impaired glucose tolerance in adults,”Diabetes Care, vol. 16, no. 1, pp. 157–177, 1993.

[58] J. E. Shaw, R. A. Sicree, and P. Z. Zimmet, “Global estimatesof the prevalence of diabetes for 2010 and 2030,” DiabetesResearch and Clinical Practice, vol. 87, no. 1, pp. 4–14, 2010.

[59] S. Yusuf, S. Islam, C. K. Chow et al., “Use of secondaryprevention drugs for cardiovascular disease in the communityin high-income, middle-income, and low-income countries(the PURE Study): a prospective epidemiological survey,” TheLancet, vol. 378, no. 9798, pp. 1231–1243, 2011.

[60] K. Fitch, P. Lazaro, M. D. Aguilar, J. P. Kahan, M. VanHet Loo, and S. J. Bernstein, “European criteria for theappropriateness and necessity of coronary revascularizationprocedures,” European Journal of Cardio-thoracic Surgery, vol.18, no. 4, pp. 380–387, 2000.

[61] A. Kapur, R. J. Hall, I. S. Malik et al., “Randomized comparisonof percutaneous coronary intervention with coronary arterybypass grafting in diabetic patients. 1-Year Results of theCARDia (Coronary Artery Revascularization in Diabetes)trial,” Journal of the American College of Cardiology, vol. 55, no.5, pp. 432–440, 2010.


Research Article

Prevalence, Awareness, Treatment and Control of Coexistence ofDiabetes and Hypertension in Thai Population

Siriwat Tiptaradol1 and Wichai Aekplakorn2

1 Office of Permanent Secretary, Ministry of Public Health, Nonthaburi 11000, Thailand2 Department of Community Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University,Rama VI Road, Rajdevi, Bangkok 10400, Thailand

Correspondence should be addressed to Wichai Aekplakorn, [email protected]

Received 9 May 2012; Accepted 5 June 2012

Academic Editor: Yackoob Kassim Seedat

Copyright © 2012 S. Tiptaradol and W. Aekplakorn. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Diabetes and hypertension are major independent risk factors for cardiovascular and renal diseases; however, prevalence andcharacteristics of the coexistence in general population is not clear. Data from Thai National Health Examination Survey III wereused to estimate the prevalence of coexistence of diabetes and hypertension, and to estimate the proportion of awareness, treatmentand control of both conditions. A total of 36,877 (male 17,614 and female 19,263) participants were included in the study. Theprevalence of people with diabetes and hypertension was 3.2% (male 2.8% and female 3.6%). Approximately half of the diabetespatients (49.0%, 95%CI 45.6, 52.5) had hypertension, and 14.4% (95%CI 13.0, 16.0) of hypertensive patients had diabetes. Aftercontrolling for covariates, factors associated with coexistence of diabetes and hypertension included; age ≥60 years (adjust oddsratio 1.38, 95%CI 1.14, 1.73), having education less than 6 years (1.83, 95%CI 1.03, 3.38) and abdominal obesity (2.49, 95%CI2.00, 3.10). More than 80% were unaware of having both conditions. Target for control of both glucose and blood pressure amongthose treated was achieved in only 6.2%. In conclusion, patients with diabetes or hypertension should be promoted to have weightcontrol and screening for the comorbidity.

1. Introduction

At present, diabetes and hypertension are among the mostcommon noncommunicable chronic diseases in developedand developing countries around the world [1]. In Thailand,burden of diseases defined as total disability-adjusted lifeyear (DALY) loss attributed to diabetes was 1.7 million years(3.1%) in men and 2.7 million years (6.4%) in women,and to hypertension was 5.5% each in both men andwomen [2]. Hypertension is commonly found in patientswith diabetes and vice versa. People with coexisting diabetesand hypertension are at increased risk of atherosclerosis,retinopathy, renal failure and nontraumatic amputations,and cardiovascular diseases [3, 4]. These conditions notonly result in high burden to the patients and family, butalso impose a high national health care cost worldwide.In Thailand, the 2004 National Health Examination survey

(NHES III) reported the prevalence of 6.8% and 21.0% fordiabetes and hypertension, respectively, in Thai populationaged ≥15 years [1, 5]. These studies also revealed thatmore than half of individuals with the each condition wereunaware of the condition. Furthermore, the percentagesof the patients who were treated and controlled to targetlevels were substantially low. Although there has been certaininformation on proportions of patients with both conditions[1], the characteristics of individuals with the coexistence ofboth conditions have not been clearly identified. Moreover,knowing factors associated with the conditions should beuseful for health service and public health action in termmanagement and prevention. The present study aimed todetermine the prevalence of coexistence of diabetes andhypertension and the proportions of awareness, treatment,and control of the coexistence of both conditions in Thaipopulation by using data from the NHES III.


