APPENDIX A Appendix A tabulates the monthly cost (US $) of available anti-hypertensive and lipid lowering drugs individually in each SAARC country. For each drug within a class the minimum effective and the ceiling recommended dosage has been listed. For both, the minimum and the maximum monthly cost packages have been calculated. These cost packages are based on the available minimum and maximal dosages of each drug in the market, in the absence of which cost for the minimum and the maximum recommended doses have been calculated from the cost of available dosage in the market. These costs have been viewed as a percentage of the monthly rural and urban household incomes and as a percentage of the monthly household heath expenditure by the private and the public sector. Local currencies have been converted into US $ based on the exchange rates as of July 18, 2001 displayed on http://theFinancial.com Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the PAKISTAN Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class available available available available available available available available available available Ace Inhibitors A2 Receptor Blockers Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class available available available available available available available available available available Beta Blockers Ca Channel Blockers Diuretics Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class available available available available available available available available available available Fibric acid derivatives Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class available available available available available available available available available available Ace Inhibitors A2 Receptor Blockers Beta Blockers Ca Channel Blockers Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly co st of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class available available available available available available available available available available Diuretics Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class available available available available available available available available available available Fibric acid derivatives BANGLADESH Ace Inhibitors Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class avai lable available available available available available available available available available A2 Receptor Blockers Beta Blockers Ca Channel Blockers Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class available available available available available available available available available available Diuretics Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class available available available available available available available available available available Fibric acid derivatives Ace Inhibitors A2 Receptor Blockers Beta Blockers Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class available available available available available available available available available available Ca Channel Blockers Diuretics Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class available available available available available available available available available available Fibric acid derivatives SRI LANKA Ace Inhibitors A2 Receptor Blockers Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Minimum Maximum Drug by Class available available available available available available available available available available Beta Blockers Ca Channel Blockers Diuretics Cost of therapy as a Cost of therapy as a Cost of therapy as a Cost of therapy as a percentage of the percentage of the Monthly cost of percentage of the percentage of the average monthly household monthly household average rural urban household income health expenditure by health expenditure by household income the public sector the private sector Drug by Class Minimum Maximum available available available available available available available available available available Fibric acid derivatives
Coronary Heart Disease Prevention in South Asia
APPENDIX B A Heart Healthy Eating Plan for South Asians
We recommend that health professionals use this guide while recommending a
Lean meat, poultry and fish
Daily allowance: a serving a day from this group; where applicable and possible at
least 2 of these daily servings a week should be of fish. It is preferable to avoid
beef. Fat should always be trimmed off meat (except fish meat) before cooking.
? One serving of beef or mutton is equal to 3 full size botis.1 ? One serving of chicken is ½ a chicken breast or chicken leg with thigh (without
? One serving of fish is the size of a deck of playing cards. ? A one-cup serving of cooked beans, peas or lentils (masur, maash, channay,
lobia), chick peas (cholay), can replace a serving of meat.
Daily allowance: due to the high cholesterol content of egg yolks, as a general rule,
if one egg is eaten then cholesterol in any other form through o ils, meat or dairy
products, should be reduced. However, egg white is a very good source of protein,
has no cholesterol and can be taken daily.
Fruits and vegetables
Daily allowance: 5 or more servings a day.
? One serving is equal to 1 medium-size piece of fruit (e.g. small apple, small
banana) or ½-1 cup cooked or raw vegetables.
? Coconuts are very high in saturated fat and should be eaten only very
occasionally. Jaggery (palm sugar – made from the sap of the coconut palm) is
a high calorie item and should b e eaten only as a treat.
1 A standard size for pieces of meat used in a curry. 85
Coronary Heart Disease Prevention in South Asia
Low fat milk products
Daily allowance: servings per day depend on age; for adults aged 19 and above, 2
One serving is 1 cup of fat-free (packaged) or fresh milk with the cream removed or 1 cup yogurt made with such milk or 1 oz. Low- fat cheese or ½
cup low fat cottage cheese. Breads, cereals, pasta and starchy vegetables
Daily allowance: 6 servings a day. ? One serving is equal to one slice of bread, one chapatti or dosa (size of
a small plate), half a naan (saada not roghni), idli, makki ki roti, etc. or 1 cup of cooked rice or pasta or ¼ - ½ cup of starchy vegetables
(potatoes, corn, green peas, sweet potatoes).
