The Drivers of Non-Communicable Diseases

Susan B. Shurin, MD

NCI Center for Global Health

Consortium of Universities for Global Health, Boston MA

27 March 2015

Declaration of Interests

• For the past decade, I have been employed by the National Institutes of Health

– 2006-2014: NHLBI as a federal employee

– 2014-present: NCI as a contractor

• Before that, I was a Professor of Pediatrics and Oncology at Case Western Reserve University in Cleveland

• I have no financial conflicts, and pitifully few financial interests

• I will not be discussing treatment of anything

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NCDs: “Non-Communicable” Diseases

A. Are chronic diseases which produce substantial disability with economic and social costs & contribute to premature death

B. Are often communicable (some cancers, lung & heart diseases have infectious causes; obesity spreads through social networks)

C. Is a term now used to refer to cardiovascular & pulmonary disease, diabetes & cancer, with overlapping causal factors

D. Does not include mental, neurologic or substance abuse, violence, trauma, inherited diseases

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Causes of death globally

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Leading Causes of Death in the 21st Century

India

1. Coronary heart disease

2. Diarrheal diseases

3. Lung disease

4. Stroke

5. Influenza & pneumonia

China

1. Stroke

2. Lung disease

3. Coronary heart disease

4. Lung cancer

5. Liver cancer

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Focus of This Discussion: Gaps

What DO we know about NCDs?

• Major contributors to DALYS and premature (<70 years) death worldwide

• Environmental factors contribute heavily

– Nutrition

– Pollution of air & water

– Behaviors with profound biological, social &emotional context

What do we NEED to know to take intelligent action?

• How to engage sectors other than the health care system in matters of health

• How to assess and project economic impact

• How to run health care systems

• How to improve nutrition, make people stop smoking, polluting and drinking to excess

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Causation Pathway for Chronic Non-communicable Disease

Adapted from: The Lancet 2011; 377:680-689

Globalisation

Urbanisation

Poverty

Low education

Stress

Tobacco use

Unhealthy diet

Physical

inactivity

High blood glucose

High blood pressure

Abnormal serum

lipids

High waist-hip

ratio/Obesity

Heart disease

Stroke

Cancer

Chronic lung disease

Type 2 Diabetes

Environ-

mental

risk

factors

Behavioral

risk factors

Biological risk

factors

Chronic non-

communicable

disease

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Developmental Origins of Chronic Disease

Hanson M, Gluckman P. Am J Clin Nutr. 2011;94:1754S-1758S

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Obesity: About 3.6% of the global burden of cancer is attributable to high BMI

Males

Females

• BMI>25 kg/m2 associated with increased risk of cancer

• Assumed 10-year lag between high BMI and cancer occurrence, numbers of new cancer cases attributable to high BMI estimated

• Globally 3.6% of all new cancers associated with excess BMI (1.9% in men; 5.4% in women).

Arnold M et al., Lancet Oncol, 2014 9

Updated from de Martel et al. Lancet Oncol 2012

0 5 10 15 20 25 30 35

Australia / New Zealand

Northern America

Europe

Northern Africa and Western Asia

Southern America

Total world

Pacific Islands

Central Asia

Eastern Asia

Sub-Saharan Africa

Helicobacter pylori

Hepatitis B/C Virus

Human PapillomaVirus

Other infectious agents

31.3

22.7

19.2

19.2

15.3

14.9

11.9

7

4.2

3.4

About 15.3% of Global burden of cancer is attributable to infectious agents

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Epidemiology Gaps

Scientific Gaps

• Detailed incidence and prevalence data in countries – Geography

– Gender

– Socioeconomic status

– Ethnicity

• Genetic/genomic factors specific to a population

• Specific exposure factors – Environmental

– Behavioral/cultural

Some Possible Approaches

• Improved surveillance and reporting – Risk factors

– Diseases

• Population-level genomic studies

• Population-level data on exposures across time

– Air, water, food quality

– Alcohol, tobacco, substance use

– Infectious agents associated with disease: Hep B/C, papillomavirus, H. pylori, HIV

– Nutritional data

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Pathophysiology Gaps

Scientific Gaps

• Mechanisms of genetic-exposure interactions

• Molecular impact of multiple environmental exposures on cells/organs

• Life course issues: levels of exposures, nutritional factors, across the entire life cycle and generations

