Global Health: The Burden of Chronic Diseases Jeffrey P. Koplan, MD, MPH Vice President for Global Health Director Global Health Institute

Global Health:Global Health:The Burden of The Burden of

Chronic DiseasesChronic DiseasesJeffrey P. Koplan, MD, Jeffrey P. Koplan, MD,

MPHMPHVice President for Global HealthVice President for Global Health

Director Global Health InstituteDirector Global Health Institute

The Demographic TransitionThe Demographic TransitionA change in the A change in the population dynamics of population dynamics of a country as it moves a country as it moves from high fertility and from high fertility and mortality rates to low mortality rates to low fertility and mortality fertility and mortality rates.rates.

The Epidemiologic TransitionThe Epidemiologic Transition

A transition from A transition from infectious disease to infectious disease to chronic, degenerative, or chronic, degenerative, or man-made diseases as the man-made diseases as the primary causes of primary causes of mortality.mortality.

Changes in Life ExpectancyChanges in Life Expectancy

1900 1950 1980 2000 2030

USA 49.3 68.9 74.1 77.4 81.2

Mexico < 30 50.8 67.4 74.9 80.1

Brazil < 30 50.9 63.3 71.1 77.4

China ≈ 30 40.8 65.5 72.0 77.4

India < 25 37.4 56.6 62.9 72.6

LDCs 40.8 58.8 64.1 71.5

Ref: The 2006 Revision and World Urbanization Prospects: The 2005 Revision, http://esa.un.org/unpp, Wednesday, March 12, 2008

http://esa.un.org/unpp

Ref: National Intelligence Council, The Global Infectious Disease Threat and Its Implications for the United States, 2000. Adapted.

The Epidemiologic TransitionThe Epidemiologic Transition

Population Pyramids by Population Pyramids by Growth PatternGrowth Pattern

Population Pyramid:Population Pyramid:Scotland, 1901Scotland, 1901

Ref: General Register Office for Scotland. Available at: www.gro-scotland.gov.uk/files/04fig2.4.gif. Accessed 12 February 2008.

Population Pyramid:Population Pyramid:Scotland, 2001Scotland, 2001

Ref: General Register Office for Scotland. Available at: www.gro-scotland.gov.uk/files/04fig2.4.gif. Accessed 12 February 2008.

2002Ischemic heart disease

Cerebrovascular disease

Lower respiratory infection

HIV/AIDS

COPD

Perinatal condition

Diarrheal disease

Tuberculosis

Trachea, bronchus, lung cancers

Road traffic accidents

Diabetes mellitus

Malaria

Hypertensive heart disease

Self-inflicted injuries

Stomach cancer

Projected rankings for 15 leading Projected rankings for 15 leading

Causes of Death, 2002 vs 2030Causes of Death, 2002 vs 2030Group I

Group II

Group III

Ref: Mathers CD, Loncar D. PLoS Med. 2006 Nov;3(11):e442.

2030Ischemic heart disease


HIV/AIDS

COPD

Lower respiratory infections


Diabetes mellitus


Perinatal conditions

Stomach cancers

Hypertensive heart disease

Self-inflicted injuries

Nephritis and nephrosis

Liver cancers

Colon and rectum cancers

High-income countriesIschemic heart disease



Diabetes mellitus

COPD

Lower respiratory infection

Alzheimer and other dementias

Colon and rectum cancers

Stomach cancer

Prostate cancer

Projected rankings for Causes of Projected rankings for Causes of Death, high vs low income, 2030Death, high vs low income, 2030

Group I

Group II

Group III

Ref: Mathers CD, Loncar D. PLoS Med. 2006 Nov;3(11):e442.

Low-income countriesIschemic heart disease

HIV/AIDS


COPD

Lower respiratory infections

Perinatal conditions


Diarrheal disease

Diabetes mellitus

Malaria

Ref: WHO. Preventing chronic diseases: a vital investment (2005).

