CINDI HEALTH MONITOR SURVEY -

AN INTEGRATED PART OF CINDI

CONCEPTUL MODEL IN MACEDONIA
National programme for NCD prevention and control

Prim. d-r PhD.

spec. of sports medicine – subspec. nutritionist
 
Lazar Licenovski 13, 1000 Skopje, phone +389-02-3225-402

mfh.cindi@makedonija.com

PUBLIC HEALTH INSITUTE OF SPORTS MEDICINE, NUTRITION UNIT, SKOPJE, MACEDONIA

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 Community and primary care-based
demonstration project for health promotion and
noncommunicable diseases (NCD) prevention has
been prepared as an integrated part of conceptual
model for CINDI National Programme.

Republic of Macedonia is in the process of

joining CINDI and implementing the CINDI concept
through the process of health care reform.

In focus of the reform in primary health care is

the implementation of health promotion and NCD
prevention measures in preventive practice of
“family” doctors.
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 The purpose of the study:
 
1. To analize professional reasons that justify realization
of the CINDI Programme based on information of health
status in the Republic of Macedonia.

2. Assessment of national capacity in primary health care

to realize CINDI project on promoting healthy nutrition
and physical activity in different age groups.

3. The role of National Health Autority in CINDI team

to confirm the Macedonian CINDI-Plan of action in
health promotion, heart disease and other chronic disease
prevention in related to physical activity and nutrition
over the next 5 year.
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 Methods:
1.-Secondary data obtained from mortality/morbidity
statistics in the Republic of Macedonia (1990-2001).
-The results for family aggregation of common risk
factors for chronic diseases obtained from medical research
(BMI, Systolic/diastolic BP, T.Chol., TG, HDL, LDL, Glyc.,
smoking, decreased VO2max, dietary habit, and stress) in
randomized simples (Demonstation Projects 1990 and 1998).
2. National capacity in primary health care obtained from
WHO questionnaire connected with “Assessment of national
capacity for noncomunicable disease prevention & control”
in 2001 year.
3. Protocol and quidelines about CINDI principles and
strategies for health promotion and disease prevention (WHO
CINDI publications).
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 Results and Conclusions:
1. NCD are the main cause of morbidity and mortality
during the last 10 years in the Republic of Macedonia.
( figures-1 and figure-2).

In the last three decades the cardiovascular disease,

esspecialy coronary heart disease, malignant neoplasm's,
and diabetes mellitus remains the most common cause of
death for the Macedonian population.

In 1972 mortality from them accounting for 37% from

total mortality, and year by year this percentage has
increasing significantly up to 55.6% in 2001 with
continuous trend to this days.
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 Figure 1. Mortality rate from noncommunicable diseases
in The Republic 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
300 359.5
250
200
150
100 140.5 142.6 150.3
129.5
50 108.3 111.4 KVB
0
Cancer
1991 1993 1995 1997 1999 2001

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Figure 2. Morbidity rate from circulatory diseases in the Republic
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

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 The results of common risk factors for
NCD include:
1. BMI distribution varies significantly
according to the stage of transition of a country.
Figure-3 illustrates the tendency for rapidly
increase in the proportion of the population
with high BMI than the proportion of the
population with low BMI in the early stage of
transition.
The distribution of BMI tends to change
again in the later phases of transition with an
increase in the prevalence of high BMI among
the poor.

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 Figure 3. BMI Distribution in adult population in Skopje
in the last 10 years (1990-2000 year)

% 1990
75.8
80 65.5 1995
58.8 1998
70
2000
60
41.6 41.5
50
40
18.2 23
30 18.6
15.9 16.8
14.9
20 9.3

10
0
BMI < 25 BMI > 25-29.9 BMI > 30

9
 
Figure 4. Prevalence of systolic and diastolic blood pressure
in adult population in Skopje

%
88.7
100
80.9 1990
73.8 1998
80 68.3

60

40 23.7
16.6 14.3
11.9
20 10 7.9
1.2 2.4

0
<140 >140 >160 <90 >90 >95

systolic BP diastolic BP
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 Figure 5. Prevalence of risk factors for NCD in adult
population from central region in Skopje
 
80
75
%

60

40 35.9 35.2
28.8 28.2
23.8 23.4
20 14.2 18.2 15.8 18.2
12.5
3.7
2.5
0
.0
5

V
5

s
)

4.

1
>6
)

25

OP

rs
6.

s
25

L<
L>

re
l>

e
y
I>
I>

ok
HD
Gl

st
ho

LD

O2
BM
BM

sm
C

<V
3(
T.

5(

.
>2
6.
l>

TG

1990
ho

1998
C
T.

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 2. There are great potencial within
primary health care to realize CINDI project
for health promotion and the primary
prevention of major chronic diseases through
changes of lifestyle of the population such as
increased physical activity and balanced diet
(average 1488 population per one MD).

