cardiovascular disease in ckd who perspectives · 5. overweight and obesity 6. high cholesterol 7....
TRANSCRIPT
Cardiovascular Disease in CKDWHO Perspectives
Dr A. Alwan
Cardiovascular Disease in CKDWHO Perspectives
Dr A. Alwan
Tobacco use
No
n-c
om
mu
nic
ab
le d
ise
as
es
Heart disease and stroke �
Diabetes �
Профилактика неинфекционных
co
mm
un
ica
ble
dis
ea
se
s
Diabetes �
Cancer �
Chronic lung disease �
Causative risk factors
Unhealthy diets
Physical inactivity
Harmful use of alcohol
� � �
� � �
неинфекционных заболеваний и борьба с ними
� � �
� � �
Noncommunicable Diseases (NCDs)
• NCDs are the single biggest cause of death. A large proportion of deaths are • NCDs are the single biggest cause of death. A large proportion of deaths are premature.
• NCDs are preventable, there are cost effective solutions that are affordable to all countries.
• Most NCDs share common risk factors and an integrated prevention strategy is essential
• Health systems in developing countries are overwhelmed with the increasing magnitude but demands for technical support remains largely unanswered.
• NCDs are a serious development problem and there is a window of opportunity to act now.
Noncommunicable Diseases (NCDs)
NCDs are the single biggest cause of death. A large proportion of deaths are NCDs are the single biggest cause of death. A large proportion of deaths are
NCDs are preventable, there are cost effective solutions that are affordable to
Most NCDs share common risk factors and an integrated prevention strategy
Health systems in developing countries are overwhelmed with the increasing magnitude but demands for technical support remains largely unanswered.
NCDs are a serious development problem and there is a window of
5.8 M5.8 M
30 million
40 million
50 million
60 million
Total number of deaths in the world
26.0 M(above the age of
26.0 M(above the age of
10
NCDs are the single biggest cause of death9 million people die every year at young age�
Low-income countriesGroup III - InjuriesGroup II – Other deaths from noncommunicable diseasesGroup II – Premature deaths from noncommunicable diseases (below the age of Group I – Communicable diseases, maternal, perinatal and nutritional conditions
0
10 million
20 million
30 million
9.0 M(below the age of
9.0 M(below the age of
18.0 M18.0 M
MM
Total number of deaths in the world
M(above the age of 60)
M(above the age of 60)
10%
NCDs are the single biggest cause of deathmillion people die every year at young age
35 million(60% of all deaths)
Other deaths from noncommunicable diseasesPremature deaths from noncommunicable diseases (below the age of 60), which are preventableCommunicable diseases, maternal, perinatal and nutritional conditions
M(below the age of 60)
M(below the age of 60)
MM
(60% of all deaths)
15 million
20 million
25 million
Annual number of deaths in the world
90% of premature deaths from NCDs occur in developing countries
10 million
High-income countries
Upper middle-income
0.6M
0.5M
3.3M3.0M3.0M
5.9M5.9M
1.1M0.9M
Low-income countriesGroup III - InjuriesGroup II – Other deaths from noncommunicable diseasesGroup II – Premature deaths from noncommunicable diseases (below the age of Group I – Communicable diseases, maternal, perinatal and nutritional conditions
2.3M
10.2M10.2M
2.3M
6.8 M6.8 M
3.7M
13.6M13.6M
Annual number of deaths in the world
% of premature deaths from NCDs occur in developing countries
Lower middle-income
Low-income countries
3.3 M3.3 M3.0M3.0M
Other deaths from noncommunicable diseasesPremature deaths from noncommunicable diseases (below the age of 60), which are preventableCommunicable diseases, maternal, perinatal and nutritional conditions
Leading causes of attributable global mortality(2004)
1. High blood pressure
2. Tobacco use
3. High blood glucose
4. Physical inactivity
5. Overweight and obesity
6. High cholesterol 6. High cholesterol
7. Unsafe sex
8. Alcohol use
9. Childhood underweight
10. Indoor smoke from solid fuels
59 million total global deaths in
Leading causes of attributable global mortality
%
High blood pressure 12.8
8.7
High blood glucose 5.8
Physical inactivity 5.5
Overweight and obesity 4.8
High cholesterol 4.5High cholesterol 4.5
4.0
3.8
Childhood underweight 3.8
Indoor smoke from solid fuels 3.3
million total global deaths in 2004
Low-income countries
1. Lower respiratory infections
2. Coronary heart disease
3. Diarrhoeal diseases
4. HIV/AIDS
Top causes of death in the po
4. HIV/AIDS
5. Stroke and cerebrovascular disease
6. Chronic pulmonary disease
7. Tuberculosis
8. Neonatal infections
9. Malaria
10. Premature and low birth weight
Middle-income countries
1. Stroke and cerebrovascular disease
2. Coronary heart disease
3. Chronic pulmonary disease
4. Lower respiratory infection
poorest countries include NCDs
4. Lower respiratory infection
5. Trachea, bronchus, lung cancers
6. Road traffic accidents
7. Hypertensive heart disease
8. Stomach cancer
9. Tuberculosis
10. Diabetes mellitus
The top-10 countries reported to have the highest diabetes prevalence are countries in developing regions of the world.