Projected foregone income due to early mortality from heart disease,

stroke and diabetes, 2005–2015

Driving the Demographic and Driving the Demographic and Epidemiologic TransitionsEpidemiologic Transitions

Western model: driven gradually by Western model: driven gradually by economic, scientific, and technological economic, scientific, and technological developmentdevelopment

New model: driven more rapidly by New model: driven more rapidly by economic development plus rapid economic development plus rapid uptake of health-related science and uptake of health-related science and technologytechnology

The New Risk FactorsThe New Risk Factors Industrialization has led to

Chronic Disease

Risk factors: Smoking Pollution Automobiles Diet Sedentary lifestyle

Aging population

Urban migration

““On one point, however, On one point, however, there is nearly complete there is nearly complete consensus of opinion, and consensus of opinion, and that is that primary that is that primary malignant neoplasms of the malignant neoplasms of the lungs are among the rarest lungs are among the rarest forms of the disease. This forms of the disease. This latter opinion of the extreme latter opinion of the extreme rarity of primary tumours rarity of primary tumours has persisted for centuries.”has persisted for centuries.”

I Adler, Primary Malignant Growths of the Lungs and Bronchi: A I Adler, Primary Malignant Growths of the Lungs and Bronchi: A pathological and clinical study. Longmans, Green and Co., London, 1912.pathological and clinical study. Longmans, Green and Co., London, 1912.

Most smokers live in developing countriesMost smokers live in developing countriesMost smokers live in developing countriesMost smokers live in developing countries

Source: Jha et al, 2002, AJPH

Current smokers in 1995 (in millions)

Region NumberLow/Middle income 933High Income 209World 1,142

Quit rates low in low income countries 5-10% in China, India 30-40% in UK

Large and growing number of deaths from smokingLarge and growing number of deaths from smokingLarge and growing number of deaths from smokingLarge and growing number of deaths from smoking

Source: Peto and Lopez, 2001

Past and future tobacco deaths (in billions)

Time Billions of deaths1901-2000 0.1 (mostly in developed

countries)

2001-2100 1.0 (mostly in developingcountries)

0.5 B among people alive today 1 in 2 of long-term smokers killed by their addiction 1/2 of deaths in middle age (35-69)

Ref: WHO. Report on the Global Tobacco Epidemic (2008).

Source: http://jat.esmartweb.com/china-2004/china-2004.htm

Obesity BrazilObesity Brazil

05

101520253035404550

Per

cent

Araca

ju

Belém

Belo H

orizo

nte

Distrit

o Fed

eral

Campo G

rande

Curitib

a

Floria

nópolis

Fortalez

a

João P

esso

a

Manaus

Natal

Porto A

legre

Recife

Rio d

e Jan

eiro

São Paulo

Vitória

Total

Prevalence of excess weight (Body Mass Index > 25)Population of 15 years of age in 15 Brazilian Capitals and FD 2002-2003

MexicoMexico From ’88 to ’99, in 2 - 4 year olds the rate of From ’88 to ’99, in 2 - 4 year olds the rate of

obesity or at risk for obesity increased from obesity or at risk for obesity increased from 21.6% to 28.7%21.6% to 28.7%

6-11 year olds, 21% obese or at risk for obesity6-11 year olds, 21% obese or at risk for obesity

24% of Mexican adults are obese24% of Mexican adults are obese

8% of adults 8% of adults >> 20 y.o. have type 2 Diabetes 20 y.o. have type 2 Diabetes

30% have HBP30% have HBP

-29.33-26.72

-18.75

6.25

37.21

-40

-30

-20

-10

0

10

20

30

40

50

%

%

Fruits and Vegetables

Milk and derivates

Meats

Refined carbohydrates

Soda

Figure 7 Changes in mean food purchases in 1996 (relative to 1994) by food group.

Source: Rivera et al., 2004

MEXICO

Chinese Household Food Chinese Household Food Consumption TrendsConsumption Trends

Ref: Wang H, Du S, Zhai F, Popkin BM. Trends in the distribution of body mass index among Chinese adults, aged 20–45 years (1989–2000). International Journal of Obesity 31(2007):272–278.

Dietary energy from fat more than 30%Dietary energy from fat more than 30%

54.7

12.1

29.5

34.6

56.660.1

58.4

51.4

19.8

39

23.123

0

10

20

30

40

50

60

70

1989 1991 1993 1997 2000 2004

year

％ urban

rural

Source: The China Economic Population Nutrition and Health Survey

Sample size: 5789 (1989), 5838 (1991),5468 (1993), 5334 (1997), 4831 (2000), 4474 (2004)

CHINA

2.4

1.7 1.8

2.5

1.31.7

2.2 2.12

0

1

2

3

Hours/day

All children(n=461)

Low income(n=215)

Middle income(n=246)

