SlideShare uma empresa Scribd logo
1 de 55
Baixar para ler offline
Hypertension the Silent Killer
Epidemiology
Prof Faisal A Alnasir FRCGP, MICGP, FFPH, PhD
President, Family & Community Medicine Council Arab Board
Chairman, Department of Family & Community Medicine
Arabian Gulf University
2
Hypertension
• Common
• Non Communicable disease
• Inevitable
• Preventable
• Serious complication
3
WHO estimated that high blood pressure
causes one in every eight deaths, making
hypertension the third leading killer in the world.
Globally, there are one billion hypertensives and
four million people die annually as a direct result
of it.
Hussein A. Gezairy
Regional Director for the Eastern Mediterranean
4
5
Size of the problem
1-World wide
• In 2010, 1.2 billion people were expected to be suffering from
hypertension worldwide
Sixth report of the Joint National Committee on prevention,1997
• Expected to increase to 1.56 billion by 2025
International Society of Hypertension
• Its prevalence from 20% to 30% of the adult population.
Alwan A 1993
• Incidence In USA between 14% to 40% in 35 to 64 years.
WHO 2002
• Prevalence in Canada 17.3%. Most patients had untreated
hypertension (68.6%), and only 15.8% had blood pressure
treated and controlled.
6
Size of the problem
2-In the Eastern Mediterranean Region
• The average prevalence of hypertension 26% and it affects
approximately 125 million individuals.
• Each year, there are several million new cases of
hypertension and more of pre-hypertension
Report on the regional consultation on hypertension
UAE, 2003
7
Size of the problem
In Bahrain
National Non-communicable Diseases Risk Factors Survey 2007
8
Size of the problem
In Bahrain
National Non-communicable Diseases Risk Factors Survey 2007
In Lebanon
•23.1% are hypertensive
•Prevalence increases with age
•Occurs more in the less educated and unemployed
•Prevalence increases significantly with an increase in
body mass index particularly in female patients
•Only14.7% exercised daily
R A Tohme, A R Jurjus, A Estephan 2005
10
Size of the problem
In Saudi Arabia:
The prevalence range from 4% to 15%.
Abolfotouh MA et al.
It may reach as high as 20.4% for systolic hypertension and
25.9% for diastolic hypertension.
Al-Nozha MM et al.
In south-western 11.1%.
Abolfotouh MA et al.
In Jeddah, the hypertensive were 22.6%.
Elkalifa Am et al.2011
In the UAE:
Hypertension has become one of the leading public health
problems
In Sudan
 of 6-12y children:
4.9% were pre-hypertensive and
4.9% were hypertensive
Salman Z, et al 2010
12
Size of the problem
It has been estimated that individuals who are
normotensive at the age 55 years have a 90%
lifetime risk for developing hypertension.
EMR0 Technical Publications
Blood pressure is under control in less than 20% of
patients with hypertension in many countries
A joint CINDI/EuroPharm Forum project WHO
13
Awareness of Hypertension
Although the prevalence of high blood pressure is high,
there is a low awareness rate (Up To 70% are unaware)
Alwan A1993
Awareness of Hypertension
Faisal Alnasir, 2004
15
Awareness of Hypertension
In Egypt only 37.5% of hypertensives were aware of
Having it.
In United States, Chile, and Cub, 32%, 37%, and 39%
of the people were not aware.
Pan American Health
16
Advantage of Controlling Hypertension
•A 5-6 mmHg reduction in diastolic BP reduces stroke by 40%.
Joint National Committee on Detection, 1992
•lowering by 5-6mmHg can reduce mortality from cerebrovascular
disease by 35%-40%, from ischemic heart disease by 15% 20%
and reduction in all deaths from cardiovascular causes by 23%.
Psaty, et al 1997
• 3 mmHg decrease in systolic BP reduces annual mortality
from stroke, coronary heart diseases and all other causes by 8%,
5% and 4%.
Whelton PK, 1994
•The chances of mortality from CVD in old hypertensive people
when taking anti hypertensive medications is decreased by 34%.
MacMahon, 1993
17
Economic Impact
The economic burden of chronic NCDs can
be analyzed on two levels.
•First, the effects of macroeconomic policies on
opportunities for prevention in different
population groups
•Second, the cost and overall efficiency of
interventions must be evaluated in terms of
effectiveness and health gains for the
population at large.
18
Economic Impact
Direct Cost:
Including prescribing medicines, inpatient visits,
outpatient visits, emergency room visits, office-
based medical provider visits, home health
visits, and other medical expenses
Sanjeev Balu, 2001
Indirect Cost:
Productivity loss ($300 per eligible employee per year)
absence & short term disability
Goetzel (2004), the only study in the U.S.
19
Economic Impact
•Poor are disproportionately affected
•more vulnerable
•Prevalence 6 time more in uneducated
•Medication cost up to US$ 100 per month
•further poverty
•Cost to Health Services
•USA total cost of CVD is 2% of the gross
domestic product
• direct medical costs estimated at nearly $55.0
billion for the year 2001
Sanjeev Balu, 2001
•Canada 21% of all diseases costs are due to
CVD (US$12 billion/Year) direct cost is $3,072
per person per year, and indirect cost is $854
Guijing Wang,2008
20
Economic Impact
In Alkhobar the total direct cost of hypertension
care for patients registered in the primary health
care represented 6.32% of the estimated cost of
treating the expected number of patients.
Al-Shahri 1998
21
Prevention
Primary prevention is the most cost-effective
approach to containing the emerging
hypertension epidemic.
Hussein AlGezairy
Regional Director for WHO
22
Prevention
Incidence of hypertension was reduced by 20% to
50% if primary prevention were implemented
Stamler 1991
For the developing countries prevention of
hypertension should be the goal.
23
Prevention
Life style Modification:
•perform aerobic exercise
•maintain a healthy body weight
•follow a healthy diet
•restrict salt intake
•stress management
•limit alcohol consumption
24