( )
10 countries reported to have the highest diabetes prevalence are countries in developing regions of the world.
( )
Source: International Diabetes Federation's Diabetes Atlas
RISING PREVALENCE OF DIABETES IN URBAN INDIA
1989
15
20
Pre
vale
nce[%
]
Within a span of 14 diabetes increased by
Chennai Urban Rural Epidemiology Studconducted on representative population of Chennai city
8.3
11.6
0
5
10
Pre
vale
nce[%
]
1989 1995
YEARS
Mohan V et al, CURES, Diabetologia,
RISING PREVALENCE OF DIABETES IN URBAN INDIA
1989 - 2005
14.3
14 years, the prevalence of diabetes increased by 72.3%
tudy [CURES] is compared with other studies conducted on representative population of Chennai city
13.5
14.3
2000 2004
YEARS
Mohan V et al, CURES, Diabetologia, 2006
2005
Geographical regions (WHO classification)
Total deaths
(millions)
NCD deaths
(millions)
Africa 10.8 2.5
Americas 6.2 4.8
Mortality Trends (2006
Eastern Mediterranean
4.3 2.2
Europe 9.8 8.5
South-East Asia 14.7 8.0
Western Pacific 12.4 9.7
Total 58.2 35.7WHO projects that over the next 10 years, the largest increase in deaths from diabetes, cardiovascular disease, cancer, and respiratory disease will occur in Africa and the Eastern Mediterranean.
(WHO, Chronic Disease Report, 2005)
2006-2015 (cumulative)
NCD deaths
(millions)
Trend: Death from infectious
disease
Trend: Death from NCD
28 +6% +27%
53 -8% +17%
Mortality Trends (2006-2015)
25 -10% +25%
88 +7% +4%
89 -16% +21%
105 +1 +20%
388 -3% +17%years, the largest increase in
deaths from diabetes, cardiovascular disease, cancer, and respiratory disease will occur in Africa and the Eastern Mediterranean.
Loss of household income
Increased exposure to common modifiable risk factors:
GlobalizationUrbanization
Population ageing
Poor and vulnerable in developing countriesPoverty at
household level
NCDs are closely related to poverty and contribute to poverty
Loss of household incomefrom high cost of health care
Loss of household incomefrom unhealthy behaviours
Limited access to effective and equitable healthwhich respond to the needs of people with non
Loss of household incomefrom poor physical status
Increased exposure to common modifiable risk factors:Unhealthy diets
Physical inactivityTobacco use
Harmful use of alcohol
Non-communicable diseases:Cardiovascular diseases
Poor and vulnerable in developing countries
NCDs are closely related to poverty and contribute to poverty
8 million people die prematurely each yearin developing countries from non-communicable diseases
Cardiovascular diseasesCancersDiabetes
Chronic respiratory diseases
Limited access to effective and equitable health-care services which respond to the needs of people with non-communicable diseases
Loss of household incomefrom poor physical status
Smoking prevalence (
20
25
30
35
40
45
(perc
enta
ge)
0
5
10
15
20
Low-income countries
Lower-middle-income countries
Upper-middleincome countries
(perc
enta
ge)
Smoking prevalence (2004)
Lowest household income quintiles
Highest household income quintiles
middle-income countries
High-incomecountries
income quintiles
Health care costs are enormous
• Cardiovascular diseases
• Chronic kidney diseases
• Cancers
• Diabetes• Diabetes
Health care costs are enormous
Cardiovascular diseases
Chronic kidney diseases
The cost of caring for a family member with diabetes can be more than
per cent of low-income household incomes in developing countries
Insulin Syringes Testing
Mali (2004) 38% 34% 8%
The cost per year of diabetes care at household level
The poorest people in develomost
Mali (2004) 38% 34% 8%
Mozambique (2003) 5% 24% 1%
Nicaragua (2007) 0% 73% 0%
Zambia (2003) 12% 63% 6%
Vietnam (2008) 39% 8% 5%
The cost of caring for a family member with diabetes can be more than 20 income household incomes in developing countries
Consultation
TravelTotal cost
% of per capita
Income
7% 12% $339.4 61%
The cost per year of diabetes care at household level
