INTEGRATED COMMUNITY AND PRIMARY CARE BASED

PREVENTION AND CONTROL OF CARDIOVASCULAR AND

OTHER NCD IN FYR of MACEDONIA

2002 – 2007

- WHO CINDI Programme -

VERA SIMOVSKA, MD.,PhD. National coordinator of

the Programme for prevention and control of CVD and other NCD in FYR of
Macedonia, 2002-2007
 .

INTEGRATED COMMUNITY AND PRIMARY CARE BASED

PREVENTION AND CONTROL OF CARDIOVASCULAR AND
OTHER NCD IN FYR of MACEDONIA

P R E F A C E

Necessity of well coordinated action aimed primarily to health promotion and primary
prevention of noncommunicable chronic diseases (NCD) such as: cardiovascular,
cerebrovascular and other circulatory diseases, diabetes, some types of carcinomas
and other NCD, leading according to morbidity, mortality, disability and the price of
health care in FYR of Macedonia imposed by larger investments by the Government
in realization of preventive measures and activities.

Giving support in preparation of coordinative activities and evaluation of interventions

aimed to prevention and control of the risk factors (RF) common for more of the NCD
is of primal importance, such as this Draft-Plan of Action for realization of integrated
intervention programme in FYR of Macedonia.

The programme is focused on prevention and control of common risk factors (RF)
related by high prevalence of behavioural unhealthy lifestyle and envoronmental
factors responsible for the appearance and development of the leading NCD such as
cardiovascular diseases (CVD), high important public health problem in the Republic.

The priority of the programme are settled on the base of the obtained results from the
clinical - epidemiologic researches of NCD, especially CVD and the problems
derived from the development of atherosclerosis in the past 10 years (1991-2001), as
well as on the base on data from the “Reports” of the regular vital statistics, published
by the State Institute of Statistics (1972-2001).

Besides this, the Draft - Action Plan is based on general information of the state
including geographic and climate conditions, demographic characteristics, social-
economic conditions, the health condition of the population, organization on the
health system and the reforms in the primary health care (PHC).
Fields of priority for action aimed to multiple reductions of morbidity and mortality
risk from NCD, according to the Action Plan are:

1.Cardiovascular diseases, especially ishaemic or coronary heart disease (CHD)

(heard attack) as well as
2.Cerebrovascular (stroke) and other circulatory diseases
3.Integrated preventive interventions are aimed to those RF that can be modified
and are common for several NCD and those are:
 - Behavioural (lifestyle) factors (unhealthy nutrition, sedentary lifestyle with
reduced level of physical activity under the necessary minimum, smoking,
increased consumption of alcohol and psycho-social stress) and
- biological factors (obesity, increased level of serum cholesterol and
tryglycerids in the blood, hyperglycemia and hypertension)

Smoking, increased consumption of alcohol and psychosocial stress are research

subject of particular national prevention programs. In purpose to achieve an adequate
evaluation of morbidity risk from prevention-therapeutic aspect and preparation of a
chart of global risk in the Republic, those risk factors are included in CINDI
Programme (questionnaires of WHO “CINDI Health Monitor” survey).

According to the Draft-Plan of action this preventive interventions are implemented in

the community and primary health care (PHC) because of their more efficient use and
with a possibility for connection with the public health institutions.
Principal achievement from organizing and implementation of this Action plan is the
integration of these projects in the health system in the period between 2002 and 2007.

Action plan is the main component in the effort of realization the reforms in health
system in FYR of Macedonia. With integration of the prevention of CVD and other
NCD in the health politic and with the reforms in the health care, a corresponding
support of the government can be acquired.

Application of the National Protocol will provide scientific information and evaluation
system, giving a contribution in the development of the health politics on national and
regional level.

The Plan of action is drawn-up on the recommendations based on theoretical

consideration presented and on the result and expiriences in North Karelia and WHO
CINDI Protocol and Quidelines.

Such concerned preventive action should reduce not only cardiovascular, but also
other major NCD , with an overall improvement in health and lengh of life.

Community-based intervention programme combined media and other messages with

broad ranging community activities involving sectors such as: PHC, NGO, school and
worksites, food manifactures, local media etc. The essential component of CINDI
Macedonia Programme is the system of first-rate monitoring and evaluation.

