Inducing remission of Type 2 diabetes in the Caribbean: findings from a mixed methods feasibility study of a low-calorie liquid diet-based intervention in Barbados.

AIM: In a high proportion of people with recently diagnosed Type 2 diabetes, a short (2-3-month) low-calorie diet is able to restore normal glucose and insulin metabolism. The aim of this study was to determine the feasibility of this approach in Barbados. METHODS: Twenty-five individuals with Type 2 diabetes diagnosed within past 6 years, not on insulin, BMI ≥ 27 kg/m2 were recruited. Hypoglycaemic medication was stopped on commencement of the 8-week liquid (760 calorie) diet. Insulin response was assessed in meal tests at baseline, 8 weeks and 8 months. Semi-structured interviews, analysed thematically, explored participants' experiences. 'Responders' were those with fasting plasma glucose (FPG) < 7 mmol/l at 8 weeks. RESULTS: Ten men and 15 women (mean age 48, range 26-68 years) participated. Mean (sd) BMI was 34.2 kg/m2 (6.0); FPG 9.2 mmol/l (2.2). Mean weight loss at 8 weeks and 8 months was 10.1 kg [95% confidence interval (CI) 8.1, 12.0] and 8.2 kg (95% CI 5.8, 10.6); FPG was lower by 2.2 mmol/l (95% CI 1.2, 3.2) and 1.7 mmol/l (95% CI 0.8, 2.7) respectively. Nine of 11 (82%) of those who lost ≥ 10 kg were 'responders' compared with 6 of 14 (43%) who lost < 10 kg (P = 0.048). The 30-min insulin increment was higher in responders at baseline and follow-up (P ≤ 0.01). A food culture based on starchy foods and pressures to eat large amounts at social events were among the challenges identified by participants. CONCLUSIONS: The feasibility of this approach to weight loss and diabetes remission in a predominantly black population in Barbados was demonstrated.

The prevalence of peripheral neuropathy severe enough to cause a loss of protective sensation in a population-based sample of people with known and newly detected diabetes in Barbados: a cross-sectional study.

AIMS: To determine the prevalence and potential risk factors for diabetic peripheral neuropathy with a loss of protective sensation in Barbados. METHODS: A representative population sample aged > 25 years with previously diagnosed diabetes or a fasting blood glucose ≥ 7 mmol/l or HbA1c ≥ 48 mmol/mol (6.5%) was tested by 10 g monofilament at four plantar sites per foot and a 28 Hz tuning fork and neurothesiometer at the hallux. Data were adjusted to the age structure of people with diabetes in Barbados. Multivariable logistic regression assessed associations with peripheral neuropathy with a loss of protective sensation. RESULTS: Of 236 participants [74% response rate, 33% men, 91% black, median age 58.6 years, mean BMI 30.1 kg/m2 , mean HbA1c 54 mmol/mol (7.1%)], 51% had previously diagnosed diabetes. Foot examination demonstrated that 25.8% (95% CI 20.2 to 31.5) had at least one insensate site with monofilament testing, 14.8% (95% CI 10.2 to 19.4) had an abnormal tuning fork test and 10.9% (95% CI 6.9 to 14.9) had a vibration perception threshold > 25 V. Peripheral neuropathy with a loss of protective sensation prevalence was 28.5% (95% CI 22.7 to 34.4) as indicated by monofilament with ≥ 1 insensate site and/or vibration perception threshold > 25 V. With previously diagnosed diabetes the prevalence was 36.4% (95% CI 27.7 to 45.2) with 98.4% of cases identified by monofilament testing. Increasing age, previously diagnosed diabetes, male sex and abdominal obesity were independently associated with peripheral neuropathy with a loss of protective sensation. CONCLUSIONS: Over a third of people with previously diagnosed diabetes had evidence of peripheral neuropathy with a loss of protective sensation. Monofilament testing alone may be adequate to rule out peripheral neuropathy with a loss of protective sensation. Monofilament and neurothesiometer stimuli are reproducible but dependent on participant response.