eloping countries affected the most
7% 12% $339.4 61%
9% 61% $273.6 75%
0% 27% $74.4 7%
6% 12% $199.1 21%
3% 46% $427.0 51%
Percent and number of men with and without CVD Percent and number of men with and without CVD experiencing catastrophic spending and experiencing catastrophic spending and
impoverishmentimpoverishment
25
510
20
30
Percent
0
Catastrophic
CVD
Source: Mahal et al 2010
Catastrophic spending >30% HH income in one year; Impoverishment from above poverty line to below during year
Number 1.4 – 2.0 million affected
Percent and number of men with and without CVD Percent and number of men with and without CVD experiencing catastrophic spending and experiencing catastrophic spending and
impoverishmentimpoverishment-- 20052005
10
22
Impoverishment
No CVD
% HH income in one year; Impoverishment from above poverty line to below
million 0.6-0.8 million
NCDs lead to catastrop
60504030
Percentcatastrophic spending and impoverishment (2004)
perc
en
tag
e
:
3020100
Catastrophic expenditures
perc
en
tag
e
ophic health expenditures in India
Cancer
No cancer
ent with and without cancer experiencing catastrophic spending and impoverishment
Catastrophic expenditures
Impoverishment
Percent and number of men with aPercent and number of men with aexperiencing catastrophic spending and impoverishment (experiencing catastrophic spending and impoverishment (
Heart disease lead to catastrophic expenses
25
20
30
Perc
en
t
Source: Worlld Bank, Mahal et al 2010
Number 1.4 – 2.0 million affected
5
0
10
0
Catastrophic
Perc
en
t
CVD
h and without cardiovascular diseases h and without cardiovascular diseases experiencing catastrophic spending and impoverishment (experiencing catastrophic spending and impoverishment (20042004) )
Heart disease lead to catastrophic expenses
million 0.6-0.8 million
10
2
Impoverishment
CVD No CVD
Families with members who have a Families with members who have a chronic disease arechronic disease are
risk and more likely to be exposed to risk and more likely to be exposed to risk and more likely to be exposed to risk and more likely to be exposed to catastrophic spending and catastrophic spending and
impoverishmentimpoverishment
Chronic diseases can play an adverse Chronic diseases can play an adverse role in efforts to reduce povertyrole in efforts to reduce poverty
Families with members who have a Families with members who have a re at increase financial re at increase financial
risk and more likely to be exposed to risk and more likely to be exposed to risk and more likely to be exposed to risk and more likely to be exposed to catastrophic spending and catastrophic spending and
impoverishmentimpoverishment
Chronic diseases can play an adverse Chronic diseases can play an adverse role in efforts to reduce povertyrole in efforts to reduce poverty
Food price volatility
Financial crisis
Infectious diseases
NCDs are the third largest
World Economic Forum:
Global Risk 2010 Report
Oil spikes
Retrenching from globalization
Asset price collapse
Non-communicable diseases
"A problem neither the developed world nor the developing world can afford""A problem neither the developed world nor the developing world can afford"
st global risk in terms of likelihoo
nor the developing world can afford"" (WEF Global Risk 2010 Report)nor the developing world can afford"" (WEF Global Risk 2010 Report)
0.24
0.33
0.45
0.53
0.8
1.14
1.16
1.33
1.65
Medical Services
Basic Nutrition
TB Control
Family Planning
Malaria Control
Basic Health Care
Reproductive Health Care
Infectious Disease Control
Health Policy
HIV/AIDS
Global commitments to public health ((measured in Official Development Assistance)
0.01
0.06
0.1
0.42
0.92
0.93
0.06
0.21
0.22
0.23
0.24
0 1 2 3
Water Education
Water Resources Protection
River Development
Waste Management
Basic Drinking Water Supply
Water Resources Policy
Water Supply/Sanitation
Health Education