2. Methods

2.1. Study Population. The sampling method and data collec-tion procedures of NHES III were described elsewhere [5, 6].Briefly, the national health examination survey is a multistageprobability sampling of Thai population aged≥15 years. Thesampling unit in each of the four stages of selection included:(1) three provinces in each of the 12 public health regions;(2) nine electoral units (EUs) or villages from urban andrural areas, respectively; and (3) 15 individuals from eachEU or village. The final sample size was targeted at 42,120individuals and the final complete data used for analysis ofthis study was 36,877 individuals (male 17,614 and female19,263) aged ≥15 years.

2.2. Data Collection. Data on demographic characteristics,lifestyle behavior, history of diabetes and hypertension,and management were interviewed by trained interviewers.Blood pressure was measured by trained field staff accordingto standard protocol [7]. Three serial measurements ofblood pressure, taken 1 minute apart, were obtained usinga mercury sphygmomanometer with subjects in the sittingposition after 5 min of rest. Weight, height, and waistcircumference (WC) were measured by trained field staffusing standard procedures and equipment according to theWorld Health Organization guideline [8]. Subjects wore lightclothing but without shoes while their height and weightwere measured. WC was measured at a level midway betweenlower rib margin and iliac crest with a measuring tape on ahorizontal plane around the body [8].

Venous blood samples were obtained in the morningafter the participants had fasted overnight. Fasting plasmaglucose (FPG) was tested using hexokinase enzyme method.Serum cholesterol was measured suing enzymatic methods.The laboratory centers were a standardized central labora-tory at the Ministry of Public Health.

2.3. Definitions. Blood pressure was the average of twoserial blood-pressure measurements with lowest variabilityin pulse pressure. Hypertension was defined as a systolic(SBP) ≥ 140 mmHg or a diastolic blood pressure (DBP)≥ 90 mmHg or on medication with blood-lowering agentsduring the past 2 weeks [7]. Diabetes was defined as FPG≥ 7.0 mmol/L (≥126 mg/dL) or previous diagnosis and ontreatment of diabetes using antiglycemic agents or insulinduring the past 2 weeks [1, 9]. Diagnosed diabetes wasdefined as those who were diagnosed by medical doctorsand were on treatment with antiglycemic drugs in the past 2weeks. Individuals reported on receiving antiglycemic drugsin the past two weeks were considered as on treatment.Individuals on diabetes treatment were considered as beingcontrolled if their FPG was less than 130 mg/dL [10]. Controltarget of blood pressure was set at SBP< 140 mmHg and DBP< 90 mmHg for hypertensive individuals without diabetes,and SBP < 130 mmHg and DBP < 90 mmHg for those withcoexistence of hypertension and diabetes [9]. Asian criteriafor obesity was used at cut-off point of BMI ≥ 25 kg/m2 and

70

60

50

40

30

20

10

0

1.59.9

0.3

2.9 30.6

5

38.9

4.94.2

46.153.5

2.9

3.1

20.917.3

1.7 5.5 8.6 7.3 6.1 2.830–44 45–59 60–69 70–79 80+ Total15–29

Percentage in men

(a)

70

60

50

40

30

20

10

030–44 45–59 60–69 70–79 80+ Total

1.33.70.2

3.312.41.7

5.8

27.6

7

7.2

36.9

11.3

5.7

44.5

9.7

2.8

55.6

6

3.5

17.4

3.6

DM and HTHTDM

15–29

Percentage in women

(b)

Figure 1: Prevalence of diabetes, hypertension, and coexistence ofboth conditions in Thai population aged ≥15 years by age group.

abdominal obesity was defined as WC ≥ 90 cm. for male and≥80 cm for female [11].

