• Research Review
• Journal Review

Authors: C Hajat, O Harrison

Reference: Progress in Cardiovascular Diseases 2010; 53: 28-38 (open access on ProCor)
http://www.procor.org/news/news_show.htm?doc_id=1305731

Reviewer: Carlos Mendoza Montano, PhD, ProCor contributing editor; President, Guatemalan Association for the Prevention of Heart Diseases (APRECOR), Guatemala City, Guatemala

Reviewer comments: Cardiovascular disease (CVD) builds through the long-term exposure to unhealthy lifestyles. There are only a handful of examples globally of success at achieving population-level behavior change leading to a reduction in CVD risk. The Abu Dhabi approach has created a solid platform for scalable intervention, and for "learning by doing," with impact being monitored at the level of individuals, groups and the whole population. The unique data architecture in Abu Dhabi will enable the first CVD risk score to be developed for the region and the incorporation of novel, modifiable risk factors into the model. This document presents a summary of the article describing the approach of the Abu Dhabi Cardiovascular Program.

Location of study: United Arab Emirates (UAE)

Abu Dhabi context and cardiovascular burden: Abu Dhabi is the largest of the seven emirates making-up the UAE. The historic depth and pace of growth have brought tremendous benefits to the population including an increase in life expectancy at birth to 78 years; however, early data suggested a substantial increase in CVD, lifestyle-related cancers, and road deaths. Data during the last decade has suggested a rising burden from CVD risk, including hypertension and diabetes, in all Gulf Cooperation Council countries, but the UAE more so than expected from benchmark countries.

Genesis of the Abu Dhabi CVD initiative: Several factors prompted the development of the program, for example: extreme CVD burden in the region; relatively contained population generating statistical power; single health and research regulator facilitating the alignment of research, clinical, and public health priority areas; and strong track record in public health initiatives, helping build capacity and raise population health literacy. To begin the response to the Emirate's high burden of CVD, the "Weqaya" Population-wide Screening Program was launched in 2008. The screening tests were based on the core Framingham' indicators with a few additions. A total of 173,501 screened subjects were included in initial analyses from Weqaya data. The crude prevalence of diabetes in the current Weqaya population represents the most reliable data to date in the UAE. Rates of prediabetes are very high in this young population; up to 41% are expected to convert to diabetes for the coming five years, resulting in a predicted diabetes prevalence rate of around 30% by 2014.

Framingham Risk Score for the Weqaya population: The Framingham Risk Score was determined for the Weqaya population using the Framingham General CVD 10-year Risk Score to predict the number of CVD events in Abu Dhabi. The data output is being used for the health sector response for individual-level interventions and public health planning, reviewing models of delivery of health care, and is a key driver for the non-health sector response.

Abu Dhabi Approach to CVD risk intervention The Abu Dhabi approach has created a solid platform for scalable intervention, and for "learning by doing," with impact being monitored at the level of individuals, groups and the whole population. Based on the unique opportunities in Abu Dhabi, program developers set ambitious targets for the CVD risk control program, for example: to create a dramatic impact through coordinated activity of government, private, and civic sectors; to reducing Framingham-predicted cardiovascular events by 75% over 25 years; to make Abu Dhabi one of the healthiest environments to live in the World by 2030; to systematically influence decisions at the key levels involving the health as well as non-health sector, public and private.

Adapting and scaling the Abu Dhabi approach: The Abu Dhabi approach to tackling its CVD burden is large scale with a strong focus on implementation. The approach addresses a spectrum of behavior change interventions including those aimed at the individual, the group, and the population levels and those delivered by both the health and the non-health sectors. Abu Dhabi's unique circumstances make it an ideal location for developing and refining a response to CVD, including the overall program architecture, screening methods, and individual interventions. Alongside delivering domestic impact, there is a clear opportunity to share lessons learnt with other health systems. After pilots and refinement of the model, scale-up should be coordinated under global health governance.

Conclusions of the article: Within the unique environment of Abu Dhabi, the innovative Weqaya program has in its first two years delivered a Framingham Risk Score for almost every adult Emirati to drive individual-level intervention. Subsequently, the Abu Dhabi approach has created a solid platform for scalable intervention and for "learning by doing," with impact being monitored at the level of individuals, groups, and the whole population. Health authorities from Abu Dhabi hope to develop a population-wide program, driven from iterative individual screening (tailor-made, based on context and by available resources), and including an array of evidence-based interventions at the individual, group, and population levels. Such programs will be driven at country level, with global coordination under an apex organization capable of identifying and disseminating best practice to drive continuous improvement.

Additional References:
R D'Agostino, R Vasan, M Pencina, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 2008; 117: 743-753. (open access) http://circ.ahajournals.org/cgi/content/full/117/6/743

Institute of Medicine: In: V Fuster, B Kelly, editors. Promoting cardiovascular health in the developing world: a critical challenge to achieving global health. Washington DC: Institute of Medicine; 2010. (open access) http://www.nap.edu/openbook.php?record_id=12815&page=1