1. HLN004 Chronic ConditionsPrevention and ManagementLecture 2Chronic Conditions burden, determinants and risk factors1

2. Hello!!Dr Ignacio Correa-VelezSenior Lecturer and Public Health DisciplineCoordinatorSchool of Public Health & Social Work, QUTignacio.correavelez@qut.edu.au2 3. Outline What are chronic conditions? Chronic conditions continuum Global burden of chronic conditions GBD study2010 Determinants of chronic conditions Indigenous Australians Professional practice Addressing risk factors Australian National Health Survey 2007-08 GBD study 2010 Co-morbidities Multidisciplinary? Interdisciplinary?3 4. What are chronic conditions? Health conditions that: Have complex and multiple causes Usually have gradual onset (and may have acutestages) Occur across the life cycle... but more prevalent aspeople age Compromise quality of life Are long term and often persistent... Gradualdeterioration of health Are leading cause of premature death Can be prevented Impact heavily on medical services4 (National Health Priority Action Council, 2006) 5. Chronic conditions continuumAdapted from McKenna &Collins, 20105 6. Global burden of chronicconditions6 7. Measuring Burden of Disease What is disease burden? Common measures of disease burden: Prevalence AT A SPECIFIC TIME (currentburden) Incidence NEW CASES DURING A PERIOD OFTIME (current risk) Cause specific mortality rates Disability-adjusted life years (DALYs) = Years of lifelost due to premature mortality (YLL) + years ofproductive life lost due to illness and disability (YLD)7 8. Global burden of chronic conditionsGBD 2010 Key findingsPositivesNegatives Life expectancy for 52.8 million deaths in 2010 (46.5 m in 1990)males and females is 8 million deaths fromincreasing cancer (1/3 more than 1990) Substantial progress 1 in 4 deaths from heartin preventingdisease or strokepremature deaths 1.3 million deaths from diabetesfrom heart disease High blood pressure is theand cancer biggest risk factor, followed by tobacco, alcohol and poor diet8 Disability from disease 9. Global deaths 2010 (15-49 years)9 10. Global death ranks for top 25 causes in 1990 and 2010 (GBD 2010, Lozano et al)10 11. Global years of life lost (YLLs) for top 25 causes in 1990 and 2010 (GBD 2010, Lozano et al)11 12. Global years lived with disability (YLDs) ranks for the 25 most common causes in 1990 and 2010 (GBD 2010, Vos et al)12 13. Disability-adjusted life years (DALYs) ranks for the top 25 causes in 1990 and 2010 (GBD 2010, Murray et al)13 14. Comparing ranking of leading chronic conditions as causes of DALYs, 2010 (GBD 2010, Murray et al) Cause Global Australasi Oceania Southeas Westerna t AsiaEurope Ischaemic heart 12632 disease Cerebrovascular 35811 3 disease Low back pain 6114 71 COPD9318 97 Major depressive11 412 64 disorder Diabetes mellitus14 1421010 Iron-deficiency15 3621 1484 anaemia Congenital 17 2717 1615 anomalies Neck pain21 1035 25 8 Trachea, 22858 26 514 bronchus & lung 15. Reducing the global burden of chronic conditions WHO: Global Non-communicable Disease Network (2009) http://youtu.be/VCfyylZdmG0 WHO: Unite in the fight against non-communicable diseases (2011) http://youtu.be/AvwX1m4LR4w15 16. Determinants of Chronic Conditions Positive Negative16 17. A conceptual framework for determinants of health (AIHW, 2012)17 18. Upstream? Downstream? In 1974, John McKinlay, a physician, recounted this story as told to a friend, at the American Heart Association conference in Seattle Washington. You know he said sometimes it feels like this. There I am standing by the shore of a swiftly flowing river and I hear a cry from a drowning man. So I jump in the river, put my arms around him, pull him to shore and apply artificial respiration. Just when he begins to breathe, there is another cry for help. So I jump in the river, reach him, pull him to shore and apply artificial respiration, and then just as he begins to breathe, there is another cry for help. So back in the river again, reaching, pulling, applying, breathing and then another yell. Again and again, without end, goes the sequence. You know, I am so busy jumping in, pulling them to shore, applying artificial18 respiration that I have no time to see who the hell is upstream pushing them all in! 19. Health and wealth over time: The world in four minutes http://www.gapminder.org/videos/200-years-that- changed-the-world-bbc/19 20. Indigenous Australians Poorest health status within the Australian population Lower life expectancy (12 years lower for males and 10 years lower for females) 80% mortality gap between indigenous and non- indigenous Australians aged 35-74 years is due to chronic health conditions Greatest contribution to mortality gap: Diseases of the circulatory system (38%) Endocrine, nutritional and metabolic diseases (14%) Diseases of the digestive system (14%)20 21. Leading specific disease groups contributing to the mortality gap, persons aged 35-74 years (AIHW, 2011)21 22. Broader determinants22 23. Professional practice Addressing risk factors for chronic conditions23 24. Chronic conditions and modifiable risk factors (AIHW, 2012)24 25. Risk factors definedAIHW, 201225 26. What is a serve of fruit and vegetables?AIHW, 201226 27. How many risk factors do we have?27 28. Number of risk factors by socio- economic status (AIHW, 2007-08)28 29. Number of risk factors by selected chronic conditions (AIHW, 2007-08)29 30. Mediated and direct effect of risk factors30 31. Most common combinations of risk factors31 32. GBD 2010: Risk factors In 2010 the three leading risk factors for global diseaseburden were: High blood pressure: 7% of global DALYs; 9.4 million deaths Tobacco smoking (including second hand smoke): 6.3% ofglobal DALYs; 6.3 million deaths Alcohol use: 5.5% global DALYs; 4.9 million deaths Regional differences: Much of the world: obesity and high body mass index Sub-Saharan Africa: underweight Dietary risk factors and physical inactivity collectively accounted for 10% of global DALYs Most prominent dietary risks: low fruit and high sodium High body mass index has increased globally: leading risk in Australasia and southern Latin America; ranks high32 in other high-income regions, and also in North Africa, Middle East and Oceania 33. Global risk factor ranks for all ages and sexes combined in 1990 and 2010 (GBD 2010, Lim et al)33 34. Comparing ranking of risk factors for chronic conditions, 2010 (GBD 2010, Lim et al) Risk factor Global Australasi Oceania SoutheaWesterna st Asia Europe High blood pressure 1361 2 Tobacco smoking 2232 1 (inc SHS) Alcohol use 3456 4 Diet low in fruits5794 7 High body mass6129 3 index High fasting plasma 7615 6 glucose Physical inactivity10578 5 Diet high in sodium11 1116 7 10 Diet low in nuts and 1281315 9 seeds34 Iron deficiency13 211112 32 35. GBD 2010 and risk factors: Policy implications Increasing burden from high blood pressure, high body mass index and high blood sugar Key role: dietary risk factors and physical inactivity Policies that encourage or facilitate lifestyle changes (balanced diet and increased physical activity) Despite efforts, tobacco smoking remains a serious issue (little change): decrease in high income countries but increase in low and middle income countries High blood pressure: dietary interventions (low salt) but also improve primary health care interventions to detect and treat35 Regional differences require regional tailoring of 36. Co-morbidities Complex interaction between specific conditions and shared risk factors Increased mortality Decline in health outcomes Increase use of health care resources Greater prevalence and impact among particular populations: Aged Indigenous Australians Survivors of torture and trauma36 37. Chronic health conditions and mental health Ischaemic heart disease: 25-30% depression; independent factor for poor prognosis Depression: independent risk factor for the development of cardiovascular disease and increased cardiac morbidity and mortality COPD: higher prevalence of depression and anxiety; increased mortality, decreased functional status, decreased quality of life Mental illness: Higher rates of chronic health conditions related to behavioural factors such as smoking, alcohol and drug abuse, obesity and poor diet37 Higher mortality and hospitalisation rates for all major conditions 38. Chronic conditions care approach Multidisciplinary Interdisciplinary Hierarchical (highest- Horizontal: leadership ranking team member)functions are shared Independent goals and Common goals and own recommendations prevention/care plans Multi-discipline assessment (but not Comprehensive/team integrated) assessment (biopsychosocial) Face-to-face Unidirectionalmeetings and patient communication team conferences38 (letters, emails, phone 39. In summary Global burden of chronic disease continues to increase Overall, the GBD 2010 has shown a broad shift from communicable, maternal, neonatal and nutritional causes of death towards non-communicable (Chronic) health conditions Regional differences (sub-Saharan Africa) Leading causes of death: Ischaemic heart disease, stroke, COPD Leading chronic conditions as measured by DALYs: Ischaemic heart disease, stroke, low back pain Leading risk factors: high blood pressure, smoking, alcohol, diet low in fruit, high body mass index, high blood sugar Key role of co-morbidities (mental health in particular) Approach: Upstream, midstream and downstream determinants of health Continuum of care Interdisciplinary39 40. 40