A global partnership between researchers in China and India has found cost-effective ways to treat people with cardiovascular disease in areas with limited resources.

The study result was recently published in Circulation with an invited editorial.

The simplified cardiovascular management program, also known as the SimCard study, was a one-year cluster-randomised controlled trial carried out in 47 villages in Tibet, China and Haryana, India where access to basic cardiovascular disease (CVD) management and appropriate medications were extremely limited.

The study enrolled 2086 (1,036 in China, 1,050 in India) individuals with high CVD risks, defined as over 40 years old with a self-reported history of CVD and a measured systolic blood pressure over 160mmHg. Community health workers (CHWs) were deployed and trained to manage those individuals with the assistance of an Android smartphone app consisting of a guideline-based but simplified CVD management program.

The combined results found in the study strongly demonstrated the effectiveness of this program in increasing the use of the anti-hypertensive medications, with the primary outcome being a net-difference of 25.5%. In China, a significant decrease in systolic blood pressure (-4.1mmHg) and increase in the proportion of taking aspirin (24.5%) were also observed. No actual lifestyle changes were found in both countries.

The study was carried out in 2011 by The George Institute for Global Health at Peking University Health Science Center (TGI @ PUHSC) in collaboration with Tibet University in China, and the Public Health Foundation of India (PHFI) in India. Larger and longer context-specific trials are needed to further refine the program and evaluate the hard outcomes.

Customised community-based intervention

As chronic disease burden has been significantly increased over the past decades, delivery of medical care has also changed from individual to population and community-based healthcare.

“Both population-based and high-risk strategies are needed for prevention and control of chronic diseases like CVD,” said Professor Lijing Yan, Principal Investigator of the study and Honorary Professorial Fellow at TGI @ PUHSC. “In resource-limited settings, it would be highly cost-effective if we could adapt the high-risk approach first and then integrate the strategies recommended by guidelines.”

A simplified ‘2+2’ intervention model, which consisted of two medications (blood pressure lowering agents and aspirin) and two lifestyle modifications (smoking cessation and salt reduction), was developed. The model was based on the international and national clinical guidelines for CVD management so that it can be easily implemented and incorporated into the existing local healthcare system as well.

The interventions were carefully tailored to the local cultures with strong support from local governments. For example, in Tibet, special education was carried out to alleviate concerns among Tibetan patients against western medicines.

The role of community health workers (CHWs)

Professor Yan said this study added to evidence demonstrating the potential effectiveness of CHWs in shifting and sharing the tasks of healthcare professionals, which can help reduce the cost of healthcare for individuals.

“Reliance on the overburdened and relatively small number of specialists to target the high-risk people in these areas is not feasible or sustainable. We need to look at models of care which can be inexpensive, accessible and available to everyone,” said Professor Yan. “CHWs are the key components of carrying out such kind of population-based strategies for CVD prevention and control, and can make things available at the doorstep.”

As a result, although no actual lifestyle changes were found, the intervention was effective in changing both the physician and patients’ behaviors in terms of medication prescription and use, as well as a potential to improve clinical outcomes.

The power of mobile technology

Dr. Maoyi Tian, senior research fellow at TGI @ PUHSC, said the smartphone-based electronic decision support system (EDSS) assisted the CHWs to provide standard and prompt care for the first time in these poorer settings.

“Preliminary results from the study have indicated that the EDSS has a large potential to assist the grass-roots level healthcare providers in clinical decisions and patient management in a highly efficient, cost-effective and time/energy-saving way,” said Dr. Tian.

“When implementing the study, it was also very encouraging to see that the CHWs, no matter whether they were young or senior, were willing and able to use the mobile devices.

“For the next steps, we should harness it and implement it on a larger-scale. We will be keen on improving it to a patient-centered design as well as link with local electronic health record system.”

Calling for more south-south collaboration

Despite the differences in the healthcare system, socioeconomic environment and culture, China and India both faced similar challenges in CVD prevention and control such as the rising burden of CVD, large urban-rural health disparities, limited resources and capacity.

Dr. Dorairaj Prabhakaran, Co-Investigator of the study in India and Vice President of PHFI, said that perception was one of the biggest challenges in combating chronic diseases like CVD and needed to be overcome. “People think chronic diseases are only problems for the rich, but we now know, having done this study in poorer settings that hypertension is a big problem. It’s affecting everyone in the population.”

“The study was the first dual-country trial of its kind worldwide and presented a good example for other collaborations between the developing countries in view of the huge synergy recognised and its inexpensiveness and sustainability. We should pool our resources together and collaborate more on areas of common interests in the future.”

Experts say more action is needed to reduce Australia’s salt consumption after new research by The George Institute for Global Health found we are falling behind other countries.

Dr Jacqui Webster, from the World Health Organisation Collaborating Centre on Salt Reduction at the Institute, said Australia needed a reboot in this important health initiative.

“The public health benefits of salt reduction can’t be stated strongly enough,” Dr Webster said.

“Simply put, reducing salt intake to the World Health Organisation target of 5 grams per person per day, will save thousands of lives at the same time as saving governments hundreds of millions of dollars in health costs.

“Excess sodium is a significant cause of high blood pressure, which is a major risk factor for cardiovascular disease (CVD), and this includes stroke and coronary heart disease.

“CVD is the world’s leading cause of death, killing 17 million people every year and around 2 million of these deaths are attributable to eating too much salt.