Adverse risk factor trends limit gains in coronary heart disease mortality in Barbados: 1990-2012.

BACKGROUND: Although most countries face increasing population levels of obesity and diabetes their effect on coronary heart disease (CHD) mortality has not been often studied in small island developing states (SIDs) where obesity rates are among the highest in the world. We estimated the relative contributions of treatments and cardiovascular risk factors to the decline in CHD mortality from 1990 to 2012 in the Caribbean island, Barbados. METHODS: We used the IMPACT CHD mortality model to estimate the effect of increased coverage of effective medical/surgical treatments and changes in major CHD risk factors on mortality trends in 2012 compared with 1990. We calculated deaths prevented or postponed (DPPs) for each model risk factor and treatment group. We obtained data from WHO Mortality database, population denominators from the Barbados Statistical Service stratified by 10-year age group (ages 25-34 up to 85 plus), population-based risk factor surveys, Global Burden of Disease and Barbados' national myocardial infarction registry. Monte Carlo probabilistic sensitivity analysis was performed. RESULTS: In 1990 the age-standardized CHD mortality rate was 109.5 per 100,000 falling to 55.3 in 2012. Implementation of effective treatment accounted for 56% DPPs (95% (Uncertainty Interval (UI) 46%, 68%), mostly due to the introduction of treatments immediately after acute myocardial infarction (AMI) (14%) and unstable angina (14%). Overall, risk factors contributed 19% DPPs (95% UI 6% to 34%) mostly attributed to decline in cholesterol (18% DPPs, 95% UI 12%, 26%). Adverse trends in diabetes: 14% additional deaths(ADs) 95% UI 8% to 21% ADs) and BMI (2% ADs 95%UI 0 to 5% ADs) limited potential for risk factor gains. CONCLUSIONS: Given the significant negative impact of obesity/diabetes on mortality in this analysis, research that explores factors affecting implementation of evidenced-based preventive strategies is needed. The fact that most of the decline in CHD mortality in Barbados was due to treatment provides an example for SIDs about the advantages of universal access to care and treatment.

Deriving an optimal threshold of waist circumference for detecting cardiometabolic risk in sub-Saharan Africa.

BACKGROUND: Waist circumference (WC) thresholds derived from western populations continue to be used in sub-Saharan Africa (SSA) despite increasing evidence of ethnic variation in the association between adiposity and cardiometabolic disease and availability of data from African populations. We aimed to derive a SSA-specific optimal WC cut-point for identifying individuals at increased cardiometabolic risk. METHODS: We used individual level cross-sectional data on 24 181 participants aged ⩾15 years from 17 studies conducted between 1990 and 2014 in eight countries in SSA. Receiver operating characteristic curves were used to derive optimal WC cut-points for detecting the presence of at least two components of metabolic syndrome (MS), excluding WC. RESULTS: The optimal WC cut-point was 81.2 cm (95% CI 78.5-83.8 cm) and 81.0 cm (95% CI 79.2-82.8 cm) for men and women, respectively, with comparable accuracy in men and women. Sensitivity was higher in women (64%, 95% CI 63-65) than in men (53%, 95% CI 51-55), and increased with the prevalence of obesity. Having WC above the derived cut-point was associated with a twofold probability of having at least two components of MS (age-adjusted odds ratio 2.6, 95% CI 2.4-2.9, for men and 2.2, 95% CI 2.0-2.3, for women). CONCLUSION: The optimal WC cut-point for identifying men at increased cardiometabolic risk is lower (⩾81.2 cm) than current guidelines (⩾94.0 cm) recommend, and similar to that in women in SSA. Prospective studies are needed to confirm these cut-points based on cardiometabolic outcomes.International Journal of Obesity advance online publication, 31 October 2017; doi:10.1038/ijo.2017.240.

Systems Science for Caribbean Health: the development and piloting of a model for guiding policy on diabetes in the Caribbean.

