CARDIOVASCULAR HEALTH IS AT THE HEART OF GLOBAL DEVELOPMENT Prof K Srinath Reddy President Public Health Foundation of India Professor of Cardiology, All India Institute of Medical Sciences Bernard Lown Professor of Global Cardiovascular Health, Harvard School of Public Health
In The Second Half of The 20th Century We Saw Progress in CVD Prevention & Care
Clinical
Public Health
Q.
In The First Half Of The 21st Century
Will Global Cardiovascular Health
Be Better Or Worse?
THE ANSWER DEPENDS ON ……… • Content of Health Care (Science; Technology; Training; Guidelines)
√√
• Delivery of Health Care (Health Systems: Outreach; Effectiveness; Practice Patterns; Access; Affordability; Regulation)
• Risk Factors At The Population Level (Social Determinants; Health Behaviours)
√ ?
THE ROSE PRINCIPLE “Sick Individuals Arise From Sick Populations” - Geoffrey Rose
WITHIN EACH POPULATION • The number of persons who will have undesirable levels of any risk factor is related to the mean level of the risk factor in the population • A shift of the whole distribution to the left would mean better health (less ‘cases’) and a shift to the right means worse health (more ‘cases’)
THE WORLD AS ONE POPULATION If we plot the distributions of: • BP • Cholesterol • Exposure to Tobacco Smoke (Active/Passive) • Physical Inactivity • Dysglycemia • Overweight & Obesity AT THE GLOBAL LEVEL
WE WILL FIND A RIGHTWARD SHIFT In Each Of Their Distributions, Compared To 20-30 Yrs. Ago
GLOBAL DEATHS BY CAUSE 2004 20000
(1000s)
15000 10000 5000
ia b D
pi ra Re s
ni c hr o C Preventing chronic diseases : a vital investment : WHO global report 2005
et es
to ry
er an c C
VD C
ar ia M al
TB
H
IV /A ID
S
0
CARDIOVASCULAR DEATHS : GLOBAL PROFILE
Projected global numbers of deaths by cause for high-, middle- and lowincome countries (WHO, 2008)
Age-adj death rates for total CVD, diseases of the heart, CHD, and Stroke: USA 1900-1996
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4830a1.htm#fig1
Deaths per 100,000 population
Males
Bennett SA et al. Med J Aust 1994;161:519-527
Females All cardiovascular diseases
All cardiovascular diseases Coronary heart disease
Coronary heart disease
Increasing CHD in India Prevalence (%)
10.5 9.5 7 6 4.1 2
2
1960
1970
4.5
2.5 1980
1990
2000
Urban Rural Gupta R. CSI Cardiology Update. Ed. Manjuran RJ. 2003
Number of deaths (millions)
11 10 9 8 7 6 5 4 3 2 1
CVD Deaths
6.0
Cardiovascular diseases
4.0
2.0
0.0 1990
2020
Trend of CVD mortality (1990-2000): China
Wang YJ, International Journal of Stroke; 2007
Why are different countries showing different patterns of CVD? • Rise/Fall of Mortality Rates • CHD/Stroke As Dominant CVD
Stages of Health Transition Stage I Age of Pestilence and Famine
Stage II Age of Receding Pandemics
Stage III Age of ‘Man Made’ Degenerativ e Diseases
Stage IV Age of Delayed Degenerativ e Diseases
Stage V Age of Social Upheaval and Health Regressio n
Stage VI Era of Environmenta l Degradation
Sub Saharan Africa Rural China & India Urban India
Russia
Latin America
Omran (1971)
Olshansky and Ault (1986)
Eastern Europe
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
STAGE I Life Expectancy
:
~ 35 years
Dominant Diseases
:
Infections; Nutritional Deficiencies
CVD
:
RHD, Cardiomyopathies
STAGE II Life Expectancy
:
~ 50 years
Dominant Diseases
:
Mixed Pattern – Stage I Diseases Prominent But Chronic Diseases Emerge
CVD
:
RHD; High BP & Hemorrhagic Stroke
HEMORRAGIC STROKE
HIGH BLOOD PRESSURE
HYPERTENSIVE HEART FAILURE THROMBOTIC STROKE CORONARY HEART DISEASE
OTHER RISK FACTORS ( Lipids; Smoking; Diabetes)
STAGE III Life Expectancy
:
~ 60 years
Dominant Diseases :
Chronic Diseases
CVD
CHD; Both Forms of Stroke
:
STAGE IV Life Expectancy
:
> 70 years
Dominant Diseases
:
Chronic Diseases
CVD*
:
CHD; Both Forms of Stroke (Mainly Thrombotic)
* CHD and Stroke are still dominant but kill much later in life
THE TASK BEFORE US
Stage I
Stage II
Stage III
Stage IV
?