2.4. Statistical Methods. All the analyses were weightedagainst the registered 2004 Thai population by public healthadministration area, urban/rural areas, sex, and 5-year agegroups. The analysis was accounted for the complex surveydesign using “svy” command in Stata software version 10.Subjects were categorized into 4 groups: no diabetes orhypertension, diabetes only, hypertension only, and thosewith coexistence of diabetes and hypertension. Mean valuesand 95% confidence interval (CI) for continuous variableswere calculated. Prevalence of diabetes, hypertension alone,and the coexistence as well as awareness and treatment ofthose having the conditions were calculated. The proportionof the controlled was calculated among those who weretreated. Multivariable logistic regression was used to examinethe association of several independent variables includingage, sex, urban/rural and educational level, obesity (BMI ≥25 kg/m2), and abdominal obesity with the coexistence ofdiabetes and hypertension.

3. Results

The prevalence of diabetes alone, hypertension alone, andthe coexistence of both was 3.3% (95%CI 2.8, 4.0), 19.1%


Table 1: Characteristics of participants with diabetes, hypertension and coexistence of both conditions in Thai population aged ≥15 years,2004.

No DM and no HT(n = 20,906)

DM only(n = 1,715)

HT only(n = 11,708)

DM and HT(n = 2,548)

P value

Male n = 9,867 n = 724 n = 5,923 n = 1,100

Age (yr) 35.7 (35.3, 36.2) 45.3 (42.5, 48.1) 48.3 (47.1, 49.4) 54.9 (52.9, 57.0) <0.01

BMI (kg/m2) 22.1 (21.9, 22.3) 23.3 (22.4, 24.2) 24.2 (23.8, 24.7) 27.0 (25.5, 28.5) <0.01

Waist (cm) 77.2 (76.6, 77.7) 81.8 (80.3, 83.4) 82.9 (81.8, 84.1) 90.9 (87.0, 94.8) <0.01

FPG (mg/dL) 89.2 (88.2, 90.2) 170.9 (165.9, 175.9) 91.4 (90.1, 92.7) 185.1 (173.5, 196.6) <0.01

SBP (mmHg) 114.0 (113.5, 114.6) 115.6 (113.9, 117.4) 137.8 (136.3, 139.4) 139.0 (137.3, 140.8) <0.01

TC (mg/dL) 185.8 (183.5, 188.2) 194.4 (178.9, 209.8) 198.0 (194.1, 201.8) 201.9 (181.1, 222.8) <0.01

TC ≥ 240 (%) 11.6 (10.4, 12.9) 20.1 (15.5, 25.5) 18.5 (15.5, 22.0) 38.0 (31.3, 45.0) <0.01

BMI ≥ 25 (%) 17.9 (16.2, 19.7) 30.5 (23.6, 38.4) 36.6 (32.7, 40.6) 57.2 (47.2, 66.7) <0.01

Abdominal obesity (%) 11.0 (9.8, 12.3) 24.9 (19.2, 31.6) 26.6 (23.3, 30.2) 50.4 (39.8, 61.0) <0.01

Female n = 11,039 n = 991 n = 5,785 n = 1,448 <0.01

Age (yr) 36.1 (35.6, 36.6) 49.1 (47.1, 51.2) 53.9 (53.0, 54.8) 56.6 (55.4, 57.9) <0.01

BMI (kg/m2) 23.3 (23.1, 23.4) 25.2 (24.3, 26.2) 25.6 (25.1, 26.3) 29.4 (28.3, 30.5) <0.01

Waist (cm) 75.2 (74.6, 75.8) 81.7 (79.2, 84.2) 80.7 (79.4, 82.0) 90.7 (88.7, 92.6) <0.01

FPG (mg/dL) 86.6 (85.6, 87.5) 181.7 (168.5, 194.9) 88.8 (87.6, 89.9) 172.8 (163.4, 182.2) <0.01

SBP (mm Hg) 110.9 (110.3, 111.5) 113.5 (112.1, 115.0) 136.6 (135.0, 138.1) 144.9 (143.3, 146.5) <0.01

TC (mg/dL) 194.6 (192.2, 197.0) 195.1 (176.6, 213.5) 203.9 (198.8, 209.0) 221.1 (213.0, 229.2) <0.01