Medical Education
Medical Research
Basic Health Infrastructure
(Source: Kaiser Family Foundation,
US$7.4
• Total Health ODA in 2007: $22.1 billion
• Health ODA for NCDs: ?There is no OECD/DAC Creditor Reporting System
• Total Health ODA in 2007: $22.1 billion
• Health ODA for NCDs: ?There is no OECD/DAC Creditor Reporting System
Global commitments to public health (2007) (measured in Official Development Assistance)
3.9
4 5 6 US$7 Billion
Creditor Reporting System Code to track commitments to NCDs
Creditor Reporting System Code to track commitments to NCDs
(Source: Kaiser Family Foundation, 23 July 2009, based on OECD/DAC)
Global Strategy for the Prevention and Control of Noncommunicable DiseasesGlobal Strategy for the Prevention and Control of Noncommunicable Diseases2000
2003
2004
Action Plan for the Global Strategy(World Health Assembly,
2008
2009
2010
2011
Global Strategy to Reduce the Harmful
Use of Alcohol
Global Strategy to Reduce the Harmful
Use of Alcohol
Set of Recommendations on the Marketing of Foods to Children
Set of Recommendations on the Marketing of Foods to Children
Ministerial Meetings
Ministerial Meetings
High-level Meeting
High-level Meeting
UNSG Report on NCDs
UNSG Report on NCDs
Action Plan for the Global Strategy(World Health Assembly, 2008)
Set of Recommendations Set of Recommendations
Doha Declaration
Doha Declaration
UN General Assembly resolution
A/RES/64/265UN General Assembly resolution
A/RES/64/265
Ministerial Meetings
(Doha)
Ministerial Meetings
(Doha)
ECOSOC Ministerial Declaration
ECOSOC Ministerial Declaration
The Global Strategy for the Pre(World Health Assembly,
Mapping the epidemic of
NCDs
Reducing the level of
exposure to risk factors
Prevention and Control of NCDs(World Health Assembly, 2000)
Strengthening health care for
people with NCDs
Reducing the level of
exposure to risk factors
Surveillance: Gaps and Lessons Leaned
• Good progress in risk factors surveillance over the last decade but NCD surveillance systems are still generally weak in member States
• No consensus on key components of an NCD surveillance system and lack of standardized indicators to monitor NCD trends at national and global levels trends at national and global levels
• When it exists, NCD surveillance work is not institutionalized and rarely integrated into the national health information systems of LMICs
• Limited capacity in epidemiology and surveillance in Member States
Surveillance: Gaps and Lessons Leaned
Good progress in risk factors surveillance over the last decade but NCD surveillance systems are still generally weak in
No consensus on key components of an NCD surveillance system and lack of standardized indicators to monitor NCD trends at national and global levels – duplication/inconsistenciestrends at national and global levels – duplication/inconsistencies
When it exists, NCD surveillance work is not institutionalized and rarely integrated into the national health information
Limited capacity in epidemiology and surveillance in Member
Exposures (Risk factors)• Behavioral and dietary/nutritional risk factors• Physiological and metabolic risk factors
Outcomes
Framework for a national NCD surveillance system
Outcomes • Mortality• Morbidity
Health System Response• Interventions• Health system capacity
Behavioral and dietary/nutritional risk factorsPhysiological and metabolic risk factors
Framework for a national NCD surveillance system
Prevention and Health PromotionPrevention and Health Promotion
PreventionReduction of Risk factors
• Actions for:
– Tobacco control
– Promoting healthy diet
– Promoting physical activity– Promoting physical activity
– Reducing the harmful use of alcohol
• Cost effectiveness and best buys..
PreventionReduction of Risk factors
Promoting healthy diet
Promoting physical activityPromoting physical activity
Reducing the harmful use of alcohol
Cost effectiveness and best buys..
