global burden of chronic disease : focus on cvd ramachandran s. vasan, md vanessa xanthakis, phd...

Global Burden of Chronic Disease : Focus on CVD Ramachandran S. Vasan, MD Vanessa Xanthakis, PhD NHLBIs Framingham Heart Study Boston University School of Medicine [email protected]

Background Present Future Causes Prevention Future Directions Global Burden of CVD

Background Basic concepts What is CVD What is Burden WHO subregions Broad causes of death Global Burden of CVD

CVD The WHO includes the following broad disease categories under CVD CHD: coronary artery disease Cerebrovascular disease Rheumatic heart disease Hypertensive heart disease Inflammatory heart disease Other CVD

DALY = YLL + YLD i i i Burden of Disease: Concept of DALYs DALY is a health gap measure that summates potential years of life lost due to premature death & the years of healthy life lost due to states of less than full health (broadly termed disability) 1 DALY = 1 year of healthy life lost; Japanese life expectancy serves as standard

EUR AMR WPR AFR SEAR EMR GBD investigators divided the world into regions based on levels of child (under 5) and adult (15-59) mortality for WHO member states

Group I includes communicable, maternal, and perinatal causes and nutritional deficiencies. Group II includes the non-communicable causes including cancers, diabetes, cardiovascular disorders and chronic respiratory diseases. Group III includes unintentional and intentional injuries. Causes of Deaths: Groups I, II and III

3 kinds of transitions determine global health Epidemiological transition Omrans stages: epidemics, receding pandemics, NCD Demographic transition From high birth and death rates to low birth rates and death rates Nutritional transition Processed foods with added sugar, saturated fats and sodium

Age Pestilence and famine Receding pandemics Degenerative man-made diseases Delayed degenerative diseases Predominant CVD Rheumatic heart disease Hypertension- related diseases CHD, stroke, diabetes at young ages CHD, stroke at older ages % of deaths due to CVD 5-1010-3535-65

Background Present Future Causes Prevention Future Directions Burden of CVD in Developing Countries

Global Health- the Good News Huge health gains in the past century increased life expectancy decrease in infant mortality Likely contributors Economic growth Social development Medical advances

McKeown T. Determinants of Health

Death Rates due to Rheumatic Fever in US Time Trends Gordis L, Circulation 1985;72:1155 Classification of Streptococci Introduction of Sulfonamides Introduction of Penicillin

Global Health- Bad News There is an ongoing epidemic of NCD (Grp II: CVD, stroke, diabetes, metabolic diseases, & cancer) world-wide Cumulative national losses>$1 trillion (China, $558 billion; Russia, $303 billion; India, $237 billion)

Global Burden of NCD: The Present World-wide NCD account for: 36 million deaths annually 63% of deaths 48% of DALYs lost

http://www.who.int/healthinfo/global_burden_disease/en/

Global Burden of NCD: The Present NCD accounts for 63% of deaths world-wide 80% of these deaths in developing countries NCD is leading cause of death in all parts of the world other than SSA 17. 1 million deaths annually due to CVD, 7.1 million deaths annually due to cancer, 4 million deaths due to diabetes

Global Burden of NCD: The Present Over 80% of cardiovascular and diabetes deaths, and almost 90% of deaths from chronic obstructive pulmonary disease, occur in low- and middle-income countries. More than two thirds of all cancer deaths occur in low- and middle-income countries. NCDs also kill at a younger age in low- and middle- income countries, where 29% of NCD deaths occur among people under the age of 60, compared to 13% in high-income countries.

63% 48%

Deaths by Broad Cause Group within WHO Region (2000) Injuries Noncommunicable conditions Communicable diseases, etc. AFR EMREURSEARWPR AMR 25 50 75 % Source: WHO, World Health Report 2001 Developing countries contribute substantially more in terms of absolute numbers

61% 48%

Global Burden of CVD: The Present CVD accounts for 30% of deaths world-wide 80% of these deaths in developing countries CVD is leading cause of death in all parts of the world other than SSA

Deaths due to CVD within WHO Regions (2000) Strokes Heart attacks AFR EMREURSEARWPR AMR 10 20 30 % Deaths Source: WHO, World Health Report 2001 Developing countries contribute substantially more in terms of absolute numbers

Global Burden of CVD: The Present CVD accounts for 10% of DALYs world-wide 86% of these DALYs lost in developing countries

A: very low child and adult mortality B: low child and adult mortality C: low child, high adult D: high child, high adult E: high child, very high adult Estimated number of people (millions) at High CVD Risk by WHO subregion 3 m 28 m 12 m 1 m 4 m 9 m 34 m 14 m 29 m 4 m 26 m 12 m 31 m

Global CVD- More Bad News The epidemic of CVD, Stroke, diabetes and metabolic diseases will hit the poor nations (low-and-middle income ) and in 2020 they will carry: 80% of the mortality from CVD 85% of the burden of disease

B. Neal et al. Eur. Heart J 2002 Projected Global Burden Of CVD Deaths (1990-2020) http://www.publichealth.pitt.edu/supercourse/SupercoursePPT/20011-21001/20111.ppt 20% 110%

Communicable diseases, maternal and perinatal conditions and nutritional deficiencies Noncommunicable Conditions Injuries 19902020 (baseline scenario) Source: WHO, Evidence, Information and Policy, 2000 Global Burden of Disease in Developing Countries (DALYs) 1990-2020

Global Burden of NCD: The Future The estimated percentage increase in cancer incidence by 2030, compared with 2008, will be greater in low- (82%) and lower-middle-income countries (70%) compared with the upper- middle- (58%) and high-income countries (40%).

Global CVD- Some Good News A Silver lining We know what are the major risk factors Epidemiology & clinical trials We have successfully stemmed the epidemic in developed countries CCUs in hospitals Public health

Global CVD- Some Bad News Dynamics of epidemic in developing countries Compressed time frame Early exposure to tobacco and high BP Societal response lags Setting of poverty & international debt Dual burden Paucity of epidemiological data Individual responses limited by low education, modest personal resources We have successfully stemmed the epidemic in developed countries Public health

Global health risks: mortality and burden of disease attributable to selected major risks. WHO 2009

BP, Smoking, Dyslipidemia Diet, Obesity, Phys. Inactivity

Continuous gradient across values No threshold (e.g., BP, Chol, glucose) More cases arise from body than tail of distribution A substantial % of CVD occurs in people with modest elevations of one or more risk factors (compared to marked elevations of a single risk factor). Risk factors cluster and interact multiplicatively Risk Factors & CVD Risk: Some Principles

Global Health Risks: WHO (2009) Global Burden of CVD Risk Factors AFRAMREURSEARWPREMRWorld Blood Pressure Mean SBP, mm Hg128126134125123127 % SBP>14027213619 23 Cholesterol Mean, mmol/l4.35.35.55.14.94.85.1 % >6 mmol/l (232 mg/dl)8283421171522 Glucose Mean glucose, mmol/l5.15.4 5.65.35.65.4 % with fpg>7mmol41012177 11

Burden of disease due to high cholesterol (% lost healthy life years in each subregion)

Burden of disease due to high BP (% lost healthy life years in each subregion)

Stroke & blood pressure in different populations Diastolic blood pressure

Blood pressure Cholesterol Systolic blood pressure (mmHg) Risk of CHD Continuous risks: blood pressure, cholesterol and the risk of coronary heart disease 0.5 1.0 2.0 4.0 Dyslipid emia 4.05.06.07.08.0 Total cholesterol (mmol/l) HTN Risks continue well below common thresholds, such as hypertension Most people have suboptimal levels of blood pressure and cholesterol % people % population

Drivers Of The CVD Epidemic Globalization = greater intercountry dietary dependance Foreign direct investment in foods & beverages in developing economies = less healthy food products MNC marketing influences persons in developing economies to prefer Western products as incomes rise Technological change speeds all these processes Technological change favors inactive lifestyle, and locus of food consumption shifts away from home Stuckler D. Milbank Quarterly 2008;86:273-326.