Modification Recommendation Approximate systolic BP
reduction
Weight reduction Maintenance of normal body weight 5–20 mmHg/10 kg
healthy eating plan Consumption a diet rich in
vegetables, fruits, and
low-fat dairy products with a
reduced content of saturated and
total fat
8–14 mm Hg
Dietary sodium Reduction dietary sodium intake to
no more than
2.4 g sodium
2–8 mmHg
Physical activity Engagement in regular aerobic
physical activity at least 30
minutes daily, most days of the
week
4–9mmHg
Recommended lifestyle modifications
25
Life style Modification
• Weight reduction
Every 1 kilogram of weight loss lower blood pressure by
1.6/1.1 mmHg
Khatib et al. EMR0 Technical Publications
26
Prevalence of overweight and obesity among
some countries of the Eastern Mediterranean
Region (WHO.2004)
Country Overweight/obesity (%)
Males Females
Saudi Arabia 64.0 70.0
Lebanon 60.0 53.0
Islamic Republic of Iran 57.0 67.7
Bahrain 56.4 79.0
Jordan 46.0 43.7
Egypt 43.8 41.0
Libyan Arab Jamahiriya 42.5 74.9
Oman 40.5 43.5
Morocco 37.2 21.7
United Arab Emirates 25.5 39.9
Tunisia 13.1 41.9
Kuwait 79 56
In Bahrain
National Non-communicable Diseases Risk Factors Survey 2007
In Sudan
 of 6-12y children:
45 (14.8%) were overweight; 32 (10.5%)
were obese
Salman Z et al 2010
29
30
Life style Modification
• Eating habits
31
32
Life style Modification
• Physical activity
Exercise lowers systolic and diastolic blood pressure
by 5-10 mmHg
Arakawa
33
Life style Modification
• Physical activity
National Non-communicable Diseases Risk Factors Survey 2007
34
Life style Modification
• Sodium moderation
Reducing dietary sodium intake to no more than 100 mEq/L
)2.4g sodium or 6 g sodium chloride), reduces the blood
pressure by an average of 4–6 mmHg.
Khatib et al. EMR0 Technical Publications
35
Life style Modification
• Diabetes
(In Bahrain)
National Non-communicable Diseases Risk Factors Survey 2007
36
Life style Modification
• Diabetes
(In Bahrain)
37
Life style Modification
• Tobacco
)In Bahrain)
National Non-communicable Diseases Risk Factors Survey 20
-Lipids
39
Life style Modification
• Lipids
(In Bahrain)
National Non-communicable Diseases Risk Factors Survey 20
40
Life style Modification
• Cocoa ingestion
100g/day of chocolate
drink reduces the systolic BP and
diastolic BP
Taubert et al 2007
41
Blood Pressure Pooled Change (mm Hg) P
Cocoa
Systolic -4.7 .002
Diastolic -2.8 .006
Tea
Systolic 0.4 .63
Diastolic -0.6 .38
Change in Blood Pressure reduction
between cocoa & Tea
Taubert et al 2007
42
Change in Blood Pressure reduction
between cocoa & Tea
Taubert et al 2007
“The magnitude of the hypotensive effects of cocoa
is in the range that is usually achieved with
monotherapy of β-blockers or angiotensin-
converting enzyme inhibitors”
Chocolate and Coronary Heart Disease: A Systematic Review
This article reviews current evidence on the effects of cocoa/chocolate on
clinical and subclinical coronary heart disease (CHD), CHD risk factors,
and potential biologic mechanisms.
 The high content of polyphenols and flavonoids present in cocoa has
been reported to play an important protective role in the development of
CHD.
 Although studies have demonstrated beneficial effects of chocolate on
endothelial function, blood pressure, serum lipids, insulin resistance, and
platelet function, it is unclear whether chocolate consumption influences
the risk of CHD.
Khawaja O et al Current Atherosclerosis Reports, Volume 13 / September 2011
44
Measurement of Blood Pressure
The "white-coat" effect
Prevalence of white coat hypertension
was 3.6% overall and 12.8% in
hypertensive patients.
Marquez Contreras et al. 2006
45
Measurement of Blood Pressure
The "white-coat" effect
Prevalence of white coat hypertension
was 3.6% overall and 12.8% in
hypertensive patients.
Marquez Contreras et al. 2006
46
Measurement of Blood Pressure
The "white-coat" effect
Prevalence of white coat hypertension
was 3.6% overall and 12.8% in
hypertensive patients.
Marquez Contreras et al. 2006
47
Hypertension Control
Very poor control of hypertension world wide
•In Egypt 23.9% were receiving treatment & 8%
controlled
Ibrahim et al.
•In Canada 15.8% had blood pressure treated and
controlled
Petrella et al, 2007
•In Saudi Arabia, 76 % were receiving treatment, but only
20% were found controlled
Abolfotouh et al,
48
Measurement of Blood Pressure
•Seated in a quiet room
•Arm muscles relaxed
•Cubital fossa at heart level
•Avoid tight sleeves
•Suitable size Cuff to be used
•Repeat if BP > 140/90
•Measurement on both arms
•Mercury sphygmomanometers are most reliable
Goodman and Gilman's1993
49
Management
Good management of hypertension is central to any
strategy formulated to control hypertension at the
community level. Randomized trials of drugs that
lower and control blood pressure clearly show a
reduction in mortality and morbidity.
Hussein A. Gezairy
Regional Director for the Eastern Mediterranean
50
Management
2 mmHg reduction in systolic blood pressure
is likely to reduce the annual mortality from
stroke, coronary heart disease and all other
causes by 6%, 4% and 3%, respectively
51
Conclusion
Hypertension is a serious problem that could
be called "the silent killer". Its prevalence is
very high especially in the GCC countries.
Effective efforts ought to be taken in order to
prevent, prevent, prevent, prevent
then diagnose and treat it.
52
Conclusion
Hypertension is a serious problem that could
be called "the silent killer". Its prevalence is
very high especially in the GCC countries.
Effective efforts ought to be taken in order to
prevent, prevent, prevent, prevent
then diagnose and treat it.
53
Conclusion
Hypertension is a serious problem that could
be called "the silent killer". Its prevalence is
very high especially in the GCC countries.
Effective efforts ought to be taken in order to
prevent, prevent, prevent, prevent
then diagnose and treat it.
54
Thank
you
55

