1

Addressing The Challenge Of The Double Burden Of Disease In

Developing Countries

Objectives:

1. Examine Progress in Addressing the Challenge of Nutrition/Physical Activity Related Chronic Diseases (NRCDs) in Latin America; lessons learnt from successes and failures.

2. Update on the Implementation of Global Strategy for the Prevention and Control of NRCDs

Years of age

The Nutrition-Infection complex determines in great part, how children grow physically and develop mentally. Diet-Physical Activity interactions greatly affect what diseases we

most likely will suffer during our life span and finally how we will age and die.

The lifecourse approach to health and nutrition

0

25

50

75

100

20 40 60 80 100 120

1930

1960

2000

Foetus / Infants / Children• LBW/IUGR • Stunting and wasting• Micronutrient deficiency (Vit A,I,Fe,Zn ) • Infection (HIV/AIDS) • Accidents

Adults / Elderly• Cardiovascular Stroke,• Obesity /Diabetes/dyslipidemia• Cancer• Osteoporosis

• Healthy Aging

Ideal

%

surv

ival

DisabilityPhysical /Mental

• Accidents

Life expectancy at birthLife expectancy at birthLife expectancy at birthDeveloped and developing countries, 1955–2002

1940 1960 1980 2000 2020

80

70

60

50

40

30

20

100

Life e

xpec

tancy

at bi

rth (y

ears)

DevelopedDeveloping: low mortality

high mortality

DevelopedDevelopedDeveloping: low mortalityDeveloping: low mortality

high mortalityhigh mortality

Albaneide Peixinho1960 1970 1980 1990 2000

LIFE EXPECTANCY AT BIRTH 1960-2000

McMichael THE LANCET Vol 363 2004

1960 1970 1980 1990 2000

LIFE EXPECTANCY AT BIRTH 1960-2000 McMichael THE LANCET Vol 363 2004

Albaneide Peixinho

Cause of Death by WHO region WHR 2002

2

Deaths, by broad cause group and by age(2000 WORLD)

0-4 5-14 15-29

45-59

30-44

Noncommunicablediseases

Injuries

Communicable, maternal,perinatal and nutritionalconditions

60-69 70-79 80+

Source: WHR 2002 Database

Deaths attributable to 16 leading risk factors: all countries, 2001

30003000 60006000 70007000 8000800000 10001000 20002000

Deaths (000)Deaths (000)40004000 50005000

Low mortality – Developing countriesHigh mortality – Developing countries

Developed countries

Adapted from World Health Report 2003

Blood pressureTobacco Use

CholesterolUnderweight

Unsafe sexFruit & vegetableHigh body mass IndexPhysical inactivityAlcohol

Unsafe water, hygiene

Indoor smoke/fuelsIron deficiency

Urban air pollutionZinc deficiencyVitamin A deficiencyUnsafe health/injections

Albaneide Peixinho

Developed countriesDeveloping countries

High Mortality Low Mortality

= Major NCD risk factor

1 Underweight Alcohol Tobacco

2 Unsafe sex Underweight Blood pressure

3 Unsafe water Blood pressure Alcohol

4 Indoor smoke Tobacco Cholesterol

5 Zinc deficiency Body mass index Body mass index

6 Iron deficiency Cholesterol Low fruit & veg. intake

7 Vitamin A deficit Iron deficiency Physical inactivity

8 Blood pressure Low fruit & vegetable intake Illicit drugs

9 Tobacco Indoor smoke from solid fuels Underweight

10 Cholesterol Unsafe water Iron deficiency

Source: World Health Report 2002

Leading 10 risk factors that contribute to the burden of disease

= Major undernutrition risk factor

Albaneide Peixinho

% of total DALYs lost

Energy Imbalance

Under nutrition

… those who need less energy have more than

they spend

Those who needmore food have less

..while...

ArgentinaChile

Peru

BoliviaCosta RicaUruguay

MexicoBrazil

NicaraguaPanama

BarbadosJamaicaColombia

Venezuela

El SalvadorSaint Lucia

HondurasSurinameHaiti

Guyana

Trinidad and Tobago

Guatemala

Dominican Republic

-10 -5 0 5 10 15

% emaciación (P/T<-2 DE) % sobrepeso (P/T>+2 DE)% Underweight (W/H <- 2 SD) % Obese (W/H <+ 2 SD)

Under and Overweight in Latin American Children

De Onis et al IJO 2004

3

,

Globalization of Unhealthy Consumption

Branding is used to promote

consumption through marketing

Interest in foreign investment is used to preclude government

regulation

GLOBAL Obesity Epidemic

Addressing The Challenge Of The Double Burden Of Disease In

Developing Countries16:05-17:00 Focus On The Nutrition Transition In Latin America

Can we Control and Prevent Malnutrition while Addressing the Challenge of Nutrition/Physical Activity Related Chronic DiseasesJuan Rivera (INSP Cuernavaca, Mexico) 15

Addressing the Inequalities in the Distribution of Nutrition/ Physical Activity Related Chronic DiseaseCarlos Monteiro (Public Health USP Sao Paulo, Brazil) 15 min

Taking Effective Action in the Prevention and Control of Nutrition /Physical Activity Related Chronic Disease: Successes and Failures.Fernando Vio (INTA U of Chile, Santiago, Chile) 15 min

General discussion 10 minutes

Addressing The Challenge Of The Double Burden Of Disease In

Developing Countries

17:00- 17:20 Implementation of the WHO Global Strategy for the Prevention and Control of NRCDs: What Should/Can Developing and Transitional Countries Actually Do (Denise Cointinho).