“In Australia if average salt intake was reduced by just three grams per day, an estimated 3,500 lives would be saved each year along with $200 million in health care costs.

“Australia has previously introduced some measures, but these results show that more can be done to help reduce that sodium content.

“We know that reducing salt takes more than just asking people to stop putting salt on their food at the dinner table, because around 70% of the salt we eat is hidden in processed foods.”

The global review assessed the progress of countries towards the World Health Organisation’s target of a 30% reduction by 2025, with the aim of achieving less than 5 grams per person per day.

Based on existing published data and country reports, it found:

• Australia’s salt intake is 8.9 grams per person, per day, placing it 19^th on the list
• This figure is higher than the United Kingdom (8.1g), Canada (8.5g), New Zealand (8.57g) and the United States (8.8g)
• Australia’s program of work with the industry has resulted in reduced salt levels in foods in some categories, including bread (9%) breakfast cereals (25%) processed meats (8%)
• A total of 75 countries now have a national salt reduction strategy
• 12 countries have so far reported a reduction in population salt intake, but Australia is not one of them

“These results show Australia still has some way to go to reach the 2025 targets that the Federal Government signed up to, but it can be done,” she said.

“Salt reduction strategies can include work with the industry, labelling and consumer education programs.

“Australia established its Food and Health Dialogue in 2010 to help improve the healthiness of the food supply.

“Some states such as Victoria are also to be commended for introducing strategies in this area, and now is the time to see an even bigger effort across the country.

“We have the targets set for reducing salt in foods set but progress seems to have slowed in recent years.

“An effective salt reduction strategy requires an improved determination and co-ordination from the government and food industry as well as more funding.

“The results will be immediate and real, saving thousands of lives and millions of dollars every year.”

Aussie children are getting a better start than their UK cousins, with Australian first research finding that the majority of baby and toddler foods sold at our supermarkets are of a high nutritional quality.

Senior author Professor Victoria Flood from the University of Sydney said the study, which examined 309 products from 17 manufacturers, showed results that appeared better than some other countries.

“The nutritional quality of baby and toddler foods has been largely overlooked in health research, but it is an increasingly important market to consider,” Prof Flood said.

“Our youngest children need the best possible start when they are naturally moved onto solid foods and begin to develop their habits and tastes.

“Only two other regions, the United Kingdom and Canada, have published research on the healthiness of their baby and toddler foods, with both countries showing higher levels of sodium and sugar overall than we have in similar products in Australia, so we are doing well.”

Director of the Food Policy division at the George Institute for Global Health, Professor Bruce Neal, said the toddler and baby food market was growing rapidly and this study provided an important benchmark to monitor changes in the sector.

“The market has grown at 4.8% a year for the past five years and is worth more than $300 million a year in Australia,” Prof Neal said.

“Part of the increase in this market can be attributed to time-poor parents needing to make quick food decisions and that isn’t likely to change any time soon, so we need to get it right.”

The findings, which have been published in the Maternal and Child Health Journal show:

• Only 19 products or 6% were high in saturated fat
• 92 products or 30% were considered high in sugar
• 72 products or 23% contained added sugar
• Salt was on the ingredient list for just 17 products and only five were considered high in sodium
• Only 25 products or just 8% had a Health Star Rating of less than 3 stars, while 45% were 4 out of 5 stars

Professor Flood said the taste preferences of infants meant that their eating habits should be carefully monitored in their early years.

“Young children naturally prefer sweet and salty foods over those with less sweet tastes such as vegetables,” she said.

“In Australia, the majority of infants are introduced to non-milk foods by the age of six months.

“Commercial baby foods are consumed by as many as 90% of children at nine months old and 50% of 18 month olds.

“So, the impact of these foods on children cannot be overestimated and we encourage all parents to pay close attention to what they are putting in their supermarket trolleys.”

It’s the 21st century way of tracking your sugar consumption. 

Producers of the popular documentary That Sugar Film, in partnership with The George Institute of Global Health, have developed a smartphone application that helps consumers calculate the exact amount of sugar they are eating. The app converts the total grams of sugar in everyday food and drinks into teaspoons, that then goes to a daily tally that helps consumers track and moderate their sugar intake.

The app uses data from The George Institute’s database of nutritional information covering around 90% of food products on Australian supermarket shelves. It is the largest independent database of packaged food products in Australia, and is the same database that powers our award-winning FoodSwitch app.

Professor Bruce Neal, Director of The George Institute’s Food Policy Unit, said: "Using technology to empower Australians to make better food choices helps address one of the nation's toughest health challenges. That Sugar App puts a much needed spotlight on sugar, which is added to the food supply in huge quantities. By combining the message of That Sugar Film with an engaging smartphone app I hope we can deliver some powerful educational and policy outcomes."

Director and star of That Sugar Film, Damon Gameau, said: "That app has been designed to be used by the whole family to help calculate the amount of sugar in food products. We are very grateful to the all the support we have received from The George Institute for Global Health and Good Pitch2 Australia, which has allowed us to make this app and information free to the public. We hope it brings greater understanding to where sugar is hiding in our food supply and arms people with the appropriate knowledge for make lasting, positive health changes."

In addition to tracking sugar intake, the app lets users take part in sugar challenges and share their progress with friends and family on Facebook. That Sugar app is available on iOS and Android in Australia.

For more information, go to thatsugarfilm.com/that-sugar-app