TC ≥ 240 (%) 14.2 (12.9, 15.6) 27.8 (19.0, 38.6) 21.0 (18.2, 24.1) 42.2 (38.96, 45.5) <0.01

BMI ≥ 25 (%) 30.1 (28.6, 31.7) 45.08 (37.4, 53.0) 52.2 (47.0, 57.2) 63.6 (56.7, 69.9) <0.01

Abdominal obesity (%) 31.0 (29.0, 33.0) 51.1 (43.3, 58.9) 51.4 (46.6, 56.2) 84.3 (81.0, 84.3) <0.01

Data were mean and percent (%) as specified; DM: diabetes; HT: hypertension; BMI: body mass index; FPG: fasting plasma glucose; SBP: systolic bloodpressure; TC: total cholesterol; Abdominal obesity, waist circumference ≥90 cm in men and ≥80 cm in women.

(17.6, 20.6), and 3.2% (2.9, 3.6), respectively. The prevalenceof the coexistence was higher in women (3.6%, 95%CI 3.2,4.0) than in men (2.8%, 95%CI 2.4, 3.3) (P < 0.05).Approximately half of the patients with diabetes (49.0%,95%CI 45.6, 52.5) had hypertension, while 14.4% (95%CI13.0, 16.0) of hypertensive individuals had diabetes.

Subjects with the coexistence were older, having higherBMI, larger waist circumference, higher systolic blood pres-sure, and higher level of blood total cholesterol comparedto those having diabetes alone or hypertension alone. Theproportion of participants with high cholesterol (TC ≥240 mg/dL) was also highest in those with the coexistence,followed by those with diabetes. People with the coexistencealso had highest rates of obesity, followed by those havinghypertension alone (Table 1). The prevalence of the coexis-tence was significantly higher in those with BMI ≥ 25 kg/m2

than in those with BMI < 25 kg/m2 (6.2% versus 2.0%, resp.,P < 0.01) as well as higher in those with abdominal obesitythan in those without (7.7% versus 1.6%, resp., P < 0.01).

Figure 1 shows the prevalence of diabetes alone, hyper-tension alone and the coexistence of both conditions byage groups. The age-specific prevalence of individuals hav-ing either conditions or both conditions increased as ageincreased and peaked at age 80 and over. Prevalence ofcoexistence of both conditions was highest in the group 60–69 years (8.6% in men and 11.3% in women).

3.1. Urban/Rural and Geographic Difference. The prevalenceof the coexistence of both conditions was significantly higherin urban men than rural men (3.9 versus 2.4%, P < 0.05) butnot significantly different between urban and rural women(3.9 versus 3.5%P > 0.05). People in Bangkok had thehighest prevalence of the coexistence for both men andwomen, followed by men in central region and women in thenortheastern region (Table 2).

3.2. Awareness, Treatment, and Control. Table 3 shows theproportion of awareness diabetes, treatment, and controlof fasting plasma glucose, high blood pressure, or bothamong individuals with coexistence of both conditions.Approximately half of the people with the coexistence wereunaware of either one condition and 85% of them wereunaware of having both conditions. More people were nottreated for hypertension compared to treatment for diabetes.Less than 20% of the individuals were controlled for eachcondition, and only 6.2% of those with both conditions andtreated had their blood glucose and blood pressure undercontrol (Table 3).

3.3. Factors Associated with Comorbidity of Diabetes andHypertension. Table 4 shows factors that were associatedwith the coexistence compared to those with having either


Table 2: Prevalence (95%CI) of diabetes, hypertension and coexistence of both conditions by area of residence and region in Thai populationaged ≥15 years.

DM only% (95%CI)

HT only% (95%CI)

Coexistence of both% (95%CI)

Male

Urban 3.8 (3.1, 4.7) 22.8 (20.6, 25.2) 3.9 (3.4, 4.5)

Rural 2.8 (2.1, 3.9) 20.2 (18.1, 22.6) 2.4 (1.9, 3.0)

Region

Central 2.8 (2.3, 3.6) 22.2 (19. 5, 25.3) 3.2 (2.7, 3.8)

Northeastern 3.7 (2.3, 5.1) 18.6 (14.9, 23.0) 2.6 (1.7, 3.8)