BACKGROUND: Diabetes is highly prevalent in the Caribbean, associated with a high morbidity and mortality and is a recognised threat to economic and social development. Heads of Government in the Caribbean Community came together in 2007 and declared their commitment to reducing the burden of non-communicable diseases (NCDs), including diabetes, by calling for a multi-sectoral, systemic response. To facilitate the development of effective policies, policymakers are being engaged in the development and use of a system dynamics (SD) model of diabetes for Caribbean countries. METHODS: Previous work on a diabetes SD model from the United States of America (USA) is being adapted to a local context for three countries in the region using input from stakeholders, a review of existing qualitative and quantitative data, and collection of new qualitative data. Three country models will be developed using one-on-one stakeholder engagement and iterative revision. An inter-country model will also be developed following a model-building workshop. Models will be compared to each other and to the USA model. The inter-country model will be used to simulate policies identified as priorities by stakeholders and to develop targets for prevention and control. The model and model-building process will be evaluated by stakeholders and a manual developed for use in other high-burden developing regions. DISCUSSION: SD has been applied with success for health policy development in high-income country settings. The utility of SD in developing countries as an aid to policy decision-making related to NCDs has not been tested. This study represents the first of its kind.

A checklist that enhances the provision of education during insulin initiation simulation: a randomized controlled trial.

AIM: The study tested the hypothesis that doctors using an insulin information checklist during simulated insulin initiation would impart more information regarding insulin use. METHODS: A total of 128 simulations were conducted. Doctors (n = 64) were recruited from practitioners recently completing internship (n = 19) and those established in primary care (n = 45). Both groups of doctors were strata randomized to control (n = 32) and intervention groups (n = 32), so that each group contained equal numbers. Doctors in each group experienced two identical simulations of insulin initiation with an intervening period of 10 min. Doctors in the intervention arm were introduced to an insulin initiation checklist, which they reviewed independently and utilized in the second simulation. Trained assessors captured the provision of education in 21 predefined educational areas. Differences in the change of the total education provided between the first and second simulations were assessed using linear regression. RESULTS: The difference in the mean change of education provided between the first and second simulations within the 21 educational areas for the control and treatment groups was 9.7 [95% confidence interval (CI): 8.8-11.1, P < 0.001] - an increase of 46.2%. The difference for the 15 areas relevant to pen use was 7.3 (95% CI: 6.2-8.4, P < 0.001) - an increase of 51.6%. CONCLUSIONS: The checklist resulted in doctors providing significantly more education applicable to syringe and insulin pen routes of insulin administration during simulations. Further research is needed on the checklist's impact on healthcare professionals and patient outcomes in the clinical context. (Clinical Trials Registry No: NCT02266303).

Fasting blood glucose and insulin sensitivity are unaffected by HAART duration in Cameroonians receiving first-line antiretroviral treatment.

AIMS: This study assessed the relationship between highly active antiretroviral therapy (HAART) duration and cardiometabolic disorders in HIV-infected Cameroonians. METHODS: HIV-infected Cameroonians aged 21 years or above were cross-sectionally recruited at the Yaoundé Central Hospital, a certified HIV care centre, and their anthropometry, body composition (impedancemetry), fasting blood glucose (FBG) and lipid levels, and insulin sensitivity (IS; short insulin tolerance test) were measured. RESULTS: A total of 143 participants with various durations of HAART [treatment-naïve (n=28), 1-13 months (n=44), 14-33 months (n=35) and 34-86 months (n=36)] were recruited. They were mostly women (72%), and had a mean age of 39.5 (SD: 9.8) years. Half (52%) were using a stavudine-containing regimen. There was a significant trend towards a positive change in body mass index and waist-to-hip ratio with increasing duration of HAART (all P=0.02). Systolic (P=0.04) and diastolic (P=0.03) blood pressure, total cholesterol (P=0.01), prevalence of hypertension (P=0.04) and hypercholesterolaemia (P=0.007) were also significantly increased with HAART duration, whereas triglycerides, FBG and IS were unaffected. Clustering of metabolic disorders increased (P=0.02 for ≥1 component of the metabolic syndrome and P=0.09 for ≥2 components) with HAART duration. CONCLUSION: HAART duration is associated with obesity, fat distribution, blood pressure and cholesterol levels in HIV-infected Cameroonians, but does not appear to significantly affect glucose metabolism.