Avoid /Abbreviate the Stage of Mid-Life Death and Disability
RAPID EPIDEMIOLOGIC TRANSITION FROM INFECTIOUS AND NON-COMMUNICABLE CAUSES, MEXICO, 1950-2010 600 500
•Massive
400
total deaths
• Large absolute and
300
proportionate in NCDs
200
• Large absolute infectious diseases
100 0 1950
1960
1970
1980
1990
Infectious &parasitic
2000
2010
NCDs
Bobadilla et al, In Jamison ed, Disease Control Priorities in DC, Oxford UP, WB, 1993
THE CVD EPIDEMICS: THE THREE TRANSITIONS DEMOGRAPHIC
BURDEN OF DISEASE SHIFTS EARLY LIFE
LIVING HABITS
SOCIO ECONOMIC
RISK BEHAVIOURS
EARLY ADAPTER (HIGH SES)
MIDLIFE
RISK FACTORS
LATE ADAPTER (LOW SES)
Risk factors: tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure – towards a high fat and refined sugar Western Diet
Accelerating rate of change in diet
Shift in activity patterns Link between diet and activity changes and increases in obesity Popkin, 2001
Mean Plasma Cholesterol Values in China 250 200
mg/dl
150 100 50 0 1958
1981
1997
2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION (AGED ≼ 20 YEARS) 350 300
Millions
250 200
2000 2025
150 100 50 0 Developed
Developing
World
Source : Global Burden of Diabetes, 1995-2025; King H. et.al, Diabetes Care,19
OECD countries: Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity & Overweight: Mexico 80 70
8.3% 1.2 pp/yr
Obesity Overweight
61.0
60
%
50 40
4% 0.57 pp/yr 6.6% 0.94 pp/yr
32.5
20 10
14%
26.8 20.2
9.2
8.7
6.9
14.3
18.1
21.6
23.3
1999
2006
1999
2006
14%
5.9 33%
32.4
24.9
28.5
30
69.3
36.1
36.9
1999
2006
0 Fernald et al., 2007
Major risk for chronic diseases in Middle East Hypertension in the EMR Based on STEPwise Surveillance Overweight & Obesity based on STEPwise Surveillance (BMI>=25)
Percent
80
81.2 66.9
76.4
67.4 56.3
60
%
100
53.9
40 20 0 Iraq
Jordan
Syria
Kuwait
Egypt
45 40 35 30 25 20 15 10 5 0
40.4 33.4
Iraq
Sudan
25.5
26
Jordan
Saudi Arabia
DM in the EMR (STEPwise Surveillance)
24.6
Syria
Kuwait
23.6
Egypt
100
20
16
17.9
19.9
19.2 16.7
Sudan
Low Physical Activity
25
15 % 10
28.8
80
16.5
%
10.4
60
56.7
55.4
40
5
86.8
79
33.8
32.9
Saudi Arabia
Syria
50.4
20
0
0 Iraq
Jordan
Saudi Arabia
Syria
Kuwait
Egypt
Sudan
Iraq
Jordan
Kuwait
Egypt
Sudan
VARIATIONS IN HEALTH TRANSITION : ETHNIC DIVERSITY What is ethnicity? Differences due to genes or environment or both? Lessons from Migrant studies . (Ni-Hon-Son; Chinese; Indians; Kenyan nomads) Multi-ethnic comparisons . (London; Canada; INTERHEART; Seven Countries)
Q. How Is Cardiovascular Health Linked to Development? Poor CV Health
• ↓Productivity
Development (-) • Unhealthy Living Habits (Urbanization)
• ↑ Poverty
• Marketing of Unhealthy Products
• ↑Health Care Costs HINDERS DEVELOPMENT
(Globalization)
Development (+) • Education & Communication (↑ Awareness) • Income (↑ Access To Healthier Products & Services)
DAMAGES CV HEALTH
PROMOTES CV HEALTH
% (not numbers) of CVD deaths by age group, 2000-2030, assuming stable risks 70 60 50 <45 45-64 65-74 75 +
40 30 20 10 0 U.S.