North 2.4 (1.8, 3.3) 25.1 (21.2, 29.4) 2.6 (2.0, 3.4)

South 2.4 (1.4, 4.3) 17.9 (15.6, 20.5) 2.2 (1.6, 3.0)

Bangkok 4.3 (3.1, 5.8) 17.5 (14.3, 21.1) 5.2 (3.8, 7.0)

Female

Urban 3.4 (2.9, 4.0) 18.0 (16.5, 19.6) 3.9 (3.5, 4.3)

Rural 3.6 (3.0, 4.5) 17.2 (15.8, 18.7) 3.5 (3.1, 4.0)

Region

Central 3.2 (2.5, 4.1) 19.2 (17.3, 21.3) 3.4 (3.0, 4.0)

North eastern 4.5 (3.3, 6.1) 16.0 (13.8, 18.4) 3.9 (3.1, 4.8)

North 3.0 (2.4, 3.7) 19.2 (16.1, 22.6) 3.6 (2.9, 4.4)

South 2.9 (2.3, 3.7) 15.0 (13.3, 16.8) 3.0 (2.2, 4.1)

Bangkok 3.9 (2.6, 5.9) 14.6 (12.9, 16.5) 4.4 (3.6, 5.4)

Table 3: Proportion of awareness, treated, and controlled of those having diabetes, hypertension, and coexistence of both conditions in Thaipopulation aged ≥15 years.

Male% (95%CI)

Female% (95%CI)

Total% (95%CI)

Diabetes only

Aware 43.3 (37.1, 49.8) 61.9 (55.4, 68.0) 54.1 (48.3, 59.8)

Treated 40.8 (34.9, 47.0) 60.2 (53.9, 66.2) 52.1 (46.5, 57.6)

Controlled among treated 33.2 (27.1, 40.0) 38.1 (32.4, 44.0) 36.5 (32.4, 40.7)

Hypertension only

Aware 43.0 (36.7, 49.5) 52.3 (46.1, 58.5) 48.4 (43.0, 53.9)

Treated 36.4 (30.5, 42.7) 46.0 (39.7, 52.1) 42.0 (36.9, 47.3)


Coexistence of both

Aware 26.6 (21.9, 32.0) 39.3 (33.5, 45.3) 34.0 (29.4, 38.9)

Treated 22.4 (18.6, 26.7) 34.6 (29.0, 40.7) 29.5 (25.3, 34.1)


Controlled target of FPG for those with diabetes alone: FPG at <130 mg/dL.Controlled target of blood pressure for those with hypertension alone: SBP/DBP at <140/90 mm Hg.Controlled target of blood pressure for those having coexistence of diabetes and hypertension: SBP/DBP at <130/80 mm Hg.

diabetes or hypertension alone. After controlling for poten-tial confounding factors of sociodemographic variablesincluding age, sex, education, urban/rural are as, geographicregion, obesity (BMI ≥ 25 kg/m2), and abdominal obesity,factors that were associated with the coexistence of bothconditions included: age ≥60 years (adjusted odds ratio(OR) 1.38, 95%CI 1.14, 1.70), living in urban area (1.15,95%CI 1.0, 1.30), having education less than 6 years (1.83,95%CI 1.03, 3.38), and abdominal obesity (2.49, 95%CI

2.00, 3.10). Note that BMI ≥ 25 kg/m2 was not significantlyassociated with the coexistence in the multivariable model.Additional analysis for multivariable logistic regression wasperformed using BMI cut-off point at 30 kg/m2, instead of at25 kg/m2. The results showed that BMI ≥ 30 kg/m2 still wasnot significantly associated with the coexistence of diabetesand hypertension (adjusted OR 1.17, 95%CI 0.91, 1.50),whereas abdominal obesity remains statistically significance(2.50, 95%CI 2.01, 2.97).


Table 4: Factors associated with coexistence of hypertension and diabetes compared to those having either diabetes or hypertension alone.

