chronic disease – management priorities in the 21st century v.k. barbiero, phd, mhs george...
TRANSCRIPT
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