16.08.2002 Vera Simovska,MD.,PhD. National coordinator

Programme for prevention and control of CVD and
other NCD in FYR of Macedonia
WHO CINDI Programme, 2002-2007
 INTEGRATED COMMUNITY AND PRIMARY CARE BASED
PREVENTION AND CONTROL OF CARDIOVASCULAR AND
OTHER NCD IN FYR of MACEDONIA
PLAN OF ACTION, 2002-2007

C O N T E N T S

INTRODUCTION

First phase: Background

1.1. Analysis of situation in FYR of Macedonia
a) General information for FYR of Macedonia
b) Administrative structure and planning in the health department
(First two part are presented in the Supplement: “Situation analysis”)
c) Health conditions of the population (1972-2001)
- Mortality and morbidity of NCD and CVD
- Prevalence of biological (morph functional) and lifestyle (behavioral) risk factors
1.2. Problem statement
1.3. Main assumptions

Second phase: Establishing a national coordination

A) Establishing a location of the CINDI coordinative center with an information base
B) Establishing an organization structure for implementation of the programme
C) Preparation of the conceptual model of the CINDI programme

Third phase: Finalization of the action plan

Fourth phase: Baseline survey – “CINDI Health Monitor” (March-May, 2002)

Development of the national recommendations and intervention
methods for reduction risk factors for CVD and other NCD

Fifth phase: Forming a national register for risk factors of CVD and NCD
A) Results from the risk factor survey on demonstration level in 2002 and
periodical research on national level in 2004 (“CINDI Health Monitor”)
B) Forming a national register for risk factors of CVD and NCD in FYROM

Sixth phase: Initiation of preventive interventions for reduction of risk factors

which are connected to the lifestyle of the population(1thsept.2002)
A) At community level and
B) primary health care (PHC)

Seventh phase: Evaluation of a five-year period (2002-2007)

Eighth phase: Future development of the national programme
II. GENERAL GOALS

III. AIMS OF THE PROGRAMME

MAIN OBJECTIVES:
- Initially
- Development
INTERMEDIATE OBJECTIVES
NATIONAL OBJECTIVES
- Initially
- Development

IV. SPECIFIC GOALS

V. NECESSARY ACTIVITIES FOR REALIZATION OF THE PROGRAMME

FOR PREVENTION AND CONTROL OF CARDIOVASCULAR DISEASES

A. Preparation period 2002

B. Educational and organizational activities (2002-2003)
C. Practical orientation of the implementation of the programme
D. Principles of prevention and control of CVD and other NCD
(strategies and human resources)

1. Population strategy (“universal”)

2. Selective or target prevention (“high risk” strategy)
INTRODUCTION

First phase: Background

1.1. Analysis of situation in FYR of Macedonia

Health conditions of the population (1972-2001)

- Mortality and morbidity of NCD and CVD

Main NCD such as CVD, cancer, diabetes, obesity and respiratory diseases, now
account 59% of the 56.5 million deaths annually worldwide.

During the last decade in FYR of Macedonia, NCD are the major cause of death and
disability. Rapid social and economic changes togather with luck of clear policy
direction and education reflects a significant change in lifestyle (unhealthy dietary
habits, reduced physical activity level, increased alcohol and tobacco use).

In 2001, one-third or 16.6 million of total global deaths are caused from the various
forms of circulatory diseases.

7.2 millions due to heart diseases and 5.5 to cerebrovascular disease. In addition, 3.9
million people die annually from hypertensive and other heart conditions.

Coronary heart disease (CHD) is the leading cause of death and other disability in the
most developed countries. Other parts of the world have shown different patterns
including high rates of CVD mortality in eastern Europe that continue to rise and an
epidemic of CHD and stroke amarging in developing countries.

In Unated States, heard disease and stroke, the principal components of CVD,
accounted for 40% of all deaths in 2001, remain the first leading cause of death.
17% were aged <65.

According to secondary data obtained from mortality/morbidity statistics in the FYR

of Macedonia, the CVD, especially CHD is continuosly increasing (1991-2001),
contrary with the trend of declining in average of the countries in European Union.

CVD with predominant CHD are the cause of 56.4% of deaths in 2001. Trends in
CHD mortality was increasing significantly up to 11% from total mortality or 1900
causes annually in the country (Source: State Statistical Office).

