Post on 17-Mar-2016
description
CARDIOVASCULAR HEALTH
IS AT THE HEART OF
GLOBAL DEVELOPMENT
Prof K Srinath ReddyPresidentPublic 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 amp 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 helliphelliphellip
bull Content of Health Care(Science Technology Training Guidelines)
bull Delivery of Health Care(Health Systems Outreach Effectiveness Practice Patterns Access Affordability Regulation)
bull Risk Factors At The Population Level(Social Determinants Health Behaviours)
radic radic
radic
THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo
- Geoffrey Rose
WITHIN EACH POPULATION
bull 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
bull A shift of the whole distribution to the left would mean better health
(less lsquocasesrsquo) and a shift to the right means worse health
(more lsquocasesrsquo)
THE WORLD AS ONE POPULATION If we plot the distributions of
bull BP
bull Cholesterol
bull Exposure to Tobacco Smoke (ActivePassive)
bull Physical Inactivity
bull Dysglycemia
bull Overweight amp ObesityAT 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
0
5000
10000
15000
20000
HIVA
IDS TB
Malaria
CVD
Cance
r
Chronic
Res
pirato
ry
Diabete
s
(100
0s)
Preventing chronic diseases a vital investment WHO global report 2005
CARDIOVASCULAR DEATHS GLOBAL PROFILE
Projected global numbers of deaths by cause for high- middle- and lowincomecountries (WHO 2008)
Age-adj death rates for total CVD diseases of the heart CHD and
Stroke USA 1900-1996
httpwwwcdcgovmmwrpreviewmmwrhtmlmm4830a1htmfig1
Deaths per 100000 population
Males Females
All cardiovascular diseases
All cardiovascular diseases
Coronary heart disease
Coronary heart disease
Bennett SA et al Med J Aust 1994161519-527
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
In The Second Half of The 20th Century
We Saw Progress in
CVD Prevention amp 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 helliphelliphellip
bull Content of Health Care(Science Technology Training Guidelines)
bull Delivery of Health Care(Health Systems Outreach Effectiveness Practice Patterns Access Affordability Regulation)
bull Risk Factors At The Population Level(Social Determinants Health Behaviours)
radic radic
radic
THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo
- Geoffrey Rose
WITHIN EACH POPULATION
bull 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
bull A shift of the whole distribution to the left would mean better health
(less lsquocasesrsquo) and a shift to the right means worse health
(more lsquocasesrsquo)
THE WORLD AS ONE POPULATION If we plot the distributions of
bull BP
bull Cholesterol
bull Exposure to Tobacco Smoke (ActivePassive)
bull Physical Inactivity
bull Dysglycemia
bull Overweight amp ObesityAT 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
0
5000
10000
15000
20000
HIVA
IDS TB
Malaria
CVD
Cance
r
Chronic
Res
pirato
ry
Diabete
s
(100
0s)
Preventing chronic diseases a vital investment WHO global report 2005
CARDIOVASCULAR DEATHS GLOBAL PROFILE
Projected global numbers of deaths by cause for high- middle- and lowincomecountries (WHO 2008)
Age-adj death rates for total CVD diseases of the heart CHD and
Stroke USA 1900-1996
httpwwwcdcgovmmwrpreviewmmwrhtmlmm4830a1htmfig1
Deaths per 100000 population
Males Females
All cardiovascular diseases
All cardiovascular diseases
Coronary heart disease
Coronary heart disease
Bennett SA et al Med J Aust 1994161519-527
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Q In The First Half Of The
21st Century
Will Global Cardiovascular Health
Be Better Or Worse
THE ANSWER DEPENDS ON helliphelliphellip
bull Content of Health Care(Science Technology Training Guidelines)
bull Delivery of Health Care(Health Systems Outreach Effectiveness Practice Patterns Access Affordability Regulation)
bull Risk Factors At The Population Level(Social Determinants Health Behaviours)
radic radic
radic
THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo
- Geoffrey Rose
WITHIN EACH POPULATION
bull 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
bull A shift of the whole distribution to the left would mean better health
(less lsquocasesrsquo) and a shift to the right means worse health
(more lsquocasesrsquo)
THE WORLD AS ONE POPULATION If we plot the distributions of
bull BP
bull Cholesterol
bull Exposure to Tobacco Smoke (ActivePassive)
bull Physical Inactivity
bull Dysglycemia