Unadjusted OR Adjusted OR∗

Female (versus male = 0) 1.48 (1.26, 1.73) 1.02 (0.85, 1.20)

Age ≥60 years (aged 15–<59 yrs = 0) 1.50 (1.30, 1.74) 1.38 (1.14, 1.70)

Urban (versus rural = 0) 1.22 (1.03, 1.45) 1.15 (1.00, 1.30)

Education (versus no formal education = 0)

less than 6 year 1.93 (1.09, 3.42) 1.83 (1.03, 3.38)

secondary 0.92 (0.52, 1.63) 0.96 (0.54, 1.72)

university 1.06 (0.54, 2.06) 1.06 (0.56, 2.01)

BMI ≥ 25 kg/m2 (versus BMI < 25 kg/m2 = 0) 1.80 (1.54, 2.10) 1.07 (0.86, 1.34)

Abdominal obesity (versus no = 0) 2.58 (2.18, 3.06) 2.49 (2.00, 3.10)∗

Adjusted OR controlled for age, area of residence, education, geographic region, BMI status, and abdominal obesity; abdominal obesity: waist circumference≥90 cm in male and ≥80 cm in female.

4. Discussion

This study added more information on characteristics ofindividuals with coexistence of diabetes and hypertension inThai population. A half of the people with diabetes also hadhypertension and about 14% of hypertensive patients haddiabetes. The prevalence of 3.2% of the coexistence corre-sponds to an estimated 1.5 million of Thai population havingboth conditions. After controlling for covariates, patientswith the coexistence of diabetes and hypertension were likelyto be older, having lower education and abdominal obesity.There were limited data on prevalence of the coexistingconditions in Asian populations. Although the prevalence ofdiabetes or hypertension in Thai population was comparableto that of other Asian countries [12], it is unclear whether theprevalence of the coexistence of both conditions is differentfrom those of other Asian populations. Further studies of thisissue might be warrant.

The coexistence of diabetes and hypertension increasesrisk of cardiovascular diseases [7, 13], renal complications,and retinopathy [7]. Randomized control trial studiesdemonstrated that aggressive control of blood pressure anddiabetes could improve the CVD outcomes [14]. Therefore,early detection and control of the coexisting of the diseaseare essential. However, the present study revealed thatawareness of the coexistence of both conditions was verylow with less than 30% of individuals with both conditionsbeing treated and less than 10% of the conditions beingsimultaneously controlled. The findings suggested that over1 million individuals with both conditions were not detectedand treated for their conditions.

Awareness of diabetes, hypertension and coexistence ofboth were lower in men than in women. This might reflectthat men are less likely to seek health care and less healthconcern compared to women. This finding is consistentwith the national survey data showing the higher healthcare utilization among women than men [15]. This findingsuggests that health education program should be focusedmore on men.

The high proportion of having hypertension in patientswith diabetes (78.4%) had been reported in a study using thedata from the Thai diabetes registry [16]. The proportion

found in this study was lower than that of the registrydata, because the cases in the registry were from the tertiarycare hospitals, where severe cases of diabetes were morelikely to be found. However, the proportion of hypertensionin patients with diabetes in this study was higher thanthat of the United Kingdom prospective diabetes study(UKPDS), which reported the proportion of 39% [17, 18].The proportion of diabetes among hypertensive patientsin this study was slightly lower than what found in theUS where the proportion of individuals with hypertensionhaving diabetes was 19.8% [19]. These findings are consistentwith previous review [13] in that approximately half ofthe diabetes patients have hypertension, and hypertensionwas about twice as frequent in individuals with diabetescompared to those without diabetes.

BMI is a measure of total obesity and abdominal obesityis an indicator for abdominal fat deposition. This studyfound that abdominal obesity was a stronger risk factor forthe coexistence of diabetes and hypertension. This findingwas consistent with many studies and review on evidence ofWC being a stronger risk factor for cardiovascular diseasesand metabolic syndrome as compared to BMI [20–23].However, some recent studies argued that the evidenceto replace BMI with waist circumference for clinical orpublic health practice has not been strong enough [24, 25].More research, particularly in Asian populations, is neededto confirm whether measuring abdominal obesity shouldreplace BMI in surveillance of cardiovascular risk factors.

Other factors associated with the coexistence includededucation level less than 6 years. In a previous study we alsoreported that hypertension was more prevalent among thosewith lower education [5]. It is possible that those with lowereducation were at high risk, because they might have worseunhealthy lifestyles. In those with inadequate control eitherdiabetes or hypertension might lead to the development ofthe other condition. A study reported that patients withhypertension are 2.5 times more likely to develop diabetescompared to those with normotension [13].