Russia
S. Africa
Brazil
Note how deaths from CVD in the U.S. occur principally at ages >75+ while in developing economies they occur at younger ages.
Years Of Life Lost Due To CVD In Populations Aged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
600 400 200
Pa ki st an
K U
ra zi l B
ia In d
us si a R
hi na
0 C
International $ (billions)
Lost National Income due to IHD, Stroke and Diabetes (2005-2015)
Preventing chronic diseases : a vital investment : WHO global report
Projected per capita income path, conditional on different CVD scenarios (Scenario 1 and 2 : 1% and 3% annual decline in mortality)
CVDs: THE SOCIAL GRADIENT As socio-economic and health transitions advance within each country…… The Social gradient for NCD risk factors and for NCD events progressively reverses till THE POOR BECOME MOST VULNERABALE
(Reddy KS et al, PNAS, 2007)
SES GRADIENT:ORDER OF REVERSAL FOR CVD RISK FACTORS Tobacco Blood Pressure Plasma Cholesterol ↓ Physical Activity Obesity
Health Transition
Tanzania: Smoking & HT â&#x2020;&#x2018; in low SES; BMI â&#x2020;&#x2018; in High SES Group (Bovet P, 2002)
China: Smoking, HT, Obesity inversely correlated with years of education in Chinese women
(Zhije Yu, 2000)
India: Higher risk of MI in urban residents with low level of education and income (Rastogi T, 2004) In Industrial employees and families, all CVD risk factors are inversely correlated with education (Reddy KS, 2007) Brazil: Obesity rates declining in High SES; Rising in Low SES (Bell, 2000)
STROKE: CHINA QUEST STUDY (2009) 4739 Survivors of stroke 71% Patients Experienced Catastrophic OOPE
â&#x20AC;˘
OOPE from Stroke pushed 37% of patients and their families below the poverty line; 62% without insurance went into poverty - Heeley E et al, Stroke, 2009; 40:2149-5
CVD: IMPACT ON HOUSEHOLDS (KERALA, INDIA) • Catastrophic Health Expenditures (72.9%) • Distress Financing Common (50%) • 40% of CVD patients lost sources of income • 82% did not have health insurance • 13% could not continue medication due to cost factors (Harikrishnan, 2010)
Response to Health Transition POPULATIONS Demographic and Social Determinants High Risk
Low Risk Public Health Interventions
INDIVIDUALS Low Risk
Biology + Beliefs + Behaviors High Risk Clinical + Behavioral Interventions
GLOBAL
NATIONAL
COMMUNITY
FAMILY
(stage and speed)
Perceptions (cultural)
Distribution (equity)
Priorities (socio-economic)
Demand- Supply (trade)
Pathways (availability, access)
Development
INDIVIDUAL
Beliefs Behaviours Biology
THE HEALTH OF PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES
WIDER SOCIETY
Social Determinants Biological Risk
INDIVIDUAL
Health Inequities
FAMILY Behavioral Risk
NEIGHBORHOOD, COMMUNITY
Education
Enhancement of Knowledge, Motivation, and Skills of Individuals Cultural and Social Norms Media
Community Interventions
Settings Based
HEALTH COMMUNICATION
HEALTH CARE DELIVERY
Environment To Enable Individuals To Make and Maintain Healthy Choices
Demographic Globalization Change
Drugs & Technologies
Trade
Quality of Care
Regulatory
Access to Care
Legal
Systems Infrastructure
Financial
Preventive, Diagnostic, Therapeutic, Rehabilitative Services
DETERMINANTS
Globalization
Health Workforce
(Global; National; Local)
As the definition of ‘normal’/’optimal’ BP moves from <160/95 to <140/90 <120/80 (or even <115/75! as WHO now says) Drug Therapy of ‘Patients’ Has Less Impact Than Dietary Changes (e.g.,Salt Reduction) Across The Whole Population Individual ‘Risk Factor’ Becomes A ‘Social Cause’ Clinical Medicine Merges Into Public Health
“Do we not always find the diseases of the populace traceable to defects in society?” “If disease is an expression of individual life under unfavourable circumstances, then epidemics must be indicative of mass disturbances.” - Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions
Enabling Environment Behaviours (Financial, Social, Physical) Individual)
Educational Interventions
Health Beliefs and (Community;
Desired Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCO Evidence is available from many countries (including LMIC) that - Taxation - Ad Bans - Smoke Free Policies - Health Warnings ARE EFFECTIVE 48.1% of mortality averted in UK (1981-2000) is attributable to reduced smoking