The motrality rate from CVD in 1991 was 359.5/100.000, in the beginning of the
nineties was 386.9/100.000 with increasing trend until 2001 with 485.6/100.000
(Figure 1).
Figure 1. Mortality rate from noncommunicable diseases in the FYR of
Macedonia for the period 1991-2001 up to 100.000 population

500
450
464,9 464,9 458,7 468,6
400
350 385,9
359,5
300
250
200
150
100 140,5 142,6 150,3
129,5
108,3 111,4
50 KVB
Cancer
0
1991 1993 1995 1997 1999 2001

The mortality rate from CHD was 99.4/100.00 in 1991 and 120.9/100.000 in 1997
among the males and 68.1/100.000 in 1997 among the females.

The mortality rate from cerebrovascular diseases in males was 130.4/100.000 in the
beginning of the nineties and the trend was increased up to 163.2 in 1997. The same
condition was noticed in females.

There are important differences in cardiovascular deaths rate by region (Map 1) and
probably also by socioeconomic status and ethnicity despite data on this are very
scarce.

The causes of these disparities in CVD burden are primarily envirovmental and likely
include differences in CVD risk factors, lifestyle and the availability of preventive
services.

For examle: in 2001 the mortality rates from CVD are high in the next towns
(>50.000 inhabitans): Bitola, Veles, Prilep, Strumica and Kumanovo.

The mortality rates are at least in Tetovo and Gostivar (Map 2).
Map 1. Deaths by causes, FYR of Macedonia, 2000.

Map 2. The high mortality rate from CVD in FYR of Macedonia, 2001.
in cities >50.000 inhabitans

472.7

437. 405.
0 4

544.0

3 5
4 472.9

529.6

659.5
The mortality rates were above the average mortality rate in the FYR of Macedonia
in the next 10 municipalities, in 2001: Berovo, Vinica, Resen, Kavadarci, Kocani,
Makedpnski Brod, Demir Hisar, Ohrid and Sveti Nikole.

The morbidity rate from CVD in the period of 1991-2000 has oscilated.
In 2000, registered cases from CVD was 10.17% of total number of ambulatory-
policlinic cases in the Republic (from the registers in general practice, occupational
health, pediatrician and school-age children ambulatories).

18.7% of total number of registered cases from CVD was in the registry of general
practice doctors in 2000 (Figure 2).

Figure 2. Morbidity rate from circulatory diseases in FYR of Macedonia

up to 100.000 population.

Hypertens ia
25000 Is chemic hard dis eas e
Cerebro vas cular
20000 Circulatory dis eas es

15000

10000

5000

0
1972 1978 1984 1990 1991 1992 1993 1994 1995 1997 1998

The CHD and cerebrovascular diseases are in increasing trend, and the hypertension
morbidity rate was in the rank 6.000-10.000/100.000 (1972-1998).

Prevalence of biological (morph functional) and lifestyle (behavioral) risk factors

for NCD and CVD in FYR of Macedonia

High prevalence of major biological risk factors such as high cholesterol, high blood
pressure, obesity and hyperglycemia as common risk factors, cause the majority of
chronic disease.

To reduce CVD mortality and morbidity first of all are needed global change in
lifestyle risk factors such as decreased physical activity level, unhealthy diet, smoking
and social stress by implementing the strategy of primary prevention and health
promotion.
It,s the strategy theoretically of simple intervention adaption of a healthy lifestyle
with major impact in reducing the rates of NCD in relatively short time.

According to the results of two finished medical research in city of Skopje, the capital
of FYR of Macedonia (Minisrty of science and education, 1990-1998) there is high
prevalence of risk factors and among them some risk factors even grown in last 8
years. In randomized simples, 41.2% was overweight and obesity in 1998 and the
percentage was increased up to 58.3 in 2000 (Figure 3).

Figure 3. BMI Distribution in adult population in Skopje

in the last 10 years (1990-2000 year)

%
1990
75,8
80 65,5 1995
70 58,8 1998
60 2000
41,6 41,5
50
40 23
18,2
30 15,9 18,6 16,8
14,9
20 9,3
10
0
BMI < 25 BMI > 25-29.9 BMI > 30

BMI distribution varies significantly according to the stage of transition of the

country. In the early stage of transition, it was estimated the tendency for rapidly
increase in the proportion of the population with high BMI than the proportion of
population with low BMI. In the later phase of transition, the distribution of BMI
tends to change again with increases in the prevalence of high BMI among poor.
16.7% have high blood pressure in 1998 (>160/95 mmHg) (Figure 4).