Mais conteúdo relacionado

Mais procurados

Coronary heart disease
Coronary heart diseaseCoronary heart disease
Coronary heart diseasedrsanjeev15
 
Non-communicalbe diseases and its prevention
Non-communicalbe diseases and its preventionNon-communicalbe diseases and its prevention
Non-communicalbe diseases and its preventionShoaib Kashem
 
Ncd gaps in ncd & obesity
Ncd gaps in ncd & obesityNcd gaps in ncd & obesity
Ncd gaps in ncd & obesitydrjagannath
 
Salon 2 13 kasim 14.00 15.00 serpi̇l akkuş topçu-ing
Salon 2 13 kasim 14.00 15.00 serpi̇l akkuş topçu-ingSalon 2 13 kasim 14.00 15.00 serpi̇l akkuş topçu-ing
Salon 2 13 kasim 14.00 15.00 serpi̇l akkuş topçu-ingtyfngnc
 
Global burden of non communicable diseases
Global burden of non communicable diseasesGlobal burden of non communicable diseases
Global burden of non communicable diseasesNayyar Kazmi
 
Malimu nutrition related non communicable diseases
Malimu nutrition related non communicable diseasesMalimu nutrition related non communicable diseases
Malimu nutrition related non communicable diseasesMiharbi Ignasm
 
Risk Assessment and Management of Cardiovascular Diseases - an English Approach
Risk Assessment and Management of Cardiovascular Diseases - an English ApproachRisk Assessment and Management of Cardiovascular Diseases - an English Approach
Risk Assessment and Management of Cardiovascular Diseases - an English ApproachPlan de Calidad para el SNS
 
Non communicable Disease Perspective : Bangladesh
Non communicable Disease Perspective : BangladeshNon communicable Disease Perspective : Bangladesh
Non communicable Disease Perspective : BangladeshMohammad Arifur Rahman
 
Association Between Passive Smoking & Cardiovascular Disease Among Woman of L...
Association Between Passive Smoking & Cardiovascular Disease Among Woman of L...Association Between Passive Smoking & Cardiovascular Disease Among Woman of L...
Association Between Passive Smoking & Cardiovascular Disease Among Woman of L...Rishad Choudhury Robin
 
ueda2013 prevalence and burden of diabetes-d.michael hirst
ueda2013 prevalence and burden of diabetes-d.michael hirstueda2013 prevalence and burden of diabetes-d.michael hirst
ueda2013 prevalence and burden of diabetes-d.michael hirstueda2015
 
Malimu non communicable disease
Malimu non communicable diseaseMalimu non communicable disease
Malimu non communicable diseaseMiharbi Ignasm
 
Epid of ncd + htn
Epid of ncd + htnEpid of ncd + htn
Epid of ncd + htnRupam Kumar
 
