The evidence supporting intervention in chronic diseases

December 04, 2007

Data from low, middle, and high income countries shows that tobacco control, salt reduction, and the use of multidrug regimens for patients with high-risk cardiovascular disease confirms these measures are cost effective and should be scaled up. These are the conclusions of Dr Thomas Gaziano, Brigham & Women's Hospital, Harvard Program for Health Division Science, Boston, MA, USA, and colleagues, author of this second paper in The Lancet's Chronic Diseases Series.

The authors also say that further assessment to determine the best national policies to achieve reductions in consumption of saturated and trans fat -- chemically hydrogenated plant oils -- could eventually lead to substantial reductions in cardiovascular disease. Changes in personal behaviour, health systems, and policy decisions are also analysed for their cost effectiveness.

One of the earliest and most cited community interventions is the North Karelia project, which began in Finland in 1972. The programme involved health education, screening, hypertension control, and treatment. In the first five years coronary heart disease mortality fell by 2.9% per year versus a 1% decline in the rest of Finland. Policy changes such as one in Poland in the early 1990s can also lead to significant health improvements. The Polish government reduced subsidies on animal fats (lard, butter) which led to a switch to polyunsaturated oils such as rapeseed and soyabean. Coronary heart disease mortality dropped by more than 25% between 1991 and 2002, an increase which could not be explained by increased fruit consumption or decreases in smoking.

The authors say that weight loss of between 5% and 10% and also minimal adherence to physical activity recommendations (expending 4200kJ per week in exercise) lead to health gains, in the case of minimal exercise this can be a 20%-30% reduction in risk of all cause mortality.

In low- and middle-income countries, cost-effectiveness of the intervention of salt reduction as a result of public education are quite favourable, ranging from being cost saving to US$200 per disability life year (DALY) averted; tobacco interventions have similar results, with measures such as increased pricing/taxation coming in at US$100 per DALY averted. Analyses from the Disease Control Priorities Project also show that replacing 2% of energy from trans fats with polyunsaturated fat can reduced coronary heart disease by 7-8%. If changes such as this are facilitated through voluntary action by industry or by regulation (eg. the banning of trans fats in New York restaurants), the US Food and Drug Administration believes this can be achieved for less than $0.50 per head. The authors say: "With this cost and the conservative estimate of an 8% reduction in coronary heart disease, the intervention is highly cost effective at $25-75 per DALY averted across the developing world. Assuming the greater reduction of 40% in coronary heart disease, the intervention is cost saving."

The authors conclude: "There is clear evidence that many interventions are cost effective. The Commission on Macroeconomics and Health has proposed a standard of three times gross national income (GNI) per head per DALY averted as being cost-effective. The World Bank estimates that GNI per head in 2006 was, on average, $650 for low-income countries and $3051 for middle-income countries. Tobacco interventions, salt reductions, and multidrug strategies to treat individuals with high-risk cardiovascular disease have acceptable cost-effectiveness ratios for low-income and middle-income countries on the basis of this criterion. If scale-up is feasible for many nations, then it would be reasonable to pursue these options immediately to achieve the projected goals of reducing rates of chronic disease by an additional 2% per year."
-end-
This paper associated with this release can be found at http://www.eurekalert.org/jrnls/lance/CD2.pdf

Lancet

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