Figure 4. Prevalence of systolic and diastolic blood pressure in adult population

in Skopje (1990-1998)

%
100 88,7
80,9 1990
73,8 1998
80 68,3

60

40 23,7
16,6
11,9 14,3
20 10 7,9
1,2 2,4

0
<140 >140 >160 <90 >90 >95
High total serum cholesterol have 38% (>6.5mmol/L) and high LDL-cholesterol have
15.8% (>4.5 mmol/L) as part of population with high risk for CHD and heart attack.

35.2% are smokers and 35.9% have low cardiorespiratory fitness (VO2max-
ml/kg/min) or low physical activity level in 1998 (Figure 5).

Figure 5. Prevalence of risk factors for CVD and other NCD in adult
population from central region in Skopje (1990-1998)

80
75
%

60

40 35,9 35,2
28,8 28,2
23,8 23,4
20 18,2
14,2 18,2 15,8
12,5
3,7
2,5
0
)

.5

0
.5

25

25

PV

ss
1.
4.

s
>6
>6

er
I>
I>

L<

re
O
L>
ly

ok
ol

2-
M

st
D
LD
G
Ch

(B

(B

sm
H

<V
.5

.3
T.

>2
>6
ol

TG

1990
Ch

1998
T.

Macedonian people have unhealthy diet habits because they don,t consume enough
fruit and vegetables. In 1999, vegetables intake has showed a slight increasing trend
from 152 gr/day in 1972 to 216gr/day as well as the fruit with annual quantities from
average 160 gr/day. The total intake, both for fruit and vegetable hasn,t reached the
recommendet daily intake of 400 gr./day min.

The average fat and oil intake is 47 gr/day in 1999. The use of animal fat is very slow
while vegetable (sunflower) oil mostly are mainly consumed.

1.2. Problem statement

Urgently are needed aggressive public health efforts and the national coordination to reduce
the CVD burden in FYR of Macedonia. At present, the role of Macedonian politicians in
giving support for development of NCD prevention at the community level is most
important.

For practical implementation of strategy for prevention of CVD, other NCD and
health promotion, some activities are required to be done in the first step:
 Official politics in public health in the FYR of Macedonia:
- formulation and implementation of political document in form of the
″Government Resolution for Health″ until 2018 – Public Health
Programme.
- set-up of a strategy with determined goals and main directions for the
″Macedonian National Politic on Public Health″ in the next 15 years.

 Official politics in area of NCD prevention in the country, focused on

CVD prevention and control:
- public health programme need to be focused primary on prevention of
CVD, and other NCD and health promotion as main goals;
- formation of administrative structure presented in the Draft – Plan of
Action for development and implementation of CINDI Programme in
the FYR of Macedonia, 2002 – 2007;
- appointment of key persons responsible for the National Programme
by establishing a CINDI Centre for co-ordination of integrated approach
at community level.

 To set-up the monitoring system “CINDI Health Monitor”:

- public health, basic surveillance and analysis of behavioural and
biological factors of risk, common for several NCD using WHO
“CINDI Health Monitor” questionnaire (locally adapted).

 New challenges and perspectives in field of CVD and other NCD

prevention and health promotion are:
- building of co-operation, exchange of experiences and ideas on the
Balkan.
- co-operation between Balkan States i.e. South Eastern Europe countries
(SEE) with long term perspective which will lead to mutual interest.

1.3. Main assumptions

It was concluded that in FYR of Macedonia there are no registers on governmental

level for cardiovascular diseases including coronary hearth disease, heart attacks of
the myocardium, neither registers for appoplectical insult (stroke).

There are no precise data for distribution of the key risk factors which are related to
NCD such as: hypertension, increased level of cholesterol and triglycerides in the
blood, smoking and the level of physical activity among the population.