Non-Communicable Diseases: The Unheralded Global Epidemic_Meer_5.12.11
Non-Communicable Diseases: The Unheralded Global Epidemic_Meer_5.12.11Non-Communicable Diseases: The Unheralded Global Epidemic_Meer_5.12.11
Non-Communicable Diseases: The Unheralded Global Epidemic_Meer_5.12.11CORE Group
 
PREVALENCE OF NON-COMMUNICABLE DISEASE
PREVALENCE OF NON-COMMUNICABLE DISEASEPREVALENCE OF NON-COMMUNICABLE DISEASE
PREVALENCE OF NON-COMMUNICABLE DISEASEPublic Health Update
 
Escalating burden of chd (1) key note address
Escalating burden of chd (1) key note addressEscalating burden of chd (1) key note address
Escalating burden of chd (1) key note addressHarivansh Chopra
 

Mais procurados (20)

Non communicable diseases
Non communicable diseasesNon communicable diseases
Non communicable diseases
 
Coronary heart disease
Coronary heart diseaseCoronary heart disease
Coronary heart disease
 
Non-communicalbe diseases and its prevention
Non-communicalbe diseases and its preventionNon-communicalbe diseases and its prevention
Non-communicalbe diseases and its prevention
 
Non c d communti
Non c d communtiNon c d communti
Non c d communti
 
Non Communicable Disease (NCD)
Non Communicable Disease (NCD)Non Communicable Disease (NCD)
Non Communicable Disease (NCD)
 
Ncd gaps in ncd & obesity
Ncd gaps in ncd & obesityNcd gaps in ncd & obesity
Ncd gaps in ncd & obesity
 
Salon 2 13 kasim 14.00 15.00 serpi̇l akkuş topçu-ing
Salon 2 13 kasim 14.00 15.00 serpi̇l akkuş topçu-ingSalon 2 13 kasim 14.00 15.00 serpi̇l akkuş topçu-ing
Salon 2 13 kasim 14.00 15.00 serpi̇l akkuş topçu-ing
 
Global burden of non communicable diseases
Global burden of non communicable diseasesGlobal burden of non communicable diseases
Global burden of non communicable diseases
 
Malimu nutrition related non communicable diseases
Malimu nutrition related non communicable diseasesMalimu nutrition related non communicable diseases
Malimu nutrition related non communicable diseases
 
INTRODUCTION TO NCDs
INTRODUCTION TO NCDsINTRODUCTION TO NCDs
INTRODUCTION TO NCDs
 
Risk Assessment and Management of Cardiovascular Diseases - an English Approach
Risk Assessment and Management of Cardiovascular Diseases - an English ApproachRisk Assessment and Management of Cardiovascular Diseases - an English Approach
Risk Assessment and Management of Cardiovascular Diseases - an English Approach
 
Non communicable Disease Perspective : Bangladesh
Non communicable Disease Perspective : BangladeshNon communicable Disease Perspective : Bangladesh
Non communicable Disease Perspective : Bangladesh
 
Non communicable diseases (final)
Non communicable diseases (final)Non communicable diseases (final)
Non communicable diseases (final)
 
Association Between Passive Smoking & Cardiovascular Disease Among Woman of L...
Association Between Passive Smoking & Cardiovascular Disease Among Woman of L...Association Between Passive Smoking & Cardiovascular Disease Among Woman of L...
Association Between Passive Smoking & Cardiovascular Disease Among Woman of L...
 
ueda2013 prevalence and burden of diabetes-d.michael hirst
ueda2013 prevalence and burden of diabetes-d.michael hirstueda2013 prevalence and burden of diabetes-d.michael hirst
ueda2013 prevalence and burden of diabetes-d.michael hirst
 
Malimu non communicable disease
Malimu non communicable diseaseMalimu non communicable disease
Malimu non communicable disease
 
Epid of ncd + htn
Epid of ncd + htnEpid of ncd + htn
Epid of ncd + htn
 
Non-Communicable Diseases: The Unheralded Global Epidemic_Meer_5.12.11
Non-Communicable Diseases: The Unheralded Global Epidemic_Meer_5.12.11Non-Communicable Diseases: The Unheralded Global Epidemic_Meer_5.12.11
Non-Communicable Diseases: The Unheralded Global Epidemic_Meer_5.12.11
 
PREVALENCE OF NON-COMMUNICABLE DISEASE
PREVALENCE OF NON-COMMUNICABLE DISEASEPREVALENCE OF NON-COMMUNICABLE DISEASE
PREVALENCE OF NON-COMMUNICABLE DISEASE
 
Escalating burden of chd (1) key note address
Escalating burden of chd (1) key note addressEscalating burden of chd (1) key note address
Escalating burden of chd (1) key note address
 

Semelhante a د فيصل الناصر

Prof faisal hypertension presentation فيصل الناصر, د فيصل الناصر
Prof faisal hypertension presentation فيصل الناصر, د فيصل الناصرProf faisal hypertension presentation فيصل الناصر, د فيصل الناصر
Prof faisal hypertension presentation فيصل الناصر, د فيصل الناصرد فيصل ال Faisal Alnasser
 
Non communicable disease
Non communicable diseaseNon communicable disease
Non communicable diseaseDalia El-Shafei
 