bull Overweight amp ObesityAT 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
0
5000
10000
15000
20000
HIVA
IDS TB
Malaria
CVD
Cance
r
Chronic
Res
pirato
ry
Diabete
s
(100
0s)
Preventing chronic diseases a vital investment WHO global report 2005
CARDIOVASCULAR DEATHS GLOBAL PROFILE
Projected global numbers of deaths by cause for high- middle- and lowincomecountries (WHO 2008)
Age-adj death rates for total CVD diseases of the heart CHD and
Stroke USA 1900-1996
httpwwwcdcgovmmwrpreviewmmwrhtmlmm4830a1htmfig1
Deaths per 100000 population
Males Females
All cardiovascular diseases
All cardiovascular diseases
Coronary heart disease
Coronary heart disease
Bennett SA et al Med J Aust 1994161519-527
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
THE ANSWER DEPENDS ON helliphelliphellip
bull Content of Health Care(Science Technology Training Guidelines)
bull Delivery of Health Care(Health Systems Outreach Effectiveness Practice Patterns Access Affordability Regulation)
bull Risk Factors At The Population Level(Social Determinants Health Behaviours)
radic radic
radic
THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo
- Geoffrey Rose
WITHIN EACH POPULATION
bull 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
bull A shift of the whole distribution to the left would mean better health
(less lsquocasesrsquo) and a shift to the right means worse health
(more lsquocasesrsquo)
THE WORLD AS ONE POPULATION If we plot the distributions of
bull BP
bull Cholesterol
bull Exposure to Tobacco Smoke (ActivePassive)
bull Physical Inactivity
bull Dysglycemia
bull Overweight amp ObesityAT 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
0
5000
10000
15000
20000
HIVA
IDS TB
Malaria
CVD
Cance
r
Chronic
Res
pirato
ry
Diabete
s
(100
0s)
Preventing chronic diseases a vital investment WHO global report 2005
CARDIOVASCULAR DEATHS GLOBAL PROFILE
Projected global numbers of deaths by cause for high- middle- and lowincomecountries (WHO 2008)
Age-adj death rates for total CVD diseases of the heart CHD and
Stroke USA 1900-1996
httpwwwcdcgovmmwrpreviewmmwrhtmlmm4830a1htmfig1
Deaths per 100000 population
Males Females
All cardiovascular diseases
All cardiovascular diseases
Coronary heart disease
Coronary heart disease
Bennett SA et al Med J Aust 1994161519-527
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo
- Geoffrey Rose
WITHIN EACH POPULATION
bull 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
bull A shift of the whole distribution to the left would mean better health
(less lsquocasesrsquo) and a shift to the right means worse health
(more lsquocasesrsquo)
THE WORLD AS ONE POPULATION If we plot the distributions of
bull BP
bull Cholesterol
bull Exposure to Tobacco Smoke (ActivePassive)
bull Physical Inactivity
bull Dysglycemia
bull Overweight amp ObesityAT 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
0
5000
10000
15000
20000
HIVA
IDS TB
Malaria
CVD
Cance
r
Chronic
Res
pirato
ry
Diabete
s
(100
0s)
Preventing chronic diseases a vital investment WHO global report 2005
CARDIOVASCULAR DEATHS GLOBAL PROFILE
Projected global numbers of deaths by cause for high- middle- and lowincomecountries (WHO 2008)
Age-adj death rates for total CVD diseases of the heart CHD and
Stroke USA 1900-1996
httpwwwcdcgovmmwrpreviewmmwrhtmlmm4830a1htmfig1
Deaths per 100000 population
Males Females
All cardiovascular diseases
All cardiovascular diseases
Coronary heart disease
Coronary heart disease
Bennett SA et al Med J Aust 1994161519-527
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
THE WORLD AS ONE POPULATION If we plot the distributions of
bull BP
bull Cholesterol
bull Exposure to Tobacco Smoke (ActivePassive)
bull Physical Inactivity
bull Dysglycemia
bull Overweight amp ObesityAT 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
0
5000
10000
15000
20000
HIVA
IDS TB
Malaria
CVD
Cance
r
Chronic
Res
pirato
ry
Diabete
s
(100
0s)
Preventing chronic diseases a vital investment WHO global report 2005
CARDIOVASCULAR DEATHS GLOBAL PROFILE
Projected global numbers of deaths by cause for high- middle- and lowincomecountries (WHO 2008)
Age-adj death rates for total CVD diseases of the heart CHD and
Stroke USA 1900-1996
httpwwwcdcgovmmwrpreviewmmwrhtmlmm4830a1htmfig1
Deaths per 100000 population
Males Females
All cardiovascular diseases
All cardiovascular diseases
Coronary heart disease
Coronary heart disease
Bennett SA et al Med J Aust 1994161519-527