Correlates of short- and long-term case fatality within an incident stroke population in Tanzania.

BACKGROUND: This study aimed to identify correlates of case fatality within an incident stroke population in rural Tanzania. METHODS: Stroke patients, identified by the Tanzanian Stroke Incidence Project, underwent a full examination and assessment around the time of incident stroke. Records were made of demographic data, blood pressure, pulse rate and rhythm, physical function (Barthel index), neurological status (communication, swallowing, vision, muscle activity, sensation), echocardiogram, chest X-ray and computed tomography (CT) head scan. Cases were followed up over the next 3 - 6 years. RESULTS: In 130 incident cases included in this study, speech, language and swallowing problems, reduced muscle power, and reduced physical function were all significantly correlated with case fatality at 28 days and 3 years. Age was significantly correlated with case fatality at 3 years, but not at 28 days post-stroke. Smoking history was the only significant correlate of case fatality at 28 days that pre-dated the incident stroke. All other significant correlates were measures of neurological recovery from stroke. CONCLUSIONS: This is the first published study of the correlates of post-stroke case fatality in sub-Saharan Africa (SSA) from an incident stroke population. Case fatality was correlated with the various motor impairments resulting from the incident stroke. Improving poststroke care may help to reduce stroke case fatality in SSA.

Increased risk of tuberculosis disease in people with diabetes mellitus: record-linkage study in a UK population.

BACKGROUND: The authors aimed to determine whether, and by how much, diabetes mellitus (DM) increases the risk of tuberculosis (TB) and conversely whether TB increases the risk of DM. METHODS: Retrospective cohort analyses using data from two Oxford Record Linkage Study (ORLS) datasets, containing information on hospital admissions and day-case care between 1963 and 1998 (ORLS1) and between 1999 and 2005 (ORLS2), were carried out. The rate ratio (RR) for tuberculosis after admission to hospital with diabetes and for diabetes after hospital admission with tuberculosis was calculated. RESULTS: In ORLS1, the RR for TB in people admitted to hospital with DM, comparing the latter with a reference cohort, was 1.83 (95% CI 1.26 to 2.60), and in ORLS2 the RR was 3.11 (1.17 to 7.03). RRs for pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) within ORLS1 were similar at, respectively, 1.80 (1.16 to 2.67) and 1.98 (0.88 to 3.92). In ORLS 2 the RR for PTB was 2.63 (0.91 to 6.30). In ORLS1, there was no indication that TB was a risk factor for DM (RR 1.12, 0.76 to 1.60). The ORLS2 dataset was too small to analyse whether TB led to DM. DISCUSSION: DM was associated with a two- to threefold increased risk of TB within this predominantly white, English population. The authors found no evidence that TB increases the risk of DM. Our findings suggest that the risks of PTB and EPTB were both raised among individuals with DM. As DM prevalence rises, this association will become increasingly important for TB control and treatment.

Undiagnosed diabetes in the over-60s: performance of the Association of Public Health Observatories (APHO) Diabetes Prevalence Model in a general practice.