The strength of this study includes having large samplesize and being a representative data that allows the analysisof each condition and the coexistence. Some limitations ofthe present study should be mentioned. First, the present


study might underestimate the true prevalence of diabetes,since only FPG was used. Two-hour glucose tolerance testwas reported to be more accurate in detection of undiag-nosed diabetes compared to measurement of fasting plasmaglucose; however, FPG test was more feasible to performin field survey [26]. Second, the measurement of bloodpressure could be subject to overestimation due to the effectof white coat hypertension. However, the measurement wasdone according to the standard protocol for blood-pressuremeasurement and the procedure was done in the community,so this effect might be minimal. Third, the cross-sectionaldesign might preclude drawing conclusion about cause effectrelationship between risk factors and the comorbidity.

The implication of this study is that the health caresystem should be designed to strengthen comprehensivehealth care of coexistence of diabetes and hypertension inorder to increase detection, treatment, and control of thoseaffected. In addition, individuals with obesity or those withlow educational levels were at higher risk and should betargeted.

5. Conclusion

Patients with diabetes or hypertension should be screenedfor coexistence of another condition, and they should bepromoted to have weight control in order to prevent thecomorbidity. More stringent control of plasma glucose andblood pressure among these patients should be applied.

Acknowledgments

This study was supported by the Bureau of Policy andStrategy, Ministry of Public Health, the National HealthExamination Survey Office, Health System Research Insti-tute, and the National Health Security Office, Thailand.The authors thank Professor Dr. Amnuay Thithapandha,Mahidol University for his help in editing the paper.

References

[1] W. Aekplakorn, J. Abbott-Klafter, A. Premgamone et al.,“Prevalence and management of diabetes and associatedrisk factors by regions of Thailand: third National healthexamination survey 2004,” Diabetes Care, vol. 30, no. 8, pp.2007–2012, 2007.

[2] Ministry of Public Health, Thailand Health Profile 2005-2006,Bureau of Policy and strategy, Ministry of Public Health,Nonthaburi, Thailand, 2007.

[3] J. Stamler, O. Vaccaro, J. D. Neaton, and D. Wentworth, “Dia-betes, other risk factors, and 12-yr cardiovascular mortality formen screened in the multiple risk factor intervention trial,”Diabetes Care, vol. 16, no. 2, pp. 434–444, 1993.

[4] A. H. Mokdad, E. S. Ford, B. A. Bowman et al., “Diabetestrends in the U.S.: 1990–1998,” Diabetes Care, vol. 23, no. 9,pp. 1278–1283, 2000.

[5] W. Aekplakorn, J. Abbott-Klafter, P. Khonputsa et al., “Preva-lence and management of prehypertension and hypertensionby geographic regions of Thailand: the third National healthexamination survey, 2004,” Journal of Hypertension, vol. 26, no.2, pp. 191–198, 2008.

[6] W. Aekplakorn, “Prevalence, treatment, and control ofmetabolic risk factors by BMI status in Thai adults: Nationalhealth examination survey III,” Asia-Pacific Journal of PublicHealth, vol. 23, no. 3, pp. 298–306, 2011.

[7] A. V. Chobanian, G. L. Bakris, H. R. Black et al., “Theseventh report of the joint National committee on prevention,detection, evaluation, and treatment of high blood pressure:the JNC 7 report,” The Journal of the American MedicalAssociation, vol. 289, no. 19, pp. 2560–2572, 2003.

[8] Report of a WHO Expert Committee, “Physical status: the useand interpretation of anthropometry,” WHO Technical Report854, World Health Organization, Geneva, Switzerland, 1995.

[9] American Diabetes Association, “Standards of medical care indiabetes—2010,” Diabetes Care, vol. 33, 1, pp. S11–S61, 2010.

[10] Ministry of Public Health, Thai Clinical Practice Guidelines forDiabetes, Ministry of Public Health, Bangkok, Thailand, 2001.

[11] Asia-Pacific Steering Committee and J. Bassett, The AsiaPacific Perspective: Redefining Obesity and Its Treatment, WorldHealth Organization, International Association for the Studyof Obesity, International Obesity Task Force, Melbourne,Australia, 2000.