Fats and Oils
Daily allowance: No more than a total of 2-4 servings per day.
? One serving is 1 tbsp. of vegetable oil like canola, corn, olive, safflower,
? or 1 ½ tsp. of seeds or nuts like almonds, walnuts, pine nuts, pistas,
? Note: Remember that all home made or commercially prepared baked and
processed foods like cakes, buns, doughnuts, mithai, sweet dishes, and biscuits
contain fat in the form of butter, ghee, or oil. This must be taken into account in
? Avoid ghee, coconut, palm kernel and palm oil (all solid at room temperature)
as they are very high in saturated fats and should be avoided.
? In Sri Lanka coconut oil is very widely used; its use should be
Recommendations for Diabetics: In addition to the above, foods that have a high content of sugar like sugar itself or foods containing high concentrations of sugar are to be avoided. Also to be avoided are very sweet fruits like mangoes, dates, melons and grapes.
Coronary Heart Disease Prevention in South Asia
APPENDIX C Methodology
At the executive council meeting of the SAARC Cardiac Society held in
Kathmandu, Nepal on July 22, 2000, it was unanimously decided to develop a set of “Guidelines for the Prevention of Coronary Heart Diseases in the SAARC Region”. The executive council selected the chief coordinator to
steer the development of the guidelines at a central level and regional coordinators to steer input at regional levels in addition to liaising with the
chief coordinator. It was also decided that all the members of the SAARC executive council would serve as the SAARC consensus panel, and that the regional coordinators should set up regional consensus panels in their own
countries. It was also agreed upon that an international advisory board should be constituted which would give its input to the final draft of the
manuscript. The preparation phase consisted of pre-evaluation surveys, literature
review, writing up the report, and input at different levels.
Pre-evaluation Survey Focus group discussions held independently in India, Pakistan and Bangladesh were employed as part of the pre-evaluation survey that guided the development of these guidelines with respect to its justification, format and content. A field guide was developed which sought responses relating to the relevance of these guidelines to practice in the region and the level of knowledge and beliefs of the health care providers. Bangladesh: in Bangladesh a focus group discussion was held with the participation of eight cardiologists and cardiovascular epidemiologists on September 28, 2000. The focus group summarized a review of literature on the prevalence of coronary heart disease within the country, in addition to furnishing details regarding the currently recommended national guidelines for primary and secondary prevention. India: the group in India felt that the recommendations should flow from a broad based group both in terms of professional involvement as well as representation from various regions of the country and therefore the views
Coronary Heart Disease Prevention in South Asia
of eminent experts all over the country were solicited. This was thought to be a good surrogate to focus group discussion, which was logistically impractical due to geographic constraints.
There was near unanimity in the need for the guidelines and also for region
specificity. Most respondents felt that the western guidelines were not ideally suited to or were either inadequate or inappropriate in the Indian context. Almost all the respondents were aware of the global CVD trends to
a varying extent and believed that the trend had serious implications for the SAARC countries and therefore emphasized upon the need to develop and
disseminate guidelines focusing on prevention. Input with regard to diet, physical activity and stress as part of the feedback, has been useful while drawing up the recommendations. It was identified that policy change was
essential for bringing CVD on the health care agendas of the SAARC countries. The importance of coordinating efforts within the SAARC
countries was also emphasized. Pakistan: in Pakistan feedback was sought through questionnaires from cardiologists, general physicians, epidemiologists, dietitians and heath policy makers. Majority of the participants of the focus group discussion found this exercise relevant within the framework of the regional health economics. It was agreed unanimously that investment in prevention for the region is imperative. There was a general agreement on the need to customize guidelines with a focus on economic issues while still working within the domain of scientific recommendations. A case was made for economically tiering these guidelines. Input relating to dietary recommendations was also received from the participants, as a result of which the Heart Healthy Eating plan for South Asians has been developed and is appended. With regard to the antismoking strategies, there were differing opinions. Some participants were inclined toward an aggressive policy-based approach whereas others favored a program-based strategy. Integration of physical activity as part of the heart health package was generally visualized as a problem for women; it was emphasized that this issue be addressed appropriately, in keeping with religious and cultural sensitivities. All participants saw pharmaceutical multinational distribution networks as a support structure and a possible conduit for the dissemination of these guidelines but expressed a concern over potential conflict of interest
Coronary Heart Disease Prevention in South Asia
particularly as these guidelines were seen as intending to decrease rather than encourage prescription expense. In this context all participants suggested using alternate means of disseminating these guidelines and highlighted the potential role of training trainers with support from the private and the public sector. After the focus group discussions and literature review, the chief coordinator prepared the initial draft, which was approved by the SAARC consensus
panel members at the executive council meeting of the SAARC cardiac society in Chennai, India on December 9, 2000. Over the following months
feedback received from the members of the International Advisory Board was also incorporated into the document.