Major Challenge
• Health in All Policies and Intersectoral Action
Major Challenge
Health in All Policies and Intersectoral Action
Improving Health Care
• Health system strengthening based on primary health care-
• Actions to achieve short term gains in • Actions to achieve short term gains in promoting access to the essential NCD interventions
Improving Health Care
Health system strengthening based on
Actions to achieve short term gains in Actions to achieve short term gains in promoting access to the essential NCD
Improving Access to Health care
Reduce cost sharing for NCD Services
Cover the uninsured
Improving Access to Health care
Reduce cost sharing for NCD Services
Current
Public
Expenditure
On HealthProvide NCD services
Six objectives:
1. Raising the priority accorded to non-development work at global and national levels
2. Establishing and strengthening national policies and programmes
Action Plan for the Global Strategy(World Health Assembly,
national policies and programmes
3. Reducing and preventing risk factors
4. Prioritizing research on prevention and health care
5. Strengthening partnerships
6. Monitoring NCD trends and assessing progress made at country level
Six objectives:
. Raising the priority accorded to -communicable diseases in
development work at global and national levels
. Establishing and strengthening national policies and programmes
Action Plan for the Global Strategy(World Health Assembly, 2008)
national policies and programmes
. Reducing and preventing risk factors
. Prioritizing research on prevention and health care
. Strengthening partnerships
. Monitoring NCD trends and assessing progress made at country level
To raise the priority accorded to NCDs in development workTo raise the priority accorded to NCDs in development work���� To raise the priority accorded to NCDs in development workTo raise the priority accorded to NCDs in development work
• Regional Ministerial Meeting on Health Literacy (Beijing, 29-30 April 2009)
• Regional Ministerial Meeting on Non-communicable Diseases and Injuries, Poverty and Development (Qatar, 10-11 May 2009)
• ECOSOC High-level Segment on Global Health (Geneva, 6-9 July 2009)
• ECOSOC Ministerial Roundtable Meeting on Non-• ECOSOC Ministerial Roundtable Meeting on Non-communicable Diseases and Injuries (Geneva, 8 July 2009)
United Nations General Assembly Resolution
A/RES/on the prevention and control of non
(adopted on 13
United Nations General Assembly Resolution
A/RES/on the prevention and control of non
(adopted on 13
ECOSOC Ministerial
Declaration
United Nations General Assembly Resolution
A/RES/64/265 on the prevention and control of non-communicable diseases
13 May 2010)
United Nations General Assembly Resolution
A/RES/64/265 on the prevention and control of non-communicable diseases
13 May 2010)
Doha Declaration on Non-
communicable Diseases
� Decides to convene a High-level Meeting of the General Assembly in September with the participation of Heads of State and Government, on the prevention and control of noncommunicable diseases;
� Also decides to hold consultations on the scope, modalities, format and organization the high-level meeting of the General Assembly on the prevention and control of noncommunicable diseases, with a view to concluding consultations, preferably before the end of 2010;
� Encourages Member States to include in their
Resolution A/RES/64/265 – Pre
� Encourages Member States to include in their Meeting of the sixty-fifth session of the General AssemblyDevelopment Goals, to be held in September economic impact of the high prevalence of non
� Requests the Secretary-General to submit a report to the General Assembly at its sixtyfifth session in collaboration with Member States, the World relevant funds, programmes and specialized agencies of the United Nations system, on the global status of non-communicable diseases, with a particular focus on the developmental challenges faced by developing countries.
level Meeting of the General Assembly in September 2011,with the participation of Heads of State and Government, on the prevention and control of non-
consultations on the scope, modalities, format and organization of level meeting of the General Assembly on the prevention and control of non-
communicable diseases, with a view to concluding consultations, preferably before the end of
Member States to include in their discussions at the High-level Plenary
revention and Control of NCDs
Member States to include in their discussions at the High-level Plenary fifth session of the General Assembly on the review of the Millennium
Development Goals, to be held in September 2010, the rising incidence and the socio-economic impact of the high prevalence of non-communicable diseases worldwide;
a report to the General Assembly at its sixty-n collaboration with Member States, the World Health Organization and the
relevant funds, programmes and specialized agencies of the United Nations system, on the communicable diseases, with a particular focus on the developmental
To establish and strengthen national policies and plans for the prevention and control of NCs
To establish and strengthen national policies and plans for the prevention and control of NCs����
To establish and strengthen national policies and plans for the prevention and control of NCs
To establish and strengthen national policies and plans for the prevention and control of NCs
To promote interventions to reduce the main risk factors for NCDs (tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol
To promote interventions to reduce the main risk factors for NCDs (tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol����
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