Application of a standard questionnaire, periodically applied (every 2 to 5 years) or

following of those risk factors was never undertaken.
Evaluation of the risks on national level was never done.
The information shown is a result of clinical-epidemiological research of aterogenic
risk factors done in 1990 and 1998. Particular surveys are done among specific
population groups and occupations (school children, adolescents, sportists), on regular
terms and on a national level.
National diet recommendation for treatment was never done.

Second phase: Establishing a national coordination

A. Establishing a location of the CINDI coordinative center with an information

base
B. Establishing an organization structure for implementation of the programme
C. Preparation of the conceptual part of the programme

A) Establishing a location of the CINDI coordinative center with an information base

1. Development, application, following and estimation of the complete intersector
activity in collaboration with the Ministry and the Government of the FYROM.
2. Foundation of a data base (“CINDI Health Monitor”survey) that obtains
information for prevention of NCD and CVD on a base of indicators, analysis
on data by application of software (SPSS) and connection with the central data
base of WHO/ EURO.
3. Establishing of national register of risk factors regarding appearance and
development of CVD and other NCD.
4. Pointing out priority aims of the programmed, application of strategies and
mechanisms for prevention of coronary diseases of the heart and some NCD.
5. Monitoring and evaluation of methodology for the research of the risk factors
on the regional and local level.
6. Preparation of national reference and establishing intervention methods of the
risk factors regarding unhealthy lifestyle.
7. Preparation of national reference for future development of the progaramme.
8. Preparation of annual reports that will be distributed to the WHO Regional
Office of Europe

B) Establishing an organization structure for implementation of the program

In order to achieve greater efficiency and even more ration implementation of the
programme activities, the territory of FYR of Macedonia is divided in 5 regions with
the following municipals and cities (Map 3):
• I Region- Skopje
• II Region- West Macedonia: Ohrid, Struga, Gostivar, Kicevo and Debar
• III Region- Central and South Macedonia: Bitola, Prilep, Resen, Demir Hisar,
Mak. Brod, Krusevo, Kavadarci and Negotino
• IV Region- Central and Southeastern Macedonia: Veles, Strumica, Stip, Radivis,
Sv. Nikole and Gevgelija
• V Region: Northeastern Macedonia: Kumanovo, Kriva Palanka, Probistip,
Kocani, Vinica, Delcevo and Berovo.
 Map 3. Organizational structure for implementation of the programme
“CINDI HEALTH MONITOR” CENTRES

167

219
1877

133
149
116

150

199

222

384

General practice doctors in PHC in FYR of Macedonia, 2001.

Corresponding regional centers that belong to the territory to one region and have
more than 50.000 inhabitants are responsible for implementation of preventive
activities on communal level, aimed to reduction of the common risk factors related to
unhealthy way of living. The staff of the Primary Health Care Department will be
responsible for those activies.

C) Preparation of the conceptual model of the program (appendix)

Third phase: Finalization of the action plan

Fourth phase:Baseline survey “CINDI Health Monitor”(March-May 2002)

Development of the national recommendations and intervention
methods for reduction for risk factors of CVD and other NCD
A) National dietary recommendations for treatment of hypercholesterolemia with
and without energetic restriction.
B) Recommendations for increasment of the level of individual programmed
physical activity in adults.

Fifth phase: Forming a national register for risk factors of CVD and NCD
A) Results from the risk factors “CINDI Health Monitor” survey on
demonstration level in 2002 and periodical research on national level in 2004.
B) Forming a national register for risk factors of CVD and NCD.
Sixth phase: Initiation of preventive interventions for reduction of risk factors
which are connected to the lifestyle of the population
A) At community level and
B) Primary health care (PHC)

Seventh phase: Evaluation of a five-year period (2002-2007)

Eighth phase: Future development of the national program

II. GENERAL GOALS:

Implementation of the WHO global strategy for cardiovascular and other

noncommunicable disease prevention and control in FYR of Macedonia through:
1. Stimulation of the global intersector collaboration in the field of
improvement of the health and the quality of life of the population and
prevention of CVD and other NCD as a base for a development of
multidisciplinary integrated communal level based approach.
2. Emphasize the role of the health workers
3. Improvement in the use of the existing resources for prevention of CVD and
NCD
4. Implementation of documented recommendations and methods

III. AIMS OF THE PROGRAMME in the FYR of MACEDONIA:

In the defining of main aims the priority is given to the leading NCD in FYR of
Macedonia determined by morbidity and mortality and their impact on the lifestyle.