(Unal B et al. Circulation 2004)
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
DIET •
Evidence of preventive potential of policy interventions available from Mauritius (Price of Edible Oils) Poland (Import of F-V and Healthy Fats) Finland (Farming; Marketing; Community Education)
New Initiatives •
Food Labeling
• •
Reduced Salt in Processed Foods Ban on Trans-Fats
•
Advertising Restrictions
Tobacco Reduction Strategy
Salt Reduction Strategy
- 8.5 Million Deaths
+
- 5.5 Million Deaths
13.8 Million Deaths Averted
In 23 Low & Middle Income Countries (During 2006-2015) - Asaria P et al, Lancet 2007
â&#x20AC;&#x153;Health leaps out of science and draws nourishment from the society around itâ&#x20AC;? -Gunnar Myrdal (Swedish Economist; Nobel Laureate)
Societal policies and processes influencing the population prevalence of obesity INTERNATIONAL FACTORS
NATIONAL/ REGIONAL
Transport
Globalization of markets
Urbanization
Health
COMMUNITY WORK/SCHOOL LOCALITY /HOME
Public Transport
Public Safety
Health Care
Development Social security
Media programs & advertising
Media & Culture
Sanitation
Manufactured/ Imported Food
INDIVIDUAL
POPULATION
Leisure Activity/ Facilities
Labour
Energy Expenditure
%
Infections
OBESE Worksite Food & Activity
Family & Home
AND Food intake : Nutrient density
OVER-WEIGHT
Education
Food & Nutrition
Agriculture/ Gardens/ Local markets
School Food & Activity
National perspective Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipathies V. IOTF website 1999: http://www.iotf.org
COMMUNICATION TO CONSUMERS; MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candy Fast food (Burgers, pizzas etc.)
IN MODERATION
PLENTY
? ?
NUTRITION PYRAMID
ADVERTISING PYRAMID
INTERNATIONAL AGENCIES; TRANS-NATIONAL TRADE AND MEDIA GLOBAL COVENANTS, COMMERCE & COMMUNICATIONS
MOULDING NATIONAL POLICY FRAME WORK Political, Economic, Social Motivators
THE MARKETS
CONSUMER CONCIOUSNESS Health Professionals, Civil Society; Media
INDUSTRY PRACTICES Private-Public Partnerships; Health Dividend
CONVERGENCE OF CONCERNS In The Policy Arena…. Common Determinants Link
• NCDs and Environment • NCDs and Zoonotic Pandemics • NCDs and Food Security • NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS • Protection of Environment • Chronic Disease Prevention Sustainable Development Needs • Urban environments which reduce vehicular congestion, promote physical activity and energy efficiency • Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level • Removal/Reduction of pollutants & toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT l
Deforestation due to - ‘Flue Curing’ - Packaging
l
Subsoil Water Depletion
l
Soil Erosion
l
Pesticide Use
l
Forest Fires
l
Litter
l
Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
Obesity CVD Cancer
+ Food Crisis (Grain Diversion)
W A T E R
Climate Change (â&#x2020;&#x2018; Methane; Deforestation)
+ Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
Praise without end the go-ahead zeal of whoever it was invented the wheel; but never a word for the poor soul’s sake that thought ahead, and invented the brake. - Howard Nemerov (“To the Congress of the United States, Entering Its Third Century”), 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS: NEW KNOWLEDGE FROM EPIGENETICS
• Epigenetic effects of Diet, Physical Activity and Smoking Are Being Increasingly Recognized
• Risk of CVD, DM and Cancers may be partly mediated through such epigenetic effects
• These epigenetic alterations and influences may be transmitted across several generations! NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE GENERATIONS - IT IS A RIGHTS ISSUE!
â&#x20AC;&#x153;Should medicine ever fulfill its great ends, it must enter into the larger political and social life of our time; it must indicate the barriers which obstruct the normal completion of the life cycle and remove them. Should this ever come to pass, Medicine, whatever it may then be, will become the common good of allâ&#x20AC;? - Rudolf Virchow (1821-1902)
MEDICINE 20th Century
PUBLIC HEALTH 21st Century
SUSTAINABLE DEVELOPMENT
Persons
People Populations PLANET