Report by Prof. Jaap Deckers and Dr Roderik Kraaijenhagen
National CVD Prevention Coordinators for the Netherlands:
(Note: National CVD Prevention Coordinator for the Netherlands since 2017: Doctor Madoka Sunamura, replacing Prof. Deckers)
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The Kingdom of the Netherlands, commonly known as the Netherlands, is a sovereign state and constitutional monarchy in Western Europe and (with four small parts) the Caribbean. It is a small and densely populated nation, with about 17 million inhabitants on 42,525 km2, and thus almost 400 inhabitants per square kilometre. The Netherlands is a representative parliamentary democracy.
The country hosts almost 10.000 general practitioners, about 90 hospitals and 900 cardiologists. The Dutch healthcare system has undergone radical changes in the last few years. It is now mandatory for everyone to purchase at least a base level of insurance. However, one is free to choose their own health insurer and change company once per year. Health insurance covers basic medical costs such as visits to the general practitioner, costs for hospitalisation, medications and most medical treatments. In adults, dental care is excluded. Expenditure on health care equals about 9.5% of GDP (Gross Domestic Product).
Despite the aging of the population, cardiovascular mortality continues to decline (standardised decline in CVD 70%). Currently, cardiovascular disease (CVD) accounts for 27% of all deaths. However, the number of subjects with some form is heart disease is quite large, according to some estimates even one million.
CV risk factors levels are unfavourable in various aspects. The use of saturated fat (almost 13%) is too high in 90% of the population. Trans-fatty acids have been removed from the food chain. Salt intake (almost 8.5 gram per day) is too high in 85% of the population: strong attempts are being made to reduce the salt, sugar and fatty acid content of food products. The percentage of smokers continues to decline: currently, 25% regularly smokes. Although about 60% of the Dutch exercises regularly, over half of the population is overweight. A third of men and women aged 30-70 years has a “desirable” (< 5 mmol/L) total cholesterol concentration. Overall, 14% of men and 11% of women in the age group of 60-70 years have diabetes, while the prevalence of hypertension in the age group of 30-60 years is 33% in men and 20% in women.
Prevalence of the most relevant cardiovascular risk factors:
|Prevalence in %||Prevalence in %|
| Hypertension (years)
- 30 – 39
- 40 – 49
- 50 – 59
- 60 – 70
- 70 – 79
|Cholesterol level (mmol/L)
Overweight, BMI > 25 kg/m2
Obese, BMI > 30 kg/m2
Universal prevention: Public private cooperation including
- The National Institute for Public Health and Environment (RIVM)
- schools, schools with the vignette “Healthy School” and local communities
- local health organisations
- The Netherlands Heart Foundation
- The Lung Foundation
- The Cancer Federation
- The national Olympic Committee
Selective prevention: the ‘Prevention Consult alliance’, including
- The Dutch Societies of General Practioners (‘Landelijke Huisartsen Vereniging (LHV)’ and ‘Nederlands Huisartsen Genootschap (NHG)’)
- The Dutch Association for Occupational Health
- The Netherlands Heart Foundation
- The Diabetes Federation
- The Kidney Foundation
- NDDO (New Drug Development Office) Institute for Prevention and Early Diagnostics (NIPED)
The fact that atherosclerotic cardiovascular disease is a slow and chronic disease process makes it difficult to define when disease actually starts and when a person is to be called diseased or afflicted. A clear separation between prevention and medical treatment - covered by basic health insurance - is thus difficult. For these reasons, a new model has recently been introduced in the Netherlands that categorizes measures to prevent disease from occurring into the following four stages:
- Universal prevention: aimed at the general population, with the goal to promote health by reducing the burden of risk factors and the development of disease.
- Selective prevention: identification of groups (of subjects) at high risk and provision of targeted and tailored preventive measures to all individuals with risk factors.
- Indicated prevention: aimed at high risk individuals to prevent further development of the disease process and its clinical sequallae. Examples: treatment of hypertension and/or elevated cholesterol level. Lifestyle interventions in subjects at high risk are also included within this prevention category.
- Care related prevention: aimed at patients / persons with health related problems with the aim to limit the burden of disease, to avoid further complications, and to promote and stimulate their independence and self-autonomy.
Reimbursement for outpatient cardiac rehabilitation (CR) is provided by all insurance companies on the condition that a patient is referred by a cardiologist. Patients entering outpatient cardiac rehabilitation in the Netherlands are offered an individualised rehabilitation programme with a typical duration of 6–12 weeks, consisting of group-based therapies (exercise training, relaxation and stress management training, education therapy, and/or lifestyle change therapy) and, when indicated, of additional individual counselling (e.g. by a psychotherapist or dietician). There are 90 hospitals and 10 rehabilitation centres providing cardiac rehabilitation in the Netherlands.
Aims for the future
- Implementation of a personalised prevention strategy based on individual risk profiling: a structured approach for ‘selective prevention’ combined with adequate implementation of ‘indicated prevention’ (cardiovascular risk management) for high risk individuals and ‘care related prevention’ for Dutch cardiac patients
- Web-based prevention support: in the Netherlands, decision support systems and web-based communication are increasingly being used to support professionals, to empower individuals and increase self-management. Large scale implementation studies to evaluate the feasibility and cost-effectiveness have been started from selective prevention to cardiac rehabilitation.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology