Global Health - Stephen T McGarvey, PhD, MPH Professor of Epidemiology & Anthropology Director, International Health Institute Health Transition Global

Global Health - Stephen T McGarvey, PhD, MPHProfessor of Epidemiology & AnthropologyDirector, International Health Institute

• Health Transition

• Global Burden of Mortality and Disease

• Overnutrition

• Translational Perspectives & Research

Terms: Epidemiologic Transition

Gaziano 2005

Stage 1 Malnutrition and infectious diseases are the leading causes of mortality and morbidity

Stage 2 Improved nutrition and public health leads to increase in CNCDs

Stage 3 Increased fat and caloric intake, widespread tobacco use, CNCD deaths surpass deaths from infections and malnutrition

Stage 4 CVD and cancer are the leading causes of morbidity and mortality; primary and secondary prevention efforts lead to declines in age-adjusted CVD

Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.

Disability Adjusted Life Years (DALYs)

Mortality – years of life lost due to the disease

Disability - decrease in healthy or functional years of life due to disease or injury (Experts decide based on previous research that some domain of function is reduced by some percent over so many years due to disease/injury.)

DALYs, thus, are estimates of health lost due to death and disability.

Cause-specific Mortality

Population Reference Bureau (Cohn 2007)






Unipolar depression – major source of disability in all income groups


WHO: Facts related to chronic diseases; Yach 2004, Strong 2005

Global Burden of NCDs• Chronic Non-communicable diseases (NCDs) are the

major cause of death and disability worldwide (except in South Asia and Sub-Saharan Africa)

• NCDs now account for 59% of all deaths and 48% of the global burden of disease

• Death rates for NCDs are higher in the developing world compared to the developed world

• Top diseases:– Cardiovascular disease – Cancer– Chronic respiratory diseases– Type 2 Diabetes– Obesity – Mental health and psychiatric conditions

Increase in ‘Dual Burden’ in LMIC• Low and middle income countries (LMIC) are now

and will suffer increasingly from the dual presence of both infectious/communicable diseases and NCDs

• Child survival to age 5 years• TB, HIV, malaria• Adult, esp age 40-80 yrs, hypertension, obesity,

type 2 diabetes, coronary artery disease• Risk behaviors – tobacco use, excess alcohol

use, risky sexual exposures

• Impact on design of health care systems, both clinical and public health

• Need for broader range of clinical specialists, esp for NCDs

Health Inequalities

Health Inequities

Marmot 2005. Social determinants of health inequalities Lancet 365: 1099–104

Leading Causes of Under Five Morbidity & Mortality in Developing World

• Infectious Diseases leading cause of death among children (about half)

• Undernutrition – Potentiating effects on infectious diseases– Related to poor learning and cognitive function

• Perinatal (extreme prematurity, stillbirth etc)

Infectious Diseases in Under 5’s• Many vaccine preventable

– Expanded Program of Immunization (EPI) established 1974– Has significantly reduced polio, neonatal tetanus, and measles

• Parasitic diseases-treatment available for almost all– Malaria major killer in sub-saharan Africa (1 million per year) and

extensive morbidity extensive ---> severe anemia, undernutrition– Helminth infections ---> anemia, undernutrition, cognitive

• HIV/AIDS

• Acute lower respiratory tract infections (number 1)

• Diarrheal illnesses - highlight precarious state of children

Nutrition TransitionPart of the Health Transition – occurs with the demographic and epidemiologic transitions.

Diets high in complex carbohydrates and fiber change to more varied diets with higher proportions of fat, saturated fats and sugars.

Assumption that it is due almost solely to the invasion by western foods into traditional regions.

Changes in modes of subsistence and occupations leads to decreased physical activity

BMI Classifications and Disease Risks

BMI Groups NCD Risks*

Underweight = <18.5 ?• Normal weight = 18.5-24.9 Standard• Overweight >25 • Pre-obese (Overwt) = 25-29.9 Increased• Obesity I = 30 – 34.9 High• Obesity II – 35 – 39.9 Very High• Obesity III - >40 Extremely High

* - NCD – non-communicable diseases,

e.g., Type 2 diabetes, hypertension, & CVD

Prevalence of Overweight & Obesity in Women 15-49 yr

0

5

10

15

20

25

30

S Asia SSAfrica

LatAmer

CEE/CIS ME/NAfr

USA

% Ovwt

% Obese

Overweight & Obesity in the US- age adjusted prevalence

0

10

20

30

40

50

60

Men25-29

Women25-29

Men>=30

Women>=30

Men>=25

Women>=25

BMI Groups

NHES 1960-62NHANES 1971-74NHANES 1976-80NHANES 1988-94

Coexistence of overweight and underweight in developing societies

1. Rapid urbanization and nutrition transition – reliance on energy dense diets and physical inactivity

2. Co-distributions of underweight and overweight individuals is conditional on stage of economic development and age distribution of households

