Resolve to Save Lives Partnering with Countries to Scale Up Prevention

Tom Frieden MD, MPH

President and Chief Executive Officer Increase global control of blood pressure from 14% to 50% When does

50 + 30 + 0 = 100? Reduce global dietary sodium intake by 30% Globally, we can save 100 million lives over Eliminate artificial trans the next 30 years 0% Cardiovascular Health A Global Movement Gains Momentum

REPLACE trans Hypertension treatment Sodium reduction Eliminate toxic New programs in India, Best practices from contaminant from China, Thailand, Bangladesh, Chile, South Korea, global food supply Vietnam, many Latin United Kingdom American countries Resolve to Save Lives’ Global Activities High 10.7 million deaths per year Hypertension is the BP leading risk factor for preventable deaths 3.2 Acute respiratory worldwide. 1.9 Diarrheal diseases

It kills more than any 1.6 AIDS other condition and more than all infectious 1.3 TB diseases combined.

0.6 Malaria For every 20 Ischemic Heart Stroke Mortality mm Hg Disease mortality

Increased Increased increase in death death begins at begins at systolic systolic systolic blood BP of 115 BP of 115 pressure, stroke and heart disease mortality doubles Clinical Clinical Definition of Definition of Hypertension Hypertension Beginning at systolic BP of 115! Lewington S., et al. Lancet. 2002;360:1903-1913. Of All Adult Primary Care Interventions, Improvement in Hypertension Control Can Save the Most Lives

25000 Blood pressure control

20000

15000

10000 Colonoscopy

Deaths prevented (per year) 5000 Mammography Pneumococcal & influenza vaccination 0 Cervical cancer 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% screening Percent eligible utilizing service Farley TA et al. Am J Prev Med 2010;38:600-609. Some Countries Do Better than Others Hypertension control in the US, Canada, and the UK Percentage of people with hypertension under control 68% 70% Canada 60% US 53% 50%

40% UK (England) 35% 28% 30% 19% 20%

10% 13%

0% 1990s 2010s

Data for Canada: McAlister et al. CMAJ, June 14, 2011, 183(9) & Padwal RS et al. Can J Cardiol 2016;32:687-694. Data for UK: Ramsey et al. BMJ 1999;319:630-635 & Health Survey for England 2015. Data for US: CDC Vital Signs, Sept. 2012; NHANES 2003-2010 & NCHS Data Brief 220, November 2015. Some Health Systems Do Better than Their Countries

100% Kaiser Permanente 90%

80%

70% US (National) Controlled

% 60%

50%

40% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

The Permanente Medical Group, Inc. (courtesy Marc Jaffe, MD) Most People With Hypertension Globally Do Not Have It Under Control 1.4 Billion 100% Less than 1 in 7 with hypertension worldwide 80% have it under control

60% 734M

40% 489M

20% 192M <14% 0% Have high blood Aware Treated Controlled pressure

Mills KT et al. Circulation. 2016 Aug 9;134(6):441 -450. 3 in 10 of England’s Adults Have Hypertension – And 5 Million People with Hypertension are Hiding in Plain Sight

15.1M 100% Only 1 in 3 adults with hypertension in England 80% have it under control 9.6M 60% 8.4M

40% 5.3M

20% 34.9%

0% Have high blood Aware Treated Controlled pressure

Data: Health Survey for England 2015.

Effective Hypertension Care As Pathfinder for Universal Health Coverage

Simple, Practical Medication and Team-Based Patient -Centered Information Protocol Equipment Care Services Systems Manage other chronic Supply Applicable to wide Improve patient support; Create feedback loops conditions; improve Improve purchasing range of chronic access to and confidence applicable to other evidence-based care; and supply chain health conditions in primary care; reduce conditions; strengthen reduce costs management reliance on hospital care; data-driven culture of reduce financial and other accountability and barriers quality improvement Treatment Protocols Improve Outcomes • Precise protocols to establish standard treatment of patients

• Drug- and dose-specific, with schedule for titration or addition of medications if blood pressure not controlled

• Eases logistics, training, task-sharing, financing, supervision, evaluation, and future changes