MAIN OBJECTIVE:

Initially: To decrease the morbidity and mortality and invalidity due to

cardiovascular disease for 5-10% in the following 5 years.
To decrease the premature mortality caused by the coronary heart
disease for 26% among population at the age from 45-64 in the
following 10 years.
Development: To reduce major chronic disease mortality, morbidity and
promote health.

INTERMEDIATE OBJECTIVES:

- Decrease the prevalence of main cardiovascular (atherogenic) risk factors :

elevated serum cholesterol, obesity and hyperglycaemia, elevated blood
pressure and smoking, at population level by introducing changes in the
lifestyle: increased physical activity, balanced diet and stoped tobacco use
(primary prevention)
- improvement of the early detection and treatment (secondary prevention).

NATIONAL OBJECTIVES:

Initially: to be pilot for all FYR of Macedonia

Development: to be demonstration and conceptual model program
IV. SPECIFIC GOALS

A tendency for accomplishment of specific goals is a key of success according to

many national health authorities. Preventive interventions are aimed to common risk
factors and are procedure in PHC by communication with the community through the
media.

A) Diet intervention measures

1. Reduction of the total energy intake (kcal/d) that are originated from the
saturated fatty acid (SFA) including alcohol within the population from 15-
74 years old for at least 0.5% a year or 2.5% in the future 5 years.
2. Increasing the consumtion of fruits and vegetables for 25 % in the following
5 years by application of the food based dietary quidellines (FBDQ).
3. To decrease the number of persons at the age from 15-64 that add salt after
cooking by routine for 2% a year.
4. To reduce the number of persons with BMI of 25 kg/m2 and increased WHR
(>0.95 for man and >0.85 for women) at the age from 15-64 for an average
1% a year (or 5% in the next five years).
5. To increase the number of persons with a BMI of 30 kgm 2 and increased
WHR at the age from 20-64 by implementation of hypocaloric diet in the
last 3 years, on PHC level for 5% a year, or 25% in the next 5 years.

B) Recommendations for increase of physical activities

1. Decrease the number of sedentary adults for 6 % until 2005.

2. Increase the number of adults that on a daily bases practice moderated physical
activity, >30minutes for 4% until 2005.
3. To increase the number of adults that train with an intensity that improves
cardiorespiratory fitness (VO2 max) according to recommendations of ACSM,
U.S. (1998), for 2% until 2005.
4. Increase the number of adolescents that practice moderated physical activity 5
days a week, for 2.5% until 2005.
5. To increase the number of adolescents that train with an intensity that improves
cardiorespiratory fitness (VO2 max) according to recommendations of ACSM,
U.S. (1998) for 10% until 2007.

C) Decrease the number of smokers for 20% until 2007.

D) Decrease the average level of blood pressure for 10mmHg in the next 5 years.

E) Decrease the average level of cholesterol (mmol/L) for 10% until 2007.
IV. NECESSARY ACTIVITIES FOR REALIZATION OF THE PROGRAMME

A) Preparation period - 2002

1. Analysis of the existing resource on regional/local level for involving of the

preventive activities in the five demonstration regions.
2. Establishing local preventive groups in PHC on community level, responsible
for the prevention of CVD and other NCD (net of units)
3. Establishing a corporation between PHC, local institutes for health care,
institutions for education, non-governmental organizations, private health
sector and the media in the five demonstration regions

B) Educational and organizational activities (2002-2003)

1. Education of health workers for practical applying of preventive intervention

aimed to unhealthy lifestyle: nutrition and physical activity (training of
educators in PHC).
2. Media activities (materials, massmedia, campaigns).
3. Establishing a net of detection and treatment of hypercholesterolemia: family
and groups of high risk.
4. Survay of prevalence and research of the major risk factors by implementation
of the programmed in PHC and building local information network i.e. system.
5. Envirovmental changes: smokefree areas, supermarkets, food industry etc.

C) Practical orientation of the implementation of the projects

The following projects in related to main risk factors are necessary :

- Activities for increase of the level of physical activity (PAL) of the macedonian
population (VO2 max / METT).
Preparation of the project in collaboration with the Agency for Youth and
Sports, Ministry of education and science and other relevant sectors in FYR of
Macedonia and collaboration with WHO/HQ working group for physical
activity “Move for Health Initiative” (2003)

- Activities for reduction of body weight. To prepare the project for the part
of population which is in vulnerability stage.
Organization of a mass media campaign “Healthy weight for everyone” (2003).