TV programs

Other video

Physical activity

Figure 5 Mean Time dedicated to video viewing and physical activity, Mexico City Children 9-16 years old 1999

Ref: Mexico Nutrition Survey 1999

MEXICO

Number of color TV sets owned per 100 householdsNumber of color TV sets owned per 100 households

year Urban ruralyear Urban rural 1985 17.211985 17.21 1990 59.041990 59.04 1995 89.79 16.921995 89.79 16.92 1999 111.571999 111.57 2000 116.56 48.742000 116.56 48.74 2001 120.52 54.412001 120.52 54.41 2002 126.382002 126.38 2003 130.502003 130.50

Source: State Statistical Bureau, China Statistical Yearbook, 1985-2005

CHINA

Ref: Yangfeng Wu; Overweight & obesity in China, website: bmj.com 19 Aug 2006

CHINA

Shifts in the BMI distribution for Shifts in the BMI distribution for Chinese men, 1989–2000Chinese men, 1989–2000

Ref: Wang H, Du S, Zhai F, Popkin BM. Trends in the distribution of body mass index among Chinese adults, aged 20–45 years (1989–2000). International Journal of Obesity 31(2007):272–278.

IndiaIndia

Metabolic Syndrome – 5 to 50% Metabolic Syndrome – 5 to 50% prevalenceprevalence

- - insulin resistanceinsulin resistance-- glucose intolerance glucose intolerance-- abdominal obesity abdominal obesity-- hyper insulinemic hyper insulinemic- - hyper triglyceridemic hyper triglyceridemic

Projected Growth in Road Projected Growth in Road Traffic Fatalities, 2002–2020Traffic Fatalities, 2002–2020

Ref: Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006 Nov;3(11):e442.

Global Prevalence of Global Prevalence of Mental Health DisordersMental Health Disorders

Ref: Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet. 2007;370:859-877.

The Behavioral The Behavioral TransitionTransitionAn increase in individual and An increase in individual and

collective behaviors, collective behaviors, promoted and spread by promoted and spread by global communication, that global communication, that leads to the increased leads to the increased prevalence of unwanted prevalence of unwanted health outcomes.health outcomes.

The behavioral transition has The behavioral transition has led to an increase in led to an increase in “communicated diseases.”“communicated diseases.”

Communicable Disease ModelHOS

T

AGENT

VECTOR

Communicated Disease Model?HOS

T

AGENT

VECTOR

Communicable/Communicated Communicable/Communicated DiseasesDiseases

CommunicableCommunicable: :

CommunicateCommunicatedd: :

AGENTS

• Micro organisms- - viruses viruses- - bacteriabacteria- - parasitesparasites

• Food• Drink• Tobacco• Inactivity


CommunicableCommunicable::

CommunicateCommunicated:d:

VectorsVectors• Insects

• Media• Sports• TV/Cinema• Social

pressure


CommunicaCommunicableble: :

CommunicatCommunicateded: :

Environmental Environmental ConditionsConditions

• Global warming

• Increased affluence

• Urbanization


CommunicabCommunicablele: :

CommunicatCommunicateded: :

Socio-cultural Socio-cultural ContextContext

• Waste disposal• Hygiene• Coughing etiquette

• No smoking places• Value of activity• Safe driving/roads

Communicable/Communicated Communicable/Communicated Diseases Diseases

Hosts OutcomesCommunica

ble:

Humans • Preventable disease and death

Communicated:

Humans Preventable disease

and death

Communicated Diseases

obesity motor vehicle collisions and

injuries decreased fitness and activity CHD diabetes hypertension stroke many cancers chronic lung disease

DEATHS DUE TO CHRONIC DISEASES DEATHS DUE TO CHRONIC DISEASES (NCDs)(NCDs)

129.4

37.7

18.7

0

10

20

30

40

50

60

1990 2020

Dea

ths

in m

illio

ns

Demographically developing countries

Established Market Economies and Former Socialist economies of Europe

InterventionsInterventions• Community health Community health promotionpromotion• School base programsSchool base programs• Legislation/regulationLegislation/regulation• TaxationTaxation• Mass mediaMass media• PartnershipsPartnerships• Government leadershipGovernment leadership

KTL website (www.ktl.fi)

Documents

Global Health: The Burden of Chronic Diseases Jeffrey P. Koplan, MD, MPH Vice President for Global Health Director Global Health Institute