Penyakit NCD di Malaysia
Penyakit NCD di Malaysia Penyakit NCD di Malaysia
Penyakit NCD di Malaysia HCY 7102
 
Increasing Burden of NCD in Malaysia: Challenges in resource allocation
Increasing Burden of NCD in Malaysia: Challenges in resource allocationIncreasing Burden of NCD in Malaysia: Challenges in resource allocation
Increasing Burden of NCD in Malaysia: Challenges in resource allocationFeisul Mustapha
 
Diet, nutrition and the prevention of cancer,ppt
Diet, nutrition and the prevention of cancer,pptDiet, nutrition and the prevention of cancer,ppt
Diet, nutrition and the prevention of cancer,pptRajeeeeeeeeeeev
 
Noncommunicable diseases worldwide 2020
Noncommunicable diseases worldwide 2020Noncommunicable diseases worldwide 2020
Noncommunicable diseases worldwide 2020PandurangChavan11
 
NEW NCD GUIDELINE.pptx
NEW NCD  GUIDELINE.pptxNEW NCD  GUIDELINE.pptx
NEW NCD GUIDELINE.pptxImanuIliyas
 
Lean in Primary Care - Redesigning the Diabetes Process
Lean in Primary Care - Redesigning the Diabetes ProcessLean in Primary Care - Redesigning the Diabetes Process
Lean in Primary Care - Redesigning the Diabetes ProcessLean Enterprise Academy
 
Epi and control of Diabetes.ppt
Epi and control of Diabetes.pptEpi and control of Diabetes.ppt
Epi and control of Diabetes.pptFaizanGMustafaMBBS
 
SLMA president address 2009
SLMA president address 2009SLMA president address 2009
SLMA president address 2009Rezvi Sheriff
 
FirstLine Therapy. Prevent chronic Disease
FirstLine Therapy. Prevent chronic DiseaseFirstLine Therapy. Prevent chronic Disease
FirstLine Therapy. Prevent chronic Diseaseadj4god
 
noncommunicalbedisease-150721175002-lva1-app6891.pdf
noncommunicalbedisease-150721175002-lva1-app6891.pdfnoncommunicalbedisease-150721175002-lva1-app6891.pdf
noncommunicalbedisease-150721175002-lva1-app6891.pdfCharmaineCanono
 
Diabetes Mellitus
Diabetes MellitusDiabetes Mellitus
Diabetes Mellitusmigom doley
 
globalhealthtrends-180504054630.pptx
globalhealthtrends-180504054630.pptxglobalhealthtrends-180504054630.pptx
globalhealthtrends-180504054630.pptxRoelTabuyo2
 
globalhealthtrends-180504054630.pptx
globalhealthtrends-180504054630.pptxglobalhealthtrends-180504054630.pptx
globalhealthtrends-180504054630.pptxRoelTabuyo2
 
PSEDM-DOH WorkshopDiabetes Management Training Using Insulin v_7 - 20170321.pptx
PSEDM-DOH WorkshopDiabetes Management Training Using Insulin v_7 - 20170321.pptxPSEDM-DOH WorkshopDiabetes Management Training Using Insulin v_7 - 20170321.pptx
PSEDM-DOH WorkshopDiabetes Management Training Using Insulin v_7 - 20170321.pptxRhoda Isip
 
Global Burden of Coronary Heart Disease
Global Burden of Coronary Heart DiseaseGlobal Burden of Coronary Heart Disease
Global Burden of Coronary Heart DiseasePERKI Pekanbaru
 

Semelhante a د فيصل الناصر (20)

Prof faisal hypertension presentation فيصل الناصر, د فيصل الناصر
Prof faisal hypertension presentation فيصل الناصر, د فيصل الناصرProf faisal hypertension presentation فيصل الناصر, د فيصل الناصر
Prof faisal hypertension presentation فيصل الناصر, د فيصل الناصر
 
Non communicable disease
Non communicable diseaseNon communicable disease
Non communicable disease
 
Penyakit NCD di Malaysia
Penyakit NCD di Malaysia Penyakit NCD di Malaysia
Penyakit NCD di Malaysia
 
Increasing Burden of NCD in Malaysia: Challenges in resource allocation
Increasing Burden of NCD in Malaysia: Challenges in resource allocationIncreasing Burden of NCD in Malaysia: Challenges in resource allocation
Increasing Burden of NCD in Malaysia: Challenges in resource allocation
 
Diet, nutrition and the prevention of cancer,ppt
Diet, nutrition and the prevention of cancer,pptDiet, nutrition and the prevention of cancer,ppt
Diet, nutrition and the prevention of cancer,ppt
 
Noncommunicable diseases worldwide 2020
Noncommunicable diseases worldwide 2020Noncommunicable diseases worldwide 2020
Noncommunicable diseases worldwide 2020
 
NEW NCD GUIDELINE.pptx
NEW NCD  GUIDELINE.pptxNEW NCD  GUIDELINE.pptx
NEW NCD GUIDELINE.pptx
 