This project form a link between precede medical research and the application
of new index as mathematical model for predicting the effects of non-
pharmacological interventions in the population at above/ average and high risk
for NCD such as truncal obese individuals with cardiovascular risk factors.
 Logistic model in form of equation is:
ln “RR” = 108.2588–1.7689 x DKN-B in +1.7087-BMI in+0.3993- Hb x 2.9423-
VO2max OPV–10.5402 x WHO in + 0.0770-50% kcal/h

Exponent B can be interpreted in terms of relative risk (“RR”) in cohort studies. The
proposed non-pharmacological intervention is hypocaloric, hiperprotein diets of
1200kcal/d and 1400 kcal/d (second phase) since the relative risk is less than 1
(ln“RR”<1).
Increased physical activity by the recommendations of ACSM (1998) and CDC (2001)
statistically significant promotes development of VO2max.

- Activities for improvement of balanced nutrition: preparation of national.

dietary quidelines for treatment of hypercholesterolemia with or without
energetic reduction based on the food based dietary quidelines (FBDQ) -
“CINDI nutrition project” (2002).
- Improvement of no medication treatment of arterial hypertension (except in
cases of high and essential hypertension).

D) Principles of prevention and control of NCD

(strategies and human resources)

The recommended principle of the strategy for prevention of NCD will be performed
in multisector, integrated and synchronized activity and in cooperation with the entire
relevant subject in the community because the health service is not capable of
providing prevention for the mentioned diseases by itself.

Numerous subjects not being a part of health care give a contribution of

approximately 75% for improvement of the health of the population.

Primarily health care which is in the focus of the health system has an important role
in performing preventive measures, and the center of the activities is aimed to
primordial and primary prevention.

70% of the health necessities should be solved on primary health protection level.
The measures of the primordial and primary prevention will apply two strategies and
their combination will give bigger effect.

Population strategy (universal)

Population strategy includes health-educational activities and it is aimed to the whole

population. It is realized through the mans of public information and printed health
educational material.
The main point of activities at this type of strategy is aimed to measures, which lead to
improvement of health. During this, the health care institutions on a PHC level will
initiate certain actions regarding the national programme CINDI.

The PHC teams from each demonstration region will prepare a plan and a method for
health educational activities, will take part in organization and involving subjects in
the community as well as coordinate their work and evaluate the effects of the
performed activities, by establishing local information net.

Non-health sectors are of special significance in the accomplishment of his type of

strategy.

Population approach:
- Dietary changes to reduce blood cholesterol and blood pressure
- Increasing level of physical activity
- Smoking cessation

Selective or target prevention (“high risk” strategy) regarding:

- performing activities for identification of the population with high risk for
development of NCD,
- performing intervention measures for reducing or eliminating risk factors.

The preventive activities for reduction of NCD will be performed by all the subjects in
the health institutions, although the major part of the activities approximately 85% are
referred of PHC (global risk assessment/identification of high risk patients, health
education of the population), while the teams of the secondary health care will
intervene according to the necessity.

“High risk” approach:

- Hypertension
- Hypercholesterolemia
- Obesity

By gradually moving towards the measures of primary prevention (suspension or

delaying of NCD by manes or reduction or elimination of risk factors) including at the
same time activities for improvement of health, the great of necessity from secondary
prevention, which is extremely expensive, will also diminish.

The Action Plan is concerned with the implementation of population strategies for
altering the lifestyle and environmental characteristics, a high risk strategy for
bringing preventive care to individuals at special risk; and secondary prevention.
Secondary prevention

Although special preventive and therapeutic measures are important for high risk and
sick individuals, respectively, they are of limited value as far as the control of
cardiovascular diseases at the community level is concerned.

Author: Vera Simovska, MD. PhD.

National coordinator of the WHO CINDI Programme in FYR of Macedonia.
Spec. of sports medicine
Subspec. of hygiene nutrition at healthy and sick people

16.08.2002 - I th submitting of the CINDI Action plan

to the Ministry of Health of FYR of Macedonia