Drivers Of The CVD Epidemic Health Transition Urbanization Global trade and marketing developments Tobacco industry Physical inactivity Tobacco use, inappropriate diet and physical inactivity (expressed through unfavourable lipid profiles, overweight and raised BP) explain at least 75% of new CHD cases

World Health in Transition Epidemiological Chronic disease replacing infectious disease; dual burden in developing countries DemographicAging of the population

World Health in Transition Nutritional - Shifting dietary pattern -high fiber low fat replaced by energy- dense high sat fat -complex CHO replaced by refined CHO - Sedentary life style - decreasing leisure-time activity Economic & Social - Globalization of time, trade & travel

Nutritional Transition

Increased caloric consumption in a milieu of reduced energy expenditure Sedentary lifestyle Motorized transport Labor-saving devices Reduced leisure time physical activity

Stone Agers on a Fast Lane ? Paleolithic versus Modern Diet Paleolithic Man Modern Man Protein, %3012 Fat, %20-2542 Fiber, gm8610-20 Sodium, mg6043400 Potassium, mg69702400 Potassium: sodium12:10.7:1 Eaton SB, J Nutr 1996;126:732-40

Diet & CVD

The real weapons of mass destruction? www.globalhealth-ec.org/GHEC/Events/Conf05/conf05_ppt/C3_Pramming.ppt 3 behavioral Risk factors 50% of global mortality

DEMOGRAPHIC TRANSITIONS?: Temporal Trends in Obesity Prevalence for Low vs High income regions Finucane et al. Lancet 2011:557-67.

Global epidemic of obesity 1.1 billion 300 million 414 million 1.5 billion Age 18+ Age 15+ www.tacd.org/events/ge2/n_rigby.ppt

The potential future of nutritional risks

Obesity www.tacd.org/events/ge2/n_rigby.ppt

Obesity & the Global Economy Shifting dietary patterns Industrialization Economic development Globalization of markets www.csrees.usda.gov/ree/Presentations/The%20Obesity%20Pandemic%20Aug%2022.ppt

Global Trends in Nutrition Reduced intake of fruit and vegetables Increase intake of fats and sugars Decrease intake of fiber www.csrees.usda.gov/ree/Presentations/The%20Obesity%20Pandemic%20Aug%2022.ppt

Global Trends in Nutrition www.csrees.usda.gov/ree/Presentations/The%20Obesity%20Pandemic%20Aug%2022.ppt

Obesity in Developing Countries Urbanization Lifestyle changes Diet Physical activity Genetics Early life www.csrees.usda.gov/ree/Presentations/The%20Obesity%20Pandemic%20Aug%2022.ppt

Global Physical activity

Source: World Health Report, 1997 Prevalence of Diabetes in Adults (millions of people, by WHO Region)

Global projection for the diabetes epidemic: 2003-2025 (millions) 23.0 36.2 57% 23.0 36.2 57% 14.2 26.2 85% 14.2 26.2 85% 48.4 58.6 21% 48.4 58.6 21% 43.0 75.8 76% 43.0 75.8 76% 7.1 15.0 111% 7.1 15.0 111% World 2003 = 194 million = 5.1% of adult population 2025 = 333 million = 6.3% of adult population Increase 72% 39.3 81.6 108% 39.3 81.6 108% 19.2 39.4 105% 19.2 39.4 105% Ref: Diabetes Atlas second edition, IDF 2003

1995 2025 19 million 57 million Diabetes Top Three Countries in the world King et al, Diabetes Care, 1998

Tobacco Over 1 billion smokers worldwide 500 million people alive today will eventually die of tobacco-related causes, including 250 million children Half of all smokers die in middle age (35-65)

Distribution of worlds smokers 2000 2025 WHO World Health Report 1999. fctc.org/mercosurasociados05/Tom.ppt

Smoking in developing world

How serious is the global tobacco epidemic? Tobacco kills almost 5 million people / yr. Tobacco killed 100 million in the last century It is projected to kill 1 billion this century By 2030, it will kill 10 million a year, and 70% of these deaths will be in developing countries. The tobacco epidemic is rapidly spreading to the worlds most vulnerable populations.

Tobacco deaths in the Industrialized and Developing World, 2000 and 2030 Industrialized countries Developing countries While tobacco- related deaths will only increase slightly in the industrialized world during the next 30 years, they will more than triple in the developing world. fctc.org/mercosurasociados05/Tom.ppt

How Did Tobacco Use Become Epidemic? Nicotine, a potent addicting agent Risks are not immediate Produced at tremendous profit by a powerful, multinational industry Advertising makes it appealing and targets children Governments profit from tobacco health.osf.lt/downloads/news/STILLMAN-Origin-and-evolution-pandemic.ppt

The Global Smoker Cognitive Globalization Social norms promote smoking with a globally shared culture of smoking; Western cigarettes as the norm (as opposed to national brands, etc); Western ideas of freedom, independence, economic success, choice (esp. emerging markets). health.osf.lt/downloads/news/STILLMAN-Origin-and-evolution-pandemic.ppt