AIM: The Association of Public Health Observatories (APHO) Diabetes Prevalence Model has been interpreted to suggest that a substantial number of people with diabetes are 'missed'. An affluent suburb of Newcastle upon Tyne has a low known diabetes prevalence. We aimed to determine the true prevalence of diabetes in the practice population aged over 60 years and compare our prevalence estimate with that of the Association of Public Health Observatories Diabetes Prevalence Model (18.0%; uncertainty limit 10.7-27.7%). At baseline, the known prevalence of diabetes in this group was 7.4%. METHODS: All individuals aged 60 years and over registered with one general practice in Newcastle-upon-Tyne, not known to have diabetes (n = 1375), were invited for a standard oral glucose tolerance test and measurement of HbA(1c). Standard World Health Organization cut points for fasting and post-challenge glucose on oral glucose tolerance test or HbA(1c) ≥ 48 mmol/mol (6.5%) were used to identify diabetes. RESULTS: Five hundred and eighty-four individuals (42.5%) attended for screening. Using oral glucose tolerance test criteria, 4.5% were identified with undiagnosed diabetes. Using HbA(1c), 3.1% had undiagnosed diabetes. The estimated prevalence of total diabetes for the practice population aged 60 years and older is 11.8 (10.5-13.2%) and 10.3 (9.3-11.6) for oral glucose tolerance test and HbA(1c) criteria, respectively. CONCLUSIONS: The prevalence of diabetes in those aged 60 years and older registered with this practice is lower than the point estimate of the Association of Public Health Observatories Diabetes Prevalence Model, but within its uncertainty limits. Application of the Association of Public Health Observatories model must take into account its uncertainty limits.

Chronic non-communicable disease risk factor survey 2010 among University of the West Indies staff at Cave Hill, Barbados.

OBJECTIVE: To determine the prevalence of risk factors for chronic non-communicable diseases (CNCDs) among staff of The University of the West Indies (UWI), Cave Hill campus, in Barbados. METHODS: A self-administered questionnaire comprising validated questions from the WHO STEPS NCD Risk Factor Survey, the Jamaica Healthy Lifestyle (JHL) Survey and the Behaviour Risk Factor (BRF) Survey, was conducted during the Staff Health Day in May 2010, and at four locations on campus during July 2010. Standardized measurements of weight, height and blood pressure were taken. Data were analysed using EXCEL and STATA and results were compared to the Barbados 2007 STEPS NCD survey. RESULTS: The target population was all staff at the Cave Hill campus of UWI. The coverage rate was 25.2% (269/1068); 63.8% of males and 75% of females were either overweight or obese. Ninety-seven per cent ate less than the recommended 5 fruits and vegetables per day. Low levels of physical activity were reported in 51.9% of males and 62.2% of females. Thirty-two per cent of males and 13% of females were binge drinkers. All participants had at least one of the risk factors (current daily smoker < 5 fruits and vegetables/day, physical inactivity, overweight/obese and raised blood pressure) whilst 48% of males and 57.2% of females demonstrated three or more risk factors. These results are similar to those found in the Barbados STEPS NCD risk factor survey of 2007. CONCLUSION: The results confirm a similar high prevalence of NCD risk factors among Cave Hill UWI staff as among the Barbadian population. The study reveals opportunities to inform policy on strategies to positively impact the risk factors.

Chronic non-communicable disease Risk Factor Survey 2010 among University of the West Indies staff at Cave Hill, Barbados / Encuesta de 2010 Sobre Factores de Riesgo de las enfermedades no comunicables entre el personal de la Universidad de West Indies, en el Campus de Cave Hill, Barbados

OBJECTIVE: To determine the prevalence of risk factors for chronic non-communicable diseases (CNCDs) among staff of The University of the West Indies (UWI), Cave Hill campus, in Barbados. METHODS: A self-administered questionnaire comprising validated questions from the WHO STEPS NCD Risk Factor Survey, the Jamaica Healthy Lifestyle (JHL) Survey and the Behaviour Risk Factor (BRF) Survey, was conducted during the Staff Health Day in May 2010, and at four locations on campus during July 2010. Standardized measurements of weight, height and blood pressure were taken. Data were analysed using EXCEL and STATA and results were compared to the Barbados 2007 STEPS NCD survey. RESULTS: The target population was all staff at the Cave Hill campus of UWI. The coverage rate was 25.2% (269/1068); 63.8% of males and 75% of females were either overweight or obese. Ninety-seven per cent ate less than the recommended 5 fruits and vegetables per day. Low levels of physical activity were reported in 51.9% of males and 62.2% of females. Thirty-two per cent of males and 13% of females were binge drinkers. All participants had at least one of the risk factors (current daily smoker, < 5 fruits and vegetables/day, physical inactivity, overweight/obese and raised blood pressure) whilst 48% of males and 57.2% of females demonstrated three or more risk factors. These results are similar to those found in the Barbados STEPS NCD risk factor survey of 2007. CONCLUSION: The results confirm a similar high prevalence of NCD risk factors among Cave Hill UWI staff as among the Barbadian population. The study reveals opportunities to inform policy on strategies to positively impact the risk factors.