The territory of Republic of Macedonia is

divided into five regions with distrinct centres
for the implementation of all NCD related
preventive activities ( figure 6).

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 Figure 6. Organizational structure – CINDI HEALTH
MONITOR SURVEY CENTRES in the Republic of Macedonia

167
167
1877
1877

149
 
149

150
150

384
222
389

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 3. The role of the Macedonian Health Authority
in CINDI - team is to accept an alternative
classification system for prevention strategies aimed
at chronic multifactorial conditions.
This is based on three levels of preventivntion
directed at everyone in the population (public health
promotion), an above/average risk groups (selective
prevention) and at high-risk individuals (targeted
prevention).
In this new scheme promotion and prevention
are used to describe those action that occur before
the full development of the condition.

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 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
atherogenic risk factors.

Logistic model in form of equation is:

ln “RR” =108.2588–1.7689  DKN-B in +1.7087 -
BMI in+0.3993- Hb 2.9423-VO2max OPV –
10.5402 WHO in + 0.0770-50% kcal/h

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 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 1400kcal/d (second phase) since the
relative risk is less than 1 (ln“RR”<1).
Increased physical activity by the recommendations of
ACSM (1993) and CDC (2001) statistically significant
promotes development of VO2max.
Change in level of VO2max at 17.16% from baseline
promotes significant greater reduction in level of WHR, OS
sm, %fat (%M), body weight (TTkg), LBM kg, BMR kcal/d
and LDL/HDL in PAD(physical activity and diet) than
those in D (diet) group obese subjects
(figure 7).
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Figure 7. Change in level of VO2max and “major” risk factors for NCD in FAD
(physical activity and diet) and D (diet) group of truncal obese subjects
 
25 %
VO2max
17,1 14,8
HDL 15
10,4

5
TT %M LBM WHR OS LDL/HDL %FAI BMR

-1.8 VO2-OPV
-3,3 -3.3 -3.1 -5
-5.3 -4,5 -5.6 -5,2
-6.3
-7,9 -9,5 -7.7 -9.3 -10,2
-10,3 -15

-25
FAD
-28,6 D
-35

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  C I NDI PR OG R AM M E I N M AC E DONI A - C ONC E PTUAL M ODE L

M inistry of Health

Coordination CINDI Centre

Administrativen delSector
Administrative

I NTERVENTNI PROCESI
INTERVENTION PROCESSES

Used from demonstaciono Community level

Demonstartion primeneti
Used from
health podra~je area population
od SINDI
CINDI
services randomizirani
randomized groups programata
programme
grupi
nezavisni
First Second
grupi
Groups(pol, vozrast)
(gender and age) -knowledge
-znaewe variables
varijabli variables
lokacija(u~il,kolekt) work)
Location (schools, -na~. na odnes.
-behaviour
-family
-semejstvo
-cultural level
-kultur. nivo
inic. indikatori:
Inicial indicators: -social support -community
-aktiviranost
1. Morpho-phisiological
-socij.podr{
1.morfo-fiziolo{.    na zaednica
-organized
risk-factors :
rizik-faktori 1.li~
1. ni zdravst.
individual health
-m asovno
groups vklu~
and
status,
BMI;BMI;
WHR,WHR Final indikatori:
fin. indicators: individuals karakteristiki
organiz. grupi 2. socio-demographic
HTA mmHg;
HTAmmHg; fc-mir/max, 1. rizik-faktori
risk factors -screening 2.socio-demogr.
Fc in rest/max i individuiof characteristics
Tot.Tot.
holest; TG 2. morbiditet na
morbidity of karakteristiki
cholest; TG na::
risk factors
-skrining 3. social enviroment
HDLHDL-holest, “major” HNB
NCD education/ 3.socij.okolina.
2 2-holest rizik-faktiri  
3. mortalitet
mortality promotion oc  
VO2 VO
max, max ./ METs.
METTs. edukac./prom  
2
 
CINDI-Conceptual model
2. Behavioural
2.rizik- faktori risk
factors: Macedonia, 2002 - 2007
na odnesuvuvawe : National coodinator:
Nutrition, Smoking and
ishrana; pu{ewe, M ONI TOR I NG I AND
MONITORING EV AL UAC
EVALUACIJ A I ON Simovska Vera MD., PhD.
Physical inactivity
hipokinezija.
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Monitoring of health behaviours and related factors on a national level is
an important vehicle for health promotion and disease prevention.

The overall puepose of the CINDI Health Monitor is:

- to evaluate and to promote favourable health behaviours in population
- to evaluate the effectiveness of national health policy.

The proposal-project to establish a CINDI national health behaviour

monitoring system in the Republic of Macedonia was created in 2002 year
as part of CINDI conceptual model for development and implementation of
National programme for chronic diseases prevention and health promotion
(WHO CINDI Programme).

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