[12] J. C. N. Chan, V. Malik, W. Jia et al., “Diabetes in Asia:epidemiology, risk factors, and pathophysiology,” The Journalof the American Medical Association, vol. 301, no. 20, pp. 2129–2140, 2009.

[13] T. W. Gress, F. J. Nieto, E. Shahar, M. R. Wofford, and F. L.Brancati, “Hypertension and antihypertensive therapy as riskfactors for type 2 diabetes mellitus,” The New England Journalof Medicine, vol. 342, no. 13, pp. 905–912, 2000.

[14] A. I. Adler, I. M. Stratton, H. A. W. Neil et al., “Association ofsystolic blood pressure with macrovascular and microvascularcomplications of type 2 diabetes (UKPDS 36): prospectiveobservational study,” British Medical Journal, vol. 321, no.7258, pp. 412–419, 2000.

[15] The 2004 Health and Welfare Survey Report, National StatisticalOffice, Ministry of Information and Communication Technol-ogy, Bangkok, Thailand, 2004.

[16] P. Bunnag, N. Plengvidhya, C. Deerochanawong et al., “Thai-land diabetes registry project: prevalence of hypertension,treatment and control of blood pressure in hypertensive adultswith type 2 diabetes,” The Journal of the Medical Association ofThailand, vol. 89, supplement 1, pp. S72–S77, 2006.

[17] B. Williams, “The hypertension in diabetes study (HDS): acatalyst for change,” Diabetic Medicine, vol. 25, no. 2, pp. 13–19, 2008.

[18] R. Turner, I. Stratton, V. Fright, R. Holman, S. Manley, andC. Cull, “Hypertension in diabetes study (HDS): I. Prevalenceof hypertension in newly presenting type 2 diabetic patientsand the association with risk factors for cardiovascular anddiabetic complications,” Journal of Hypertension, vol. 11, no.3, pp. 309–317, 1993.

[19] B. M. Egan, Y. Zhao, and R. N. Axon, “US trends in prevalence,awareness, treatment, and control of hypertension, 1988–2008,” The Journal of the American Medical Association, vol.303, no. 20, pp. 2043–2050, 2010.

[20] G. Vazquez, S. Duval, D. R. Jacobs Jr., and K. Silventoinen,“Comparison of body mass index, waist circumference, andwaist/hip ratio in predicting incident diabetes: a meta-analysis,” Epidemiologic Reviews, vol. 29, no. 1, pp. 115–128,2007.

[21] W. Aekplakorn, V. Kosulwat, and P. Suriyawongpaisal, “Obe-sity indices and cardiovascular risk factors in Thai adults,”International Journal of Obesity, vol. 30, no. 12, pp. 1782–1790,2006.


[22] T. Pischon, H. Boeing, K. Hoffmann ” et al., “General andabdominal adiposity and risk of death in Europe,” The NewEngland Journal of Medicine, vol. 359, no. 20, pp. 2105–2120,2008.

[23] V. Hirani, P. Zaninotto, and P. Primatesta, “Generalisedand abdominal obesity and risk of diabetes, hypertensionand hypertension-diabetes co-morbidity in England,” PublicHealth Nutrition, vol. 11, no. 5, pp. 521–527, 2008.

[24] A. E. Taylor, S. Ebrahim, Y. Ben-Shlomo et al., “Comparisonof the associations of body mass index and measures ofcentral adiposity and fat mass with coronary heart disease,diabetes, and all-cause mortality: a study using data from 4UK cohorts,” American Journal of Clinical Nutrition, vol. 91,no. 3, pp. 547–556, 2010.

[25] P. Sebo, S. Beer-Borst, D. M. Haller, and P. A. Bovier, “Reli-ability of doctors’ anthropometric measurements to detectobesity,” Preventive Medicine, vol. 47, no. 4, pp. 389–393, 2008.

[26] C. C. Cowie, K. F. Rust, E. S. Ford et al., “Full accounting ofdiabetes and pre-diabetes in the U.S. population in 1988–1994and 2005-2006,” Diabetes Care, vol. 32, no. 2, pp. 287–294,2009.

Hypertension and Diabetes: Entry Points for Prevention and...

Documents

Transcript of Hypertension and Diabetes: Entry Points for Prevention and...