Lean in Primary Care - Redesigning the Diabetes Process
Lean in Primary Care - Redesigning the Diabetes ProcessLean in Primary Care - Redesigning the Diabetes Process
Lean in Primary Care - Redesigning the Diabetes Process
 
Epi and control of Diabetes.ppt
Epi and control of Diabetes.pptEpi and control of Diabetes.ppt
Epi and control of Diabetes.ppt
 
SLMA president address 2009
SLMA president address 2009SLMA president address 2009
SLMA president address 2009
 
cpg prev cvd 17.pptx
cpg prev cvd 17.pptxcpg prev cvd 17.pptx
cpg prev cvd 17.pptx
 
FirstLine Therapy. Prevent chronic Disease
FirstLine Therapy. Prevent chronic DiseaseFirstLine Therapy. Prevent chronic Disease
FirstLine Therapy. Prevent chronic Disease
 
Diabesity with Sharon Weinstein
Diabesity with Sharon WeinsteinDiabesity with Sharon Weinstein
Diabesity with Sharon Weinstein
 
noncommunicalbedisease-150721175002-lva1-app6891.pdf
noncommunicalbedisease-150721175002-lva1-app6891.pdfnoncommunicalbedisease-150721175002-lva1-app6891.pdf
noncommunicalbedisease-150721175002-lva1-app6891.pdf
 
Diabetes Mellitus
Diabetes MellitusDiabetes Mellitus
Diabetes Mellitus
 
globalhealthtrends-180504054630.pptx
globalhealthtrends-180504054630.pptxglobalhealthtrends-180504054630.pptx
globalhealthtrends-180504054630.pptx
 
globalhealthtrends-180504054630.pptx
globalhealthtrends-180504054630.pptxglobalhealthtrends-180504054630.pptx
globalhealthtrends-180504054630.pptx
 
PSEDM-DOH WorkshopDiabetes Management Training Using Insulin v_7 - 20170321.pptx
PSEDM-DOH WorkshopDiabetes Management Training Using Insulin v_7 - 20170321.pptxPSEDM-DOH WorkshopDiabetes Management Training Using Insulin v_7 - 20170321.pptx
PSEDM-DOH WorkshopDiabetes Management Training Using Insulin v_7 - 20170321.pptx
 
STEP.ppt
STEP.pptSTEP.ppt
STEP.ppt
 
Global Burden of Coronary Heart Disease
Global Burden of Coronary Heart DiseaseGlobal Burden of Coronary Heart Disease
Global Burden of Coronary Heart Disease
 

Último

Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.aarjukhadka22
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisNilofarRasheed1
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
Microbiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxMicrobiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxkitati1
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptx
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptxGood Laboratory Practice (GLP) in Pharma-LikeWays.pptx
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptxLikeways
 
introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)Mohamed Rizk Khodair
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxMAsifAhmad
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingAnonymous
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 

Último (20)

Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid Arthritis
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
Microbiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxMicrobiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptx
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptx
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptxGood Laboratory Practice (GLP) in Pharma-LikeWays.pptx
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptx
 
introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_Wellbeing
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 