3. Intrahousehold food allocation influences the under/over weight phenomenon

Am Samoa Market 1976

Fast Food & Vehicles Am Samoa – Now

Prevalence of Obesity, BMI >32 kg/m2, in American Samoa Adults 1976-2002

25

35

45

55

65

75

All Men M 45-54 y All Women W 45-54 y

1976-7819902002

Type 2 diabetes, FSG>126 mg/dl, Dx & Rx, by Age in American Samoa Adults

1990-2002

0

5

10

15

20

25

30

M 25-34 M 35-44 M 45-54 W 25-34 W 35-44 W 45-54

19902002

Overweight & Obesity, in American Samoa Children & Adolescents Girls – 1976-78 and 2002

0

10

20

30

40

50

60

70

80

90

100

G 6-8 y G 9-11 y G 12-14 y G 15-17 y

1976-78 Ovwt/Obese1976-78 Obese2002 Ovwt/Obese2002 Obese

Hypothesis

ECONOMIC DEVELOPMENT CONTINUUM Early: Samoa Middle: A. Samoa Advanced: US/UK

CV

D R

ISK

FA

CT

OR

S,

MO

RB

IDIT

Y &

MO

RT

AL

ITY

Socioeconomic Status

Diet and BMI

inSamoa1961-2010

Poverty & Obesity: energy density & costs

• Strong negative or inverse association in the US and other developed nations between BMI, overweight and SES

• WHY? • Nutritional health literacy• Food costs & availability • Food insecurity - limited/uncertain

availability of affordable and nutritionally acceptable or safe foods


• In US women food insecurity is associated with overweight: 58% overweight from food insecure households vs 47% non-insecure households

• Theory – low income households first consume less expensive foods to maximize caloric intake relative to the cost of food


• Due to changes in food production by food corporations, energy dense foods are more abundant and cheaper than ever before.

• Energy dense foods (high fat & sugar) are less costly but have high hedonic properties and produce less satiety, also long shelf life

• Energy density and energy cost are inversely related through deliberate choices of food-insecure or low income households to save $$.


• Low cost, high pleasure & low satiety=

overconsumption, and chronic positive energy balance.

• In the US portion sizes have increased and proportions of macronutrients have changed: increase in CHO

• Marketing of energy dense foods by large food corporations and widespread availability in stores

NCD Control Common Myths• Myth: “Chronic diseases are diseases of

affluence” – 80% of deaths from chronic disease are in low-income

and middle-income countries. – Chronic disease affects economic development.

• Myth: “People must die of something” – Certainly everyone has to die of something, but death

does not need to be slow, painful, or premature. – In low-income and middle-income countries, where

people tend to develop disease at younger ages, suffer longer— often with preventable complications—and die sooner than those in high-income countries.

– Death is inevitable, but a life of protracted ill health is not.

NCD Control Common Myths• Myth: “Chronic diseases develop over a lifetime so effective

prevention will take generations”– Risk factor reduction can lead to surprisingly rapid health gains. – The effect of tobacco control is almost immediate leading to decreases in

tobacco use, rates of cardiovascular disease, and hospital admissions.

• Myth: “Interventions for chronic disease are less cost-effective”– Many chronic disease interventions are cost-effective and inexpensive

throughout the world, including sub-Saharan Africa. – They include salt reduction, changes in oil and produce consumption,

tobacco taxation and advertising bans, and combination drug therapy for individuals at high risk.

Population vs individual approaches to health and disease

• Personal/individual• Family• School• Work• Social organizations such as religious groups• Neighborhoods• Community• Regional• Governments• Health care systems

Population vs individual approaches to reducing the burdens of disease and health

promotion

Importance of Structural Factors

• Political & economic context

• Role of public policies and laws

• Enfranchisement of individuals

• Empowerment of community

Translation & Implementation Research• Need to translate fundamental knowledge of biological and

behavioral processes - to clinical settings - to communities of free-living individuals

• Requires implementing program delivery into communities - with strong attention to socio-cultural, economic and

historical variations

• Avoid the invidious distinction between basic and applied scholarship

• Implementation research offers the opportunity to produce generalizable knowledge about design and delivery of programs.

• Global health inequalities and evidence about how risk factor exposures lead to disease and ill health, translating and implementing is a required step

Translation & Implementation Research• As anthropologists, we must critically think and teach our students

and the public about - evidence for linkages among poverty, health and mortality - identify hidden or poorly specified assumptions involved - avoid easy refuge of imprecise evolutionary concepts about relative

survival and mortality and a too-easy acceptance of inequalities.

• Our intellectual mission as anthropologists includes attempts: - to observe and measure human biocultural phenomena - with special attention to heterogeneities within & among communities - to develop & employ causal webs with factors operating at many

levels - to maintain unique biocultural, historical and population-based

perspectives

• Explicit interdisciplinary collaborations with biomedicine and public health probably required

• Assert primacy of community in such collaborations

Increase in ‘Dual Burden’ in LMIC• Low and middle income countries (LMIC) are now

and will suffer increasingly from the dual presence of both infectious/communicable diseases and NCDs

• Child survival to age 5 years• TB, HIV, malaria• Adult, esp age 40-80 yrs, hypertension, obesity,

type 2 diabetes, coronary artery disease• Risk behaviors – tobacco use, excess alcohol

use, risky sexual exposures

• Impact on design of health care systems, both clinical and public health

• Need for broader range of clinical specialists, esp for NCDs

Documents

Global Health - Stephen T McGarvey, PhD, MPH Professor of Epidemiology & Anthropology Director, International Health Institute Health Transition Global