Coronary Heart Disease Prevention in South Asia
Coronary Heart Disease Prevention in South Asia
GLOSSARY
CAD: Coronary Artery Disease CHD: Coronary Heart Disease COT:
Cigarette and Othe r Forms of Tobacco Use
CVD: Cardiovascular Disease CRP: C-Reactive Protein DALY: Daily Adjusted Life Years GNP: Gross National Product GDP: Gross Domestic Product HDL:
JNC: Joint National Committee criteria LDL:
Lp(a): Lipoprotein A NCD: Non Communicable Diseases NRT: Nicotine Replacement Therapy PAI:
FLUORIDE COMPOUNDS ARE: Bio-accumulating, carcinogenic, protoplasmic, poisons and enzyme inhibitors. ( Inactivate 62 enzymes) They are also teratogenic, phyto-toxic, corrosive (class 8), neurotoxic, fetotoxic, clastogenic, thyrotoxic, mutagenic, and immuno-suppressive. Fluorides have a synergistic effect with other pollutants, including radioactive isotopes. They destroy vitamins and are
A. Biological Chemistry(though water is the universal medium for life on earth, living organisms are made of chemicals based mostly on the element a. contain Carbon. total of 6e-, 2 in 1st shel , 4 in 2nd that holds 8 i. Carbon has 4 valence electrons that can join with an electron from another atom to form a strong covalent bond-usual y with C, H, O, or N ex/ CH4 (methane) ii. Carbon can
Coronary Heart Disease Prevention in South Asia
APPENDIX B 
Coronary Heart Disease Prevention in South Asia
Low fat milk products 
Coronary Heart Disease Prevention in South Asia
APPENDIX C 
Coronary Heart Disease Prevention in South Asia
of eminent experts all over the country were solicited. This was thought to be a good surrogate to focus group discussion, which was logistically impractical due to geographic constraints.
There was near unanimity in the need for the guidelines and also for region
specificity. Most respondents felt that the western guidelines were not ideally suited to or were either inadequate or inappropriate in the Indian context. Almost all the respondents were aware of the global CVD trends to
a varying extent and believed that the trend had serious implications for the SAARC countries and therefore emphasized upon the need to develop and
disseminate guidelines focusing on prevention. Input with regard to diet, physical activity and stress as part of the feedback, has been useful while drawing up the recommendations. It was identified that policy change was
essential for bringing CVD on the health care agendas of the SAARC countries. The importance of coordinating efforts within the SAARC
countries was also emphasized. 
Coronary Heart Disease Prevention in South Asia
particularly as these guidelines were seen as intending to decrease rather than encourage prescription expense. In this context all participants suggested using alternate means of disseminating these guidelines and
highlighted the potential role of training trainers with support from the private and the public sector.
After the focus group discussions and literature review, the chief coordinator prepared the initial draft, which was approved by the SAARC consensus
panel members at the executive council meeting of the SAARC cardiac society in Chennai, India on December 9, 2000. Over the following months
feedback received from the members of the International Advisory Board was also incorporated into the document.
Coronary Heart Disease Prevention in South Asia
Coronary Heart Disease Prevention in South Asia