cardiovascular disease in ckd who perspectives · 5. overweight and obesity 6. high cholesterol 7....

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


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


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


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


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


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


(Doha)


(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


A/RES/on the prevention and control of non

(adopted on 13

ECOSOC Ministerial

Declaration


A/RES/64/265 on the prevention and control of non-communicable diseases

13 May 2010)


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 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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cardiovascular disease in ckd who perspectives · 5. overweight and obesity 6. high cholesterol 7....

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