OBJETIVO: Determinar la prevalencia de los factores de riesgo de ENCs entre el personal de la Universidad de West Indies (UWI), en el campus de Cave Hill, Barbados. MÉTODOS: El Día de la Salud del Personal en mayo de 2010, y en cuatro localidades del campus durante julio de 2010, se aplicó un cuestionario auto-administrado formado por varias preguntas validadas de las encuestas conocidas como WHO STEPS NCD Risk Factor Survey, JHL Survey y BRF Survey. Se hicieron mediciones estandarizadas del peso, la altura, y la presión arterial. Los datos fueron analizados usando EXCEL y STATA, y los resultados fueron comparados como los de la encuesta de Barbados 2007 STEPS NCD. RESULTADOS: La población objeto del estudio estuvo formada por todo el personal en el campus de Cave Hill de la Universidad de West Indies (UWI). La tasa de cobertura fue 25.2% (269/1068); el 63.8% de los varones y el 75% de hembras tenían sobrepeso o eran obesos. Noventa y siete por ciento consumía menos de las 5 frutas y vegetales recomendados por día. Se reportaron bajos niveles de actividad física en 51.9% de los varones y 62.2% de las hembras. Treinta y dos por ciento de los varones y 13% de las hembras eran bebedores consumados. Todos los participantes tenían al menos uno de los factores de riesgo (fumador consuetudinario, < 5 frutas y vegetales/día, inactividad física, sobrepeso/obeso, y alta presión arterial) en tanto que el 48% de los varones y el 57.2% de las hembras mostraron tres o más factores de riesgo. Estos resultados son similares a los hallados en la encuesta Barbados STEPS NCD Risk Factor Survey del 2007. CONCLUSIÓN: Los resultados confirman una alta prevalencia de factores de riesgo de ENC entre el personal de Cave Hill de UWI similar a la existente entre la población barbadense en general. El estudio revela oportunidades de informar las políticas sobre estrategias de modo que puedan lograr un impacto positivo sobre los factores de riesgo.

Dutch versus English advantage in the epidemic of central and generalised obesity is not shared by ethnic minority groups: comparative secondary analysis of cross-sectional data.

BACKGROUND: Ethnic minority groups in Western European countries tend to have higher levels of overweight than the majority populations for reasons that are poorly understood. Investigating relative differences between countries could enable an investigation of the importance of national context in determining these inequalities. OBJECTIVE: To explore: (1) whether Indian and African origin populations in England and the Netherlands are similarly disadvantaged compared with the White populations in terms of the prevalence of overweight and central obesity; (2) whether the previously known Dutch advantage of relatively low overweight prevalence is also observed in Dutch ethnic minority groups and (3) the contribution of health behaviour and socio-economic position to the differences observed. METHODS: Secondary analyses of population-based studies of 16 406 participants from England and the Netherlands. Prevalence ratios were estimated using regression models. RESULTS: Except for African men, ethnic minority groups in both countries had higher rates of overweight and central obesity than their White counterparts. However, the Dutch minority groups were relatively more disadvantaged than English minority groups as compared with the majority populations. The Dutch advantage of the low prevalence of obesity was only seen in White men and women and African men. In contrast, English-Indian (prevalence ratio=0.87, 95% confidence interval (CI): 0.81-0.93) and English-Caribbean (prevalence ratio=0.82, 95% CI: 0.76-0.89) women were less centrally obese than their Dutch equivalents. The Dutch-Indian men were very similar to the English-Indian men. The contribution of health behaviour and socio-economic position to the observed differences were small. CONCLUSION: Contrary to the patterns in White groups, the Dutch ethnic minority women were more obese than their English equivalents. More work is needed to identify factors that may contribute to these observed differences.

International Diabetes Federation: An update of the evidence concerning the prevention of type 2 diabetes.

This article aims to provide an updated summary of diabetes prevention efforts by reviewing relevant literature published between 2007 and 2009. These include results from the long-term follow-up of diabetes prevention trials and the roll-out of community-based interventions in "real world" settings. Some countries have begun to implement population-based strategies for chronic disease prevention, but investment in developing and evaluating population-level interventions remains inadequate. By focussing on the "small change" approach and involving a number of different agencies, it may be possible to shift the population distribution of risk factors for diabetes and cardiovascular disease in a favourable direction. The cost-effectiveness of primary prevention strategies for type 2 diabetes has not been universally demonstrated. Some of the uncertainties relating to screening for diabetes have now been resolved but longer-term data on hard cardiovascular outcomes are still needed. In summary, individual countries should aim to develop and evaluate cost-effective, setting-specific diabetes risk identification and prevention strategies based on available resources. These should be linked to initiatives aimed at reducing the burden of cardiovascular disease, and complemented with population-based strategies focusing on the control and reduction of behavioural and cardiovascular risk factors by targeting their key determinants.

Meeting report on the Bellagio Conference 'prevention of vascular diseases in the emerging world: An approach to global health equity'.

Representatives from five international organizations (International Society of Nephrology, World Heart Federation, International Diabetes Federation, International Atherosclerosis Federation, and International Society of Hypertension) participated in a strategic planning workshop in December 2005 in Bellagio, Italy sponsored by the Rockefeller Foundation. There were equal representatives from developed and developing countries. Global perspectives on diabetes and cardiovascular and renal diseases were presented, with special emphasis on China, India, Latin America, and Africa. The rationale and effectiveness of preventive measures were discussed. It was apparent that measures for primary prevention and early intervention for all the chronic vascular diseases are similar. The five organizations agreed that an integrated global approach to chronic vascular diseases is needed. They resolved to collaborate and work towards an integrated approach to chronic vascular diseases with the establishment of a 5-year plan for the prevention and treatment of chronic vascular diseases, including public advocacy, advising international and national agencies, and improving education and the practice of established approaches.

Chronic non-communicable diseases.

Chronic non-communicable diseases (NCD) account for almost 60% of global mortality, and 80% of deaths from NCD occur in low- and middle-income countries. One quarter of these deaths--almost 9 million in 2005--are in men and women aged <60 years. Taken together, NCD represent globally the single largest cause of mortality in people of working age, and their incidences in younger adults are substantially higher in the poor countries of the world than in the rich. The major causes of NCD-attributable mortality are cardiovascular disease (30% of total global mortality), cancers (13%), chronic respiratory disease (7%) and diabetes (2%). These conditions share a small number of behavioural risk factors, which include a diet high in saturated fat and low in fresh fruit and vegetables, physical inactivity, tobacco smoking, and alcohol excess. In low- and middle-income countries such risk factors tend to be concentrated in urban areas and their prevalences are increasing as a result of rapid urbanization and the increasing globalisation of the food, tobacco and alcohol industries. Because NCD have a major impact on men and women of working age and their elderly dependents, they result in lost income, lost opportunities for investment, and overall lower levels of economic development. Reductions in the incidences of many NCD and their complications are, however, already possible. Up to 80% of all cases of cardiovascular disease or type-2 diabetes and 40% of all cases of cancer, for example, are probably preventable based on current knowledge. In addition, highly cost-effective measures exist for the prevention of some of the complications of established cardiovascular disease and diabetes. Achieving these gains will require a broad range of integrated, population-based interventions as well as measures focused on the individuals at high risk. At present, the international-assistance community provides scant resources for the control of NCD in poor countries, partly, at least, because NCD continue to be wrongly perceived as predominantly diseases of the better off. As urbanization continues apace and populations age, investment in the prevention and control of NCD in low-and middle-income countries can no longer be ignored.