The Challenges of Chronic Disease

in Transitional Societies

Cristina Rabadan-Diehl, Ph.D., MPH. Deputy Director

Office of Global Health

National Heart, Lung, and Blood Institute

Health Policy Round Table 2011

Challenges and Strategies for Chronic Disease Prevention

and Control in Transitional Society

June 3, 2011

Great Epidemics of Today

Chronic diseases took the lives of over 35 million people in 2005, including many young people and those in middle age.

The total number of people dying from chronic diseases is double that of all infectious diseases (including HIV/AIDS, tuberculosis and malaria), maternal and perinatal conditions, and nutritional deficiencies combined.

80% of chronic disease deaths occur in low and middle income countries and half are in women.

Without action to address the causes, deaths from chronic diseases will increase by 17% between 2005 and 2015.

http://www.who.int/chp/chronic_disease_report/part2_ch1/en/index8.html

3

The Need: NCDs Now Comprise 60% of

Global Mortality

35

30

25

20

15

10

5

0 CVD Cancer Diabetes COPD

Diabetes Atlas, 3rd edition, IDF 2006

World

2007 = 246 million

2025 = 380 million

Increase +55%

28.3 40.5

+43%

16.2 32.7

+102%

10.4 18.7

+80%

53.2 64.1 +21%

24.5 44.5

+81% 67.0 99.4

+48% 46.5 80.3

+73%

Global projections type 2 diabetes (20-79 Age Group) 2007-2025 (Millions)

Karar, Z et al; Global Health Action, 2009.

Change in broad cause of death for both sexes

in Matlab, Bangladesh 1986-2006

Chronic Disease Conundrum: Developmental

Dilemma?

Economic Growth

Industrialization

Urbanization

Globalization

Among the Top

10 Threats To

Global Economic

Growth*

Global Chronic

Disease

Epidemics

Economic

Growth

Life

Expectancy

Good Health

* World Economic Forum (2009; 2010)

Potential Productive Years of Life Lost due to

Cardiovascular Disease Deaths (Age group 35-64 years)

7

1.6

3.3

6.7

9.2

2.03.2

10.5

17.9

US Rus

sia

Chi

na

Ind

ia

In Millions

2030

2000

Estimated Economic Loss for India due to

Heart Disease, Stroke and Diabetes (2005-2015) : US $ 237 Billion-WHO

Activity

Work

School

Leisure

Consumption

Foods

Calories

Fats/oils

Salt

Tobacco

Blood pressure

Blood cholesterol

Obesity

Blood glucose

Incidence

Morbidity

Mortality

We know the risk factors that contribute to CVD…

It seems simple…

To reduce the burden, reduce the risk factors and treat disease

Institute of Medicine. 2010. Promoting Cardiovascular Health in the

Developing World: A Critical Challenge to Achieve Global Health.

Systematic Drivers of Global CVD

Institute of Medicine. 2010. Promoting Cardiovascular Health in the

Developing World: A Critical Challenge to Achieve Global Health.

A Lifecourse Perspective

• CVD risk accumulates starting early in life

• Trends in early life risks are rising in low and middle

income countries

Childhood &

Adolescence Pre-Natal

Early

Childhood

Maternal smoking

Low birth weight/infant undernutrition

+ rapid weight gain

Overweight &

Obesity

Initiation of

tobacco use

Lifelong CVD Risk

Adult

Response to Health Transition

Low Risk High Risk

POPULATIONS

Demographic and Social Determinants

Public Health Interventions

Low Risk High Risk

INDIVIDUALS

Biology + Beliefs + Behaviors

Clinical + Behavioral Interventions

Promoting Cardiovascular Health

in the Developing World

A Critical Challenge to Achieve Global

Health

Report Brief, Report Summary,

and Full Prepublication Report

can be downloaded for free:

www.iom.edu/globalcvd

Institute of Medicine. 2010. Promoting Cardiovascular Health in the

Developing World: A Critical Challenge to Achieve Global Health.

POLICY APPROACHES (Global; National; Local)

Financial Trade Regulatory Legal

Environment To Enable Individuals To Make

and Maintain Healthy Choices

INDIVIDUAL

FAMILY

NEIGHBORHOOD, COMMUNITY

Enhancement of Knowledge, Motivation, and

Skills of Individuals

Media Settings Based Community Interventions

HEALTH COMMUNICATION P

reven

tive,

Dia

gn

osti

c,

Th

era

peu

tic,

Reh

ab

ilit

ati

ve S

erv

ices

HE

ALT

H C

AR

E D

EL

IVE

RY

WIDER SOCIETY

DE

TE

RM

INA

NT

S Globalization

Ac

ce

ss

to C

are

Sys

tem

s

Infr

as

tru

ctu

re

Hea

lth

Wo

rkfo

rce

Qu

ali

ty

of

Ca

re

Dru

gs &

Te

ch

no

log

ies

Demographic

Change

Globalization

Social

Determinants

Health

Inequities

Cultural and

Social Norms

Education

Biological

Risk

Behavioral

Risk

Institute of Medicine. 2010.

Promoting Cardiovascular

Health in the

Developing World.

IOM Report recommendations

14 Fuster et al. Circulation 2011; 123;1671-1678

Recognize and respect the realities of multiple competing priorities

Recognize the realities of resource constraints

Integrate health promotion and prevention efforts with other diseases that share common risk factors and common social, structural, economic, and developmental-related determinants

Build partnerships across sectors such as agriculture, finance, education, transportation, and the private sector

Integrate healthcare delivery and capacity-building efforts with ongoing initiatives to strengthen health systems

Balance integrated approaches with disease-specific approaches where appropriate for research, training, and clinical care

15

Key Principles for Organizing and Coordinating for

Action to Control Global Cardiovascular Disease

Global Health Leadership: Key Issues

Policy and public health approaches are essential to crafting solutions.

Economic factors have promoted spread of NCDs

Prevention requires approaches which are not in the health care sector

Research needs are poorly understood

What needs to happen

How to actually

implement

16

Implementation

Research Agenda

1. Define, frame and communicate the nature and magnitude of the problems and issues

2. Generate the evidence to inform practice

3. Engage those who must implement solutions

17

Essential leadership roles of clinicians,

academics, researchers, scientists

Power of Policy

Tobacco Diet

• Taxes • Salt

• Smoke Free Policies •Trans-Fats

• Ad Bans • Edible Oils

• Health Warnings • Fruits & Vegetables

• Regulation of Advertising

• Labeling

Focus is on cancer, cardiovascular diseases,

chronic respiratory diseases and diabetes.

Topics selected because of importance of

behavioral, social, economic and

environmental factors, including

Tobacco

Diet and Nutrition

Physical Activity

Alcohol

19

UN General Assembly Summit on Non-

Communicable Diseases: September 19-20, 2011

NHLBI Priorities

Priorities are driven by

scientific opportunities

public health needs

Basic, clinical and population research inform each other.

Gene-environment interactions bring observational and population-based studies closer to the basic science.

Basic Clinical Population

20

11 NHLBI and UnitedHealth

Collaborating Centers of Excellence