Some Possible Approaches

• Valid animal models for development of human disease across lifespan

• Effective measures of exposure of individuals and populations

• Measures of nutritional status across development

• Measures of body composition (leanness, fat) of individuals & populations

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Primary Prevention Gaps

Scientific Gaps

• Optimal nutrition – Undernutrition

– Overnutrition

– Micronutrient deficiency

• Lifecourse issues –underfeeding girls

• Reduce toxic environmental exposures

• Decrease tobacco in LMICs

• Vaccine prevention of cancers

Some Possible Approaches

• Develop better biomarkers of nutritional status

• Develop better biomarkers of environmental exposures

• Economic & cultural studies of tobacco markets, determinants of use

• Economic and cultural studies on use of vaccines against hepatitis & papillomavirus

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Prevention works but takes time – lung and cervix

Lung, men Cervix uteri

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Secondary Prevention Gaps

Scientific Gaps

• Cancer: How to best use early detection to minimize morbidity and mortality

• CVD: Population approaches to management of hypertension, cholesterol

• T2DM: Population approaches to management of obesity and T2DM

• Pulmonary: effective approaches to smoking cessation

Some Possible Approaches

• Cancer: – Develop better data on

screening for breast & prostate cancer – who, when, how

– integrate screening for cervical, oral & colorectal cancer into care systems

• CVD, lung, T2DM: better interventions in the health care system and social supports for interventions

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Cultural and Behavioral Gaps

Scientific Gaps

• How to effectively change the behavior of individuals in society

• Prevention & management of addictive substances such as tobacco & alcohol

• Cultural issues in diet, food preparation, use of psycho-active substances (nicotine, alcohol, others)

Some Possible Approaches

• Realistic examination of relative impact of interventions targeted at economics, cultural & individual behaviors.

• Understand biology of addiction

• Understand cultural aspects of foods, cooking practices, psychoactive substances

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Treatment Gaps

Scientific Gaps

• Scaling & implementing therapies of varying efficacy and impact

• How to build effective health systems to facilitate primary & secondary prevention &treatment

• How to encourage investments of known high impact which don’t make a profit

Some Possible Approaches

• Build global capacity in implementation science

• Coordinated global programs in health care delivery with meaningful short and long-term outcomes.

• Engagement of politicians & advocates in setting research priorities

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Some system issues to consider: funding

• Research on prevention, public health & implementation of knowledge is relatively neglected.

– Not sexy

– Doesn’t pay off quickly

– Pays off in costs avoided, not in profits

– Those most likely to benefit are poor, voiceless, & often have short term concerns

– Requires a team 18

Some system issues to consider: setting priorities

• Biomedical researchers tend to focus on health care systems. Many of the causes of NCDs are outside the health care system.

• Other economic sectors see changes as likely to cut into profits by decreasing revenue or increasing costs.

• Politicians are not rewarded for advancing the common good.

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• Age-adjusted death rates from heart disease and stroke have fallen >30% since 1950

• Multiple factors contribute

Resources matter: CVD in the U.S.

600

500

400

300

200

100

0 1960 1970 1980 1990 2000 2005

Heart Disease

Cancer

Stroke Accidental Injuries

Alzheimer’s

Data source: New York Times, April 24, 2009 20

Less Pollution = Better Lungs

Levels of Pollutants/time Children’s Lung Function

Gauderman WJ et al. N Engl J Med 2015;372:905-913 21

Leadership matters! NYC banned.. • 2003: Smoking in commercial

establishments

• 2011: Smoking in public spaces

• 2013: Cigarette sales to those under 21

• 2009: Sales of "flavored" tobacco products

• 2013: Smoking e-cigarettes in public spaces

• 2013: Cigarette in-store displays

• 2010: High Sodium levels in processed foods

• 2006-13: Illegal guns

• 2006: Trans-fats in restaurants

• 2013: Commercial music over

45 decibels

• 2013: Loud headphones

• 2012: Sodas larger than 16 ounces

• 2008: Chain restaurant menus without calorie counts

• 2013: Non-hurricane-proof buildings in coastal areas

Under Mayor Bloomberg

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For Discussion

• How can the biomedical research community take leadership addressing NCDs?

• Be objective about what we know?

• Communicate risks and uncertainties?

• Engage other sectors in research?

• Share control of research priority-setting?

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Center for Global Health (CGH) Contact Information

Website:

www.cancer.gov/globalhealth

Telephone number:

+1-240-276-5810

Street address:

9609 Medical Center Drive, Rockville, MD (near Shady Grove Adventist Hospital)

Email: NCIGlobalHealth@mail.nih.gov Twitter Handle: @NCIGlobalHealth

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