د فيصل الناصر

  • 1. Hypertension the Silent Killer Epidemiology Prof Faisal A Alnasir FRCGP, MICGP, FFPH, PhD President, Family & Community Medicine Council Arab Board Chairman, Department of Family & Community Medicine Arabian Gulf University
  • 2. 2 Hypertension • Common • Non Communicable disease • Inevitable • Preventable • Serious complication
  • 3. 3 WHO estimated that high blood pressure causes one in every eight deaths, making hypertension the third leading killer in the world. Globally, there are one billion hypertensives and four million people die annually as a direct result of it. Hussein A. Gezairy Regional Director for the Eastern Mediterranean
  • 4. 4
  • 5. 5 Size of the problem 1-World wide • In 2010, 1.2 billion people were expected to be suffering from hypertension worldwide Sixth report of the Joint National Committee on prevention,1997 • Expected to increase to 1.56 billion by 2025 International Society of Hypertension • Its prevalence from 20% to 30% of the adult population. Alwan A 1993 • Incidence In USA between 14% to 40% in 35 to 64 years. WHO 2002 • Prevalence in Canada 17.3%. Most patients had untreated hypertension (68.6%), and only 15.8% had blood pressure treated and controlled.
  • 6. 6 Size of the problem 2-In the Eastern Mediterranean Region • The average prevalence of hypertension 26% and it affects approximately 125 million individuals. • Each year, there are several million new cases of hypertension and more of pre-hypertension Report on the regional consultation on hypertension UAE, 2003
  • 7. 7 Size of the problem In Bahrain National Non-communicable Diseases Risk Factors Survey 2007
  • 8. 8 Size of the problem In Bahrain National Non-communicable Diseases Risk Factors Survey 2007
  • 9. In Lebanon •23.1% are hypertensive •Prevalence increases with age •Occurs more in the less educated and unemployed •Prevalence increases significantly with an increase in body mass index particularly in female patients •Only14.7% exercised daily R A Tohme, A R Jurjus, A Estephan 2005
  • 10. 10 Size of the problem In Saudi Arabia: The prevalence range from 4% to 15%. Abolfotouh MA et al. It may reach as high as 20.4% for systolic hypertension and 25.9% for diastolic hypertension. Al-Nozha MM et al. In south-western 11.1%. Abolfotouh MA et al. In Jeddah, the hypertensive were 22.6%. Elkalifa Am et al.2011 In the UAE: Hypertension has become one of the leading public health problems
  • 11. In Sudan  of 6-12y children: 4.9% were pre-hypertensive and 4.9% were hypertensive Salman Z, et al 2010
  • 12. 12 Size of the problem It has been estimated that individuals who are normotensive at the age 55 years have a 90% lifetime risk for developing hypertension. EMR0 Technical Publications Blood pressure is under control in less than 20% of patients with hypertension in many countries A joint CINDI/EuroPharm Forum project WHO
  • 13. 13 Awareness of Hypertension Although the prevalence of high blood pressure is high, there is a low awareness rate (Up To 70% are unaware) Alwan A1993
  • 15. 15 Awareness of Hypertension In Egypt only 37.5% of hypertensives were aware of Having it. In United States, Chile, and Cub, 32%, 37%, and 39% of the people were not aware. Pan American Health
  • 16. 16 Advantage of Controlling Hypertension •A 5-6 mmHg reduction in diastolic BP reduces stroke by 40%. Joint National Committee on Detection, 1992 •lowering by 5-6mmHg can reduce mortality from cerebrovascular disease by 35%-40%, from ischemic heart disease by 15% 20% and reduction in all deaths from cardiovascular causes by 23%. Psaty, et al 1997 • 3 mmHg decrease in systolic BP reduces annual mortality from stroke, coronary heart diseases and all other causes by 8%, 5% and 4%. Whelton PK, 1994 •The chances of mortality from CVD in old hypertensive people when taking anti hypertensive medications is decreased by 34%. MacMahon, 1993
  • 17. 17 Economic Impact The economic burden of chronic NCDs can be analyzed on two levels. •First, the effects of macroeconomic policies on opportunities for prevention in different population groups •Second, the cost and overall efficiency of interventions must be evaluated in terms of effectiveness and health gains for the population at large.
  • 18. 18 Economic Impact Direct Cost: Including prescribing medicines, inpatient visits, outpatient visits, emergency room visits, office- based medical provider visits, home health visits, and other medical expenses Sanjeev Balu, 2001 Indirect Cost: Productivity loss ($300 per eligible employee per year) absence & short term disability Goetzel (2004), the only study in the U.S.
  • 19. 19 Economic Impact •Poor are disproportionately affected •more vulnerable •Prevalence 6 time more in uneducated •Medication cost up to US$ 100 per month •further poverty •Cost to Health Services •USA total cost of CVD is 2% of the gross domestic product • direct medical costs estimated at nearly $55.0 billion for the year 2001 Sanjeev Balu, 2001 •Canada 21% of all diseases costs are due to CVD (US$12 billion/Year) direct cost is $3,072 per person per year, and indirect cost is $854 Guijing Wang,2008
  • 20. 20 Economic Impact In Alkhobar the total direct cost of hypertension care for patients registered in the primary health care represented 6.32% of the estimated cost of treating the expected number of patients. Al-Shahri 1998
  • 21. 21 Prevention Primary prevention is the most cost-effective approach to containing the emerging hypertension epidemic. Hussein AlGezairy Regional Director for WHO
  • 22. 22 Prevention Incidence of hypertension was reduced by 20% to 50% if primary prevention were implemented Stamler 1991 For the developing countries prevention of hypertension should be the goal.
  • 23. 23 Prevention Life style Modification: •perform aerobic exercise •maintain a healthy body weight •follow a healthy diet •restrict salt intake •stress management •limit alcohol consumption
