Chronic Disease – Management Priorities in the 21st Century

V.K. Barbiero, PhD, MHS

George Washington University

Department of Global Health

Setting the Stage…

Remember…averages mean squat…

Chronic Diseases

What Are Chronic Diseases

Cardiovascular (heart disease) (hypertension)

Cerebrovascular (stroke) Cancer Chronic Respiratory Disease Diabetes Mental disorders Oral disease Bone and joint Genetic disorders

Characteristics of Chronic Diseases

Take time to become fully established Have origins at young ages Required long, systematic and often

expensive approaches to treatment Require integration with responses to

acute, infectious diseases Many opportunities for prevention They are the leading cause of death in all

regions except Africa

Eight Myths of Chronic Diseases

Wait until infectious diseases are controlled Economic growth will improve all health

conditions Chronic diseases affect only the affluent Chronic diseases are diseases of the elderly Chronic diseases result from individual

behaviors Benefits of CD control are for individuals only ID models apply to chronic diseases Chronic diseases should only be addressed in

the health sector

Source: Merson, et. al., 2005

The Demographic Transition

The Epidemiologic Transition

~2005

Source: Omran, A.R., 1971. The Epidemiologic TransitionSource: Omran, A.R., 1971. The Epidemiologic Transition.

The Nutrition Transition

Pre-processed foodsPre-processed foods More food of animal originMore food of animal origin Fall in cereal and fiber intakeFall in cereal and fiber intake More sugar added to food More sugar added to food More alcoholMore alcohol UrbanizationUrbanization

Source: Popkin, BM, 2001. Source: Popkin, BM, 2001. Journal of Nutrition;Journal of Nutrition; 131:871S-873S, 2001) 131:871S-873S, 2001)

Pathways of the Nutrition Transition

Prevalence of Overweight (BMI >25) of Women by Income Strata

0

10

20

30

40

50

60

70

80

Low Income Lower Middle Upper Middle High Income

200520102015

Pre

vale

nce

(%

) of

BM

I >

25

Pre

vale

nce

(%

) of

BM

I >

25

Source: WHO, 2005

The Urban Transition

2008World 50% Urban

Four Stages of The Health Transition

CVD = Cardiovascular disease; PVD = peripheral vascular disease

Ghana’s Days of Healthy Live Lost

Measles otherMeasles otherPreventablePreventable

Non Non PreventablePreventableAdult DeathsAdult Deaths

Preventable Preventable Adult DeathsAdult Deaths

UndernutritionUndernutritionDD, ARIDD, ARI

MalariaMalaria

Non PreventableNon PreventableChildhood DeathsChildhood Deaths

Source: Merson, et. al., 2005Source: Merson, et. al., 2005

ADULTS

CHILDREN

Disability-Death Model

Birth

PYLLs, HeaLYs, QALYys, DALYs

High CaseFatality

DisabilityDeath

MortalityDeath

The Ideal

90 Yrs

Early Deaths

24-36Months

ContinuingEarly Deaths

2007 – Death/Disability

2025 – Disability/Death

Population/Family Planning the Development Imperative

0

1

2

3

4

5

6

7

8

1950 1960 1970 1980 1990 2000 2010 2020

TOTAL LDC DC

Bil

lio

ns

of

Peo

ple

Pyramids Tell the Tale…

China – 2000 & 2050Population = 1.42B

Pyramids Tell the Tale…

Nigeria – 2000 & 2050Population = 307M

Chronic Diseases - Fact Sheet

35 million will die from chronic diseases in 2005 More people die from chronic diseases than infectious

diseases worldwide 60% of all deaths are from chronic diseases

80% of chronic disease deaths occur in mid-low income countries

12 million die of heart attacks annually 50% of deaths are women > 1 billion adults are overweight worldwide – 30%

obese Behavioral interventions are effective

Global Chronic Disease Profile

Source: WHO, 2006

Total Deaths 2005

~58 Million

Estimated Causes of Death Worldwide

Comm30%

CVD30%

Cancer13%

COPD7%

Diabetes2%

Injuries9%

Violence/ Other9%

Comm CVD Cancer COPD Diabetes Injuries Violence/ Other

Source: WHO, 2002

Total Deaths 2005

~58 Million

Projections of Future Deaths

There will be about 64 million deaths in 2015… 17 million from communicable diseases 41 million from chronic diseases ~6 million from injuries CVD and stroke will remain highest with

~20 million

Source: WHO, 2002

Estimated DALYs By Condition

Comm39%

CVD10%

Cancer5%

COPD4%

Injuries13%

Violence/ Other28%

Diabetes1%

Comm CVD Cancer COPD Injuries Violence/ Other Diabetes

Source: WHO, 2002

The Double Burden for the Poor…

Estimated Causes of Death by Income 2005

0

100

200

300

400

500

600

700

LowIncome

L/ MIncome

U/ MidIncome

High World

Communicable Chronic Injuries

Source: WHO, 2002, vkb/extrapolated from World Bank graph

Age S

tand

ard

ized

Death

Rate

s P

er

100

,000

Estimated DALYs by Income

0

2000

4000

6000

8000

10000

12000

14000

16000

Low Middle High World

Comm Chronic Injuries

Source: WHO, 2002, vkb/extrapolated from World Bank graph

Elements & Progression of Chronic Diseases

UnderlyingSocial &

EnvironmentalDeterminants

Urbanization&

AgingPopulation

Source: vkb adapted from WHO, 2002

ModifiableRisk Factors

DietActivitySmoking

Non-ModifiableRisk Factors

AgeHeredity

ImmediateRisk

Factors

Blood PressureHigh Glucose

Abdominal FatOverweight

Obesity

MainChronicDiseases

Heart DiseaseStrokeCancerCOPD

Diabetes

No Quick Fixes…No Magic Bullets…

Preventing and Managing Chronic Disease

Health Promotion (to shift distribution of risks)

Specific Prevention Programs Diet, smoking, exercise Environmental and Occupational

Exposures e.g. Sexual Health (AIDS, HPV, etc) Retooling Health Service Programs

‘Health Impact’ of ‘Non-Health Policy’ Food Safety Agriculture/Trade Urban Planning

Preventing and Managing Chronic Disease

WHAT TO DO IS THE EASY PART…

HOW TO DO IT IS ANOTHER STORY…

Policy to Action

Talk is free Ink is cheap Action takes a lot of money,

time, commitment and effort…

Lessons to Date…

HIV/AIDS Prevention, Care and Treatment Insurance Schemes and Tiered pricing Training and Task Shifting

Level of training, brain drain DOTS and TB Diagnosis and treatment? Prevention…?..blah, blah, blah…

do we know?...witness USA’s BMI… Facility care, HBC, palliative care?

Conclusions

Chronic disease epidemiology is a worldwide issue

We need more thought and demonstration interventions on this issue

AIDS requires chronic disease management…what lessons can we learn?

Double and triple burden of disease in LDCs will cause millions to suffer

Action is required…we must begin…now…

THANK YOU