• >15 consensus conferences, >10 countries – common themes Treatment protocol: Punjab Primary most needed, most neglected Universal health Providing effective coverage must be hypertension treatment servicesrequires and more than a slogan facilitates establishment of effective primary health care systems Excessive Salt Increases Blood Pressure 99% of adults worldwide are above the WHO recommendation of 5g of salt per day

1.6 MILLION Lives could be saved each year by reducing sodium intake by 30% Sodium Reduction

Chile model Low sodium salts, Food-specific Government Educational industry targets as in buying standards approaches engagement United Kingdom Intervention Strategies Depend on the Sources of Salt

PACKAGED FOOD AWAY-FROM-HOME FOOD HOME

• Front-of-pack warnings • Food procurement • Behavior change policies campaigns • Reformulation by industry • Interventions that • Promotion of low-sodium address restaurants and salt substitutes vendors Salt Substitutes • Salt substitutes reduce blood pressure Sales of low-sodium salt increased –5.5 mmHg Systolic BP / 3 mmHg Diastolic BP during Shandong Province Initiative • Subsidies work +30% increase in use compared with promotion alone • Strong evidence of benefit Unpublished • Kitchens in retirement home randomized to data either regular sodium chloride or 50/50 potassium chloride/sodium chloride • Potassium salt group • 41% less likely to die of CVD • Spent less on health care

Hernandez AV, et al. Heart. 2019 Jan 19:heartjnl -2018. Li N, et al. PloSone. 2016. Chang H-Y et al. Am J Clin Nutr 2006;83:1289 -1296. Global Trans Fat Elimination Is Gaining Momentum At this pace, global elimination is achievable by 2023 In 2021, trans fat limits go into effect in the European Union

53

In 2015, Eurasian Economic Union countries limit trans fat 27 28 29 Denmark is the first 22 country to limit artificial 19 21 trans fat in 2003 13 9 6 7 1 1 1 1 1 2 3 3

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Public Food Procurement Policies for a Healthy Diet Require healthy nutrition standards for all food and beverages Venues Promote Core Government Settings Nutrition Standards • Hospitals • Purchased or subsidized with • Schools Trans-fat government funds • Childcare centers Sugar-sweetened • Military bases beverages • Served or sold by government • Prisons Sodium • Public parks and agencies either directly by the Sugar community centers government itself or through Saturated fat • Senior programs Government Retail Outlets private vendors or caterers Fruit and vegetables • Cafeterias/Canteens Whole grains • Vending machines • Kiosks, tuck shops 10 Lessons from Our First 2½ Years

1 Intense interest from countries: Don’t need 6 In-country teams essential for rapid progress convincing, need partnership, technical and to build capacity support, funds 7 For sodium reduction and blood pressure 2 World Health Organization: Branding/ treatment, industry engagement has so far reputation key, implementation often been unfruitful delayed 8 We can accelerate progress, but there are 3 : Funding key, spending is partner, country, and topical speed limits difficult 9 Prototyping is powerful and has helped build 4 Resolve is doing more direct a revolutionary digital tool for blood pressure implementation and sub-granting with a treatment and has potential for other areas wider range of partners than anticipated 10 Improving hypertension treatment requires 5 Donor flexibility has been crucial for rapid and facilitates improved primary health care progress ENGLAND

A Tale of Two Countries in CVD Prevention Progress

• Legacy of John Snow– father of modern epidemiology

• Dawson INTERIMReport, 1920 – outlined role and structure of future NHS

• Recognized importance of primary care and team-based care

• NHS – a national treasure

• Model for many country health systems

• Most valued national institution

• University of Oxford, Imperial College and others – impressive work on CVD

• Pioneer in sodium reduction – NYC and others sought guidance from England Unfinished Business Decline in sodium consumption stalled after 2011 • Universal access to healthcare hasn’t 9.5 translated to high rates of hypertension control or optimal other cardiovascular prevention 9

• Despite strong tobacco control polices, 6 million people continue to use tobacco 8.5

• Stall in sodium reduction after initial progress person) per (grams 8

appears to have resulted in thousands of Mean salt consumption daily additional heart attacks and strokes each year 7.5 • Unfinished business of complete trans fat 2005-06 2008 2011 2014

elimination Data: Public Health England. RESOLVETOSAVELIVES.ORG