17:20-17:30 FAO update on Global Food Systems in Transition (Kraisid Tontisirin).

17:30 -17:55 General discussion

17:55 Concluding remarks R. Uauy

Infection and other

EnvironmentalFactors

Brain Development

Growth muscle/boneWeight & HEIGHTBody composition

Metabolic ProgrammingCHO, Lipids, Proteinshormone,receptor,gene

Fetal & Infant

nutrition

Short term

Immunity

Work Capacity

DiabetesObesityCardiovascularDisease,Stroke Hyper-tensionCancerAging

Cognitivecapacity & Education

Long termNutritionDiet

Age (years)

302826242220181614121086420

BMI '

Z Sc

ore'

.4

.3

.2

.1

0.0

-.1

-.2

Population average

Diabetic/IGT

Age (years)

302826242220181614121086420

BM

I 'Z

Sco

re'

.7

.6

.5

.4

.3

.2

.1

0.0

-.1

-.2

Population average

Hypertension

Early Origins of Adult Health Diabetes/IGT

Hypertension

BM

IZ

Age yrs

BM

IZ

Age yrs

4

Albaneide Peixinho

BMI SD Score from birth to adulthood(forthose developing impaired GTT or Diabetes)

Bhargava SK et al NEJM 350: 865-875 2004Albaneide Peixinho

Height SD Score from birth to adulthood (for those developing impaired GTT or Diabetes)

Bhargava SK et al NEJM 350: 865-875 2004

Intergenerational effectsIntergenerational effects

ADULTSMalnourished

AdolescentStunted

PregnancyLow Weight

Gain

ElderlyMalnourished

ChildStunted

BabyLow Birth

Weight

Higher maternal mortality

Inadequate food, health &

care

Inadequate food, health

& care

Inadequate food,

health & care

Reduced mental

capacity

Reduced mental

capacity

Reduced capacity to

care for baby

Foetal Malnutrition

Higher mortality

rateImpaired mental

development

Untimely / inadequate weaning

Frequent infections

Inadequate food, health

& care

Inadequate growth

Visceral obesity, BP, Diabetes

Rapid catch-upweight not length

Energy Excess CHO/FAT

Albaneide Peixinho

G Eriksson BMJ 2001;322:949–53

BMJ 2001

Albaneide Peixinho Albaneide Peixinho

Each red dot is 5000 deaths per year

Global Death in Children < 5years old (WHO 2000)

5

Sources:For cause-specific mortality: EIP/WHO using 1999 data.For deaths associated with malnutrition: Caulfield LE, Black RE. Malnutrition and the global burden of disease: underweight and cause-specific mortality.

Diarrhoea12%

Other29%

Pneumonia20%

Malaria8%

Measles5%HIV/AIDS

4%

Perinatal22%

Major causes of death among children under five, global, 2000

Deaths associated with undernutrition

60%

Albaneide Peixinho

**

**

**

**

Risks Associated to Global Deaths 2000*

**

(x 000)

Albaneide Peixinho

1961

1999

Dietary energy Supply (DES)

Kcal/kg/dGNP US $ per caput

% Obesity by GNP & Education

Monteiro and Popkin 2004

Very poor Poor

More educated

Less educated

0 20 40 60 80

Chile

Mexico

Colombia

Brasil

Ecuador

Peru

Bolivia

Haiti

Guatemala

80's

95's

Prevalence of Stunting in Children < 3yrs

% Height for age < 2 SDWHO/PAHO 2000

Albaneide Peixinho

Progress in MDGs Latin America

Albaneide Peixinho

6

- Fundo Nacional de Desenvolvimento da Educação

“VAMOS CRIAR AS CONDICIONES PARA QUE TODAS AS PESSOAS NO NOSSO PAÍS POSSAM COMER DECENTEMENTE TRÊS VEZES AO DIA, TODOS OS DIAS.

O BRASIL ÑAO PODE CONTINUAR CONVIVENDO COM TANTA DESIGUALDADE. PRECISAMOS VENCER A FOME, A MISÉRIA E A EXCLUSION SOCIAL.

NOSSA GUERRA ÑAO É PARA MATAR NINGUÉM – É PARA SALVAR VIDAS”

LUIZ INÁCIO LULA DA SILVAPRESIDENTE DA REPÚBLICA DO BRASIL

Consultation Process Consultation Process

Memberstates

Memberstates

Civil SocietyCivil

SocietyPrivatesector

Privatesector

UN agencies

UN agenciesPh

ase

II

WHO Strategy on Diet, Physical Activity and HealthWHO Strategy on Diet, Physical Activity and Health

WHA 2004WHA 2004

EB Jan 2004EB Jan 2004SecretariatSecretariatReference

groupReference

group

Phas

e III

Preparation of consultation process and finalization of expert report

Preparation of consultation process and finalization of expert report

Phas

e I