Is Tobacco Use a Global Infectious Disease? Host Government and People Vector Tobacco Industry Agent Advertising Movies and Media Political Influence health.osf.lt/downloads/news/STILLMAN-Origin-and-evolution-pandemic.ppt

fctc.org/mercosurasociados05/Tom.ppt The Global Smoker

Global trends in HTN Prevalence

Present Future Causes Prevention Future Directions Global Burden of CVD

Commonality of Risk Factors Tobacco Diet Physical Activity Alcohol Cardiovascular Cancers Diabetes Chronic Respiratory Diseases Osteoporosis Oral Health Mental Health Source:

Optimal & Actual BP Distributions in Populations Global health risks: mortality and burden of disease attributable to selected major risks. WHO 2009

Population-based & High-Risk Strategies for CVD Prevention

The Global NCD Strategy Focus on Integration WHA endorsed framework for the integrated prevention and control of NCDs May 2000 HoweverMember State capacities pose challenges for supporting an integrated NCD agenda High level UN meeting in Sept 2011 on Global NCD

NCD Control: Public Health Policy Comprehensive health programs led by primary care Appropriate balance between primary and secondary prevention Particularly population approaches (Only 5% in wealthy countries at ideal cholesterol, BP, weight) Also high-risk approaches to primary prevention (although latter may increase inequalities) Acute management and secondary prevention Surveillance and monitoring

NCD Prevention And Control WHO 2001 39% 65% 76% 94% 88% http://www.publichealth.pitt.edu/supercourse/SupercoursePPT/20011-21001/20111.ppt

Comprehensive National Tobacco Control Policy Fiscal policy Increase price of all tobacco products beyond inflation, use part of the revenue for tobacco control Information policy Ban tobacco advertising and promotion; ensure effective health warnings are placed on all tobacco products; invest in counter-advertising and health education Establish smoke-free public places Provide tobacco dependence treatment Ensure adequate institutional support To tobacco control capacity building, applied research, routine surveillance and program evaluation Work with the media On the need for tobacco control, the availability of policies that work, and the role of the industry in thwarting implementation of healthy policies Assist farmers to diversify out of tobacco

Examples of integrated NCD prevention projects North Karelia Project, Finland North Karelia Project, Finland Tian-Jin Project, China Tian-Jin Project, China NCD prevention project, Mauritius NCD prevention project, Mauritius Coris project, South Africa Coris project, South Africa Mirame project, Chile Mirame project, Chile Isfahan Healthy heart Project, Iran Isfahan Healthy heart Project, Iran

NCD Prevention: WHO

Summary Tobacco: Almost 6 million people die from tobacco use each year, both from direct tobacco use and second-hand smoke. By 2020, this number will increase to 7.5 million, accounting for 10% of all deaths. Smoking is estimated to cause about 71% of lung cancer, 42% of chronic respiratory disease and nearly 10% of cardiovascular disease.

Summary Insufcient physical activity: Approximately 3.2 million people die each year due to physical inactivity Harmful use of alcohol: Approximately 2.3 million die each year from the harmful use of alcohol, accounting for about 3.8% of all deaths in the world. More than half of these deaths occur from NCDs including cancers, cardiovascular disease and liver cirrhosis.

Summary Raised blood pressure: Raised blood pressure is estimated to cause 7.5 million deaths, about 12.8% of all deaths. Overweight and obesity: At least 2.8 million people die each year as a result of being overweight or obese. Raised cholesterol: Raised cholesterol is estimated to cause 2.6 million deaths annually

Double burden of diseases, resource competition Myths: Personal Behaviours vs. Public health problem Treatment vs. Prevention Ageing (natural) population vs. Young population Modernization ( Rich) vs. local problem (poor) Future vs. present problem Measurement of NCDs vs. CD Under-estimation of intervention effectiveness Commercial pressure Institutional inertia Challenges

Few clear policies and strategies Limited resources Fragmented and uncoordinated care Low commitment to prevention Lack of surveillance systems Inadequate treatment guidelines PHC capacity to deal with NCDs is poor Severe lack of investment in research Developing Countries: Challenges

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global burden of chronic disease : focus on cvd ramachandran s. vasan, md vanessa xanthakis, phd...

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