  • 24. 24 Modification Recommendation Approximate systolic BP reduction Weight reduction Maintenance of normal body weight 5–20 mmHg/10 kg healthy eating plan Consumption a diet rich in vegetables, fruits, and low-fat dairy products with a reduced content of saturated and total fat 8–14 mm Hg Dietary sodium Reduction dietary sodium intake to no more than 2.4 g sodium 2–8 mmHg Physical activity Engagement in regular aerobic physical activity at least 30 minutes daily, most days of the week 4–9mmHg Recommended lifestyle modifications
  • 25. 25 Life style Modification • Weight reduction Every 1 kilogram of weight loss lower blood pressure by 1.6/1.1 mmHg Khatib et al. EMR0 Technical Publications
  • 26. 26 Prevalence of overweight and obesity among some countries of the Eastern Mediterranean Region (WHO.2004) Country Overweight/obesity (%) Males Females Saudi Arabia 64.0 70.0 Lebanon 60.0 53.0 Islamic Republic of Iran 57.0 67.7 Bahrain 56.4 79.0 Jordan 46.0 43.7 Egypt 43.8 41.0 Libyan Arab Jamahiriya 42.5 74.9 Oman 40.5 43.5 Morocco 37.2 21.7 United Arab Emirates 25.5 39.9 Tunisia 13.1 41.9 Kuwait 79 56
  • 27. In Bahrain National Non-communicable Diseases Risk Factors Survey 2007
  • 28. In Sudan  of 6-12y children: 45 (14.8%) were overweight; 32 (10.5%) were obese Salman Z et al 2010
  • 29. 29
  • 31. 31
  • 32. 32 Life style Modification • Physical activity Exercise lowers systolic and diastolic blood pressure by 5-10 mmHg Arakawa
  • 33. 33 Life style Modification • Physical activity National Non-communicable Diseases Risk Factors Survey 2007
  • 34. 34 Life style Modification • Sodium moderation Reducing dietary sodium intake to no more than 100 mEq/L )2.4g sodium or 6 g sodium chloride), reduces the blood pressure by an average of 4–6 mmHg. Khatib et al. EMR0 Technical Publications
  • 35. 35 Life style Modification • Diabetes (In Bahrain) National Non-communicable Diseases Risk Factors Survey 2007
  • 36. 36 Life style Modification • Diabetes (In Bahrain)
  • 37. 37 Life style Modification • Tobacco )In Bahrain) National Non-communicable Diseases Risk Factors Survey 20
  • 39. 39 Life style Modification • Lipids (In Bahrain) National Non-communicable Diseases Risk Factors Survey 20
  • 40. 40 Life style Modification • Cocoa ingestion 100g/day of chocolate drink reduces the systolic BP and diastolic BP Taubert et al 2007
  • 41. 41 Blood Pressure Pooled Change (mm Hg) P Cocoa Systolic -4.7 .002 Diastolic -2.8 .006 Tea Systolic 0.4 .63 Diastolic -0.6 .38 Change in Blood Pressure reduction between cocoa & Tea Taubert et al 2007
  • 42. 42 Change in Blood Pressure reduction between cocoa & Tea Taubert et al 2007 “The magnitude of the hypotensive effects of cocoa is in the range that is usually achieved with monotherapy of β-blockers or angiotensin- converting enzyme inhibitors”
  • 43. Chocolate and Coronary Heart Disease: A Systematic Review This article reviews current evidence on the effects of cocoa/chocolate on clinical and subclinical coronary heart disease (CHD), CHD risk factors, and potential biologic mechanisms.  The high content of polyphenols and flavonoids present in cocoa has been reported to play an important protective role in the development of CHD.  Although studies have demonstrated beneficial effects of chocolate on endothelial function, blood pressure, serum lipids, insulin resistance, and platelet function, it is unclear whether chocolate consumption influences the risk of CHD. Khawaja O et al Current Atherosclerosis Reports, Volume 13 / September 2011
  • 44. 44 Measurement of Blood Pressure The "white-coat" effect Prevalence of white coat hypertension was 3.6% overall and 12.8% in hypertensive patients. Marquez Contreras et al. 2006
  • 45. 45 Measurement of Blood Pressure The "white-coat" effect Prevalence of white coat hypertension was 3.6% overall and 12.8% in hypertensive patients. Marquez Contreras et al. 2006
  • 46. 46 Measurement of Blood Pressure The "white-coat" effect Prevalence of white coat hypertension was 3.6% overall and 12.8% in hypertensive patients. Marquez Contreras et al. 2006
  • 47. 47 Hypertension Control Very poor control of hypertension world wide •In Egypt 23.9% were receiving treatment & 8% controlled Ibrahim et al. •In Canada 15.8% had blood pressure treated and controlled Petrella et al, 2007 •In Saudi Arabia, 76 % were receiving treatment, but only 20% were found controlled Abolfotouh et al,
  • 48. 48 Measurement of Blood Pressure •Seated in a quiet room •Arm muscles relaxed •Cubital fossa at heart level •Avoid tight sleeves •Suitable size Cuff to be used •Repeat if BP > 140/90 •Measurement on both arms •Mercury sphygmomanometers are most reliable Goodman and Gilman's1993
  • 49. 49 Management Good management of hypertension is central to any strategy formulated to control hypertension at the community level. Randomized trials of drugs that lower and control blood pressure clearly show a reduction in mortality and morbidity. Hussein A. Gezairy Regional Director for the Eastern Mediterranean
  • 50. 50 Management 2 mmHg reduction in systolic blood pressure is likely to reduce the annual mortality from stroke, coronary heart disease and all other causes by 6%, 4% and 3%, respectively
  • 51. 51 Conclusion Hypertension is a serious problem that could be called "the silent killer". Its prevalence is very high especially in the GCC countries. Effective efforts ought to be taken in order to prevent, prevent, prevent, prevent then diagnose and treat it.
  • 52. 52 Conclusion Hypertension is a serious problem that could be called "the silent killer". Its prevalence is very high especially in the GCC countries. Effective efforts ought to be taken in order to prevent, prevent, prevent, prevent then diagnose and treat it.
  • 53. 53 Conclusion Hypertension is a serious problem that could be called "the silent killer". Its prevalence is very high especially in the GCC countries. Effective efforts ought to be taken in order to prevent, prevent, prevent, prevent then diagnose and treat it.
  • 55. 55