Control of Six Risk Factors Would Reduce CVD Mortality by One-Third: 25x25 Global Road Map

May 04, 2014

MELBOURNE, AUSTRALIA – By adopting a comprehensive plan to reduce tobacco use, harmful alcohol use, salt intake, physical inactivity, and elevated blood pressure and glucose levels, countries can a go a long way toward reducing the risk of premature mortality from noncommunicable diseases (NCDs), including CVD, according to a new report[1].

In fact, if countries achieved the goals set out by the 25x25 World Health Assembly (WHA) road map, there would be a 22% reduction in premature deaths from CVD, cancer, diabetes, and chronic respiratory disease in men and a 19% reduction in women. Overall, controlling these six risk factors would reduce CV morality by more than one-third.

If it's just business as usual and risk factors aren't reduced, there would only be an 11% reduction in NCDs in men and a 10% reduction in women, according to investigators.

The NCD road map, which aims to reduce premature mortality from NCDs by 25% by 2025—the so-called 25x25 target—has been adopted by the WHA and was the focus of the first session on day one of the World Congress of Cardiology (WCC) 2014 Scientific Sessions in Melbourne, Australia.

Dr Majid Ezzati (Imperial College London, UK), who led the study of the effects of risk-factor control on premature NCD mortality, said the largest driver of the overall reduction is the decrease in CVD deaths. "In some sense, if you put aside tobacco, which obviously has large effects on cancer and CVD, these are really CV targets we're looking at rather than NCD targets," he told heartwire . "We don't have targets for a lot of the drivers of big cancers."

The article by Ezzati, first author Dr Vasilis Kontis (Imperial College London), and colleagues was published online May 3, 2014 in the Lancet to coincide with the WCC meeting.

High-Level UN Meeting on NCDs

The 25x25 goal is part of a United Nations political declaration to prevent and control NCDs; the declaration was developed after a high-level meeting among member countries three years ago. Back in 2011, CVD was identified as the number-one killer worldwide, with more than 80% of deaths occurring in low- and middle-income countries.

As part of their commitment to combat the problem, the countries adopted nine global targets, one of which is the 25% reduction in premature mortality from NCDs by 2025 (relative to 2010 levels). The World Heart Federation (WHF) has since set a goal to achieve a 25% reduction in premature CVD mortality given the recognition that a large focus on CVD would be necessary to achieve the WHA targets.

To achieve a 25% reduction in premature deaths from NCDs, participating countries agreed to reduce tobacco use by 30%, harmful alcohol intake by 10%, salt consumption by 30%, and hypertension by 25%, stem the rising obesity tide, and halt the rise in diabetes.

Speaking during the WCC session about the 25x25 plan, Dr Robert Beaglehole (University of Auckland, New Zealand), LancetNCD Action Group member and study author, said that population interventions are "absolutely key" to dealing with the preventable burden of NCDs. "They are cost-effective, they're the best buy, and they're easy," said Beaglehole. "There is no need to muck around with population interventions. We just have to get on and do it. And of particular priority is the importance of tobacco control."

Regarding tobacco control, banning smoking in public places, raising taxes on tobacco, banning tobacco advertising, using plain packaging, and helping people quit smoking with the help of their primary caregiver are all ways to achieve the 30% to 50% reduction in tobacco use, especially in lower- and middle-income countries, say the researchers.

Beaglehole noted their model showed that by improving control of the six risk factors, countries will come close to achieving the 25% reduction in premature mortality from NCDs by 2025. Teasing out four NCDs, the risk-factor intervention reduces premature mortality from all CVD by 34%, chronic respiratory diseases by 24%, all cancers by 7%, and diabetes by 5%.

Although the model predicts an overall 21% reduction in premature deaths from NCDs if the six variables are controlled, Ezzati told heartwire that if countries adopt a more aggressive reduction in tobacco use—say 50% instead of the recommended 30%—the 25% reduction in premature mortality from NCDs could be achieved in men and would come close in women (mainly because more men smoke than women globally).

Burden of Disease in Low- and Middle-Income Countries

Over 15 years, the 25x25 plan would delay or prevent 37 million deaths, with 16 million deaths prevented in people aged 30 to 69 years. In those younger than 70 years, approximately 11 million deaths from CVD could be averted between now and 2025. In terms of delayed and prevented deaths, most occur in low- and middle-income countries, and most are preventable CVD deaths. To heartwire , Ezzati said that high-income countries already do a good job treating CVD and have seen reductions in blood pressure, tobacco use, alcohol use, and cholesterol levels.

"The vast majority of these deaths averted are in low- and middle-income countries," added Beaglehole. "Achieving these targets will do a lot for reducing the inequalities in CVD death rates between high-income countries and low- and middle-income countries. This agenda can be seen to be part of a grand convergence in global health."

Dr Shanthi Mendis (World Health Organization, Geneva, Switzerland), who also spoke during the WCC session, said the recommendations on risk-factor control are extremely cost-effective when implemented at the population level, costing less than 50 cents per person. However, she acknowledged that accountability remains problematic, as member countries are not legally bound to fulfill their obligations and targets. In an accompanying editorial, Dr Rifat Atun (Harvard University, Boston, MA) makes the same point, noting that the "challenge of NCDs is less technical than political"[2]. However, Atun points to the HIV response and recent maternal and child health movement, which show what is possible when political will is mobilized.

Dr Mariell Jessup (University of Pennsylvania School of Medicine, Philadelphia), president of the American Heart Association(AHA), said the AHA supports the global initiative and has adopted their own strategic goal to improve the CV health of all Americans by 20% and reduce deaths from CVD and stroke by 20% by 2020.

The study authors and Atun report no conflicts of interest.

References

Kontis V, Mathers CD, Rehm J, et al. Contribution of six risk factors to achieving the 25x25 noncommunicable disease mortality reduction target: a modelling study. Lancet 2014; DOI: 10.1016/S0140-6736(14)60616-4. Summary
Atun R. Decisive action to end apathy and achieve 25x25 NCD targets. Lancet 2014; DOI: 10.1016/S0140-6736(14)60728-5 Extract