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
GLOBAL DEATHS BY CAUSE 2004
0
5000
10000
15000
20000
HIVA
IDS TB
Malaria
CVD
Cance
r
Chronic
Res
pirato
ry
Diabete
s
(100
0s)
Preventing chronic diseases a vital investment WHO global report 2005
CARDIOVASCULAR DEATHS GLOBAL PROFILE
Projected global numbers of deaths by cause for high- middle- and lowincomecountries (WHO 2008)
Age-adj death rates for total CVD diseases of the heart CHD and
Stroke USA 1900-1996
httpwwwcdcgovmmwrpreviewmmwrhtmlmm4830a1htmfig1
Deaths per 100000 population
Males Females
All cardiovascular diseases
All cardiovascular diseases
Coronary heart disease
Coronary heart disease
Bennett SA et al Med J Aust 1994161519-527
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
CARDIOVASCULAR DEATHS GLOBAL PROFILE
Projected global numbers of deaths by cause for high- middle- and lowincomecountries (WHO 2008)
Age-adj death rates for total CVD diseases of the heart CHD and
Stroke USA 1900-1996
httpwwwcdcgovmmwrpreviewmmwrhtmlmm4830a1htmfig1
Deaths per 100000 population
Males Females
All cardiovascular diseases
All cardiovascular diseases
Coronary heart disease
Coronary heart disease
Bennett SA et al Med J Aust 1994161519-527
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Projected global numbers of deaths by cause for high- middle- and lowincomecountries (WHO 2008)
Age-adj death rates for total CVD diseases of the heart CHD and
Stroke USA 1900-1996
httpwwwcdcgovmmwrpreviewmmwrhtmlmm4830a1htmfig1
Deaths per 100000 population
Males Females
All cardiovascular diseases
All cardiovascular diseases
Coronary heart disease
Coronary heart disease
Bennett SA et al Med J Aust 1994161519-527
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Age-adj death rates for total CVD diseases of the heart CHD and
Stroke USA 1900-1996
httpwwwcdcgovmmwrpreviewmmwrhtmlmm4830a1htmfig1
Deaths per 100000 population
Males Females
All cardiovascular diseases
All cardiovascular diseases
Coronary heart disease
Coronary heart disease
Bennett SA et al Med J Aust 1994161519-527
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Deaths per 100000 population
Males Females
All cardiovascular diseases
All cardiovascular diseases
Coronary heart disease
Coronary heart disease
Bennett SA et al Med J Aust 1994161519-527
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
2
67
95105
2 25
41 45
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in IndiaPrevalence ()
Gupta R CSI Cardiology Update Ed Manjuran RJ 2003
00
20
40
60
1990 2020Nu
mb
er
of
death
s (
mil
lio
ns)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Trend of CVD mortality (1990-2000) China
Wang YJ International Journal of Stroke 2007
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Why are different countries
showing different patterns of
CVD
bull RiseFall of Mortality Rates
bull CHDStroke As Dominant CVD
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Stages of Health TransitionStage IAge of Pestilence and Famine
Stage IIAge of Receding Pandemics
Stage IIIAge of lsquoMan Madersquo Degenerative Diseases
Stage IVAge of Delayed Degenerative Diseases
Stage VAge of Social Upheaval and Health Regression
Stage VIEra of Environmental Degradation
Omran (1971) Olshansky and Ault (1986)
Yusuf and Reddy (2001)
Thakker and Reddy (2008)
Sub Saharan Africa
Rural China amp India
Urban India Russia
Latin AmericaEastern Europe
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
STAGE I
Life Expectancy ~ 35 years
Dominant Diseases Infections Nutritional Deficiencies
CVD RHD Cardiomyopathies
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
STAGE II
Life Expectancy ~ 50 years
Dominant Diseases Mixed Pattern ndashStage I DiseasesProminent But Chronic Diseases Emerge
CVD RHD High BP ampHemorrhagic Stroke
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
HIGH BLOOD PRESSURE
HEMORRAGIC STROKE
HYPERTENSIVE HEARTFAILURE
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 gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
STAGE III
Life Expectancy ~ 60 years
Dominant Diseases Chronic Diseases
CVD CHD Both Forms of Stroke
STAGE IV
Life Expectancy gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
STAGE IV
Life Expectancy gt 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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
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
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
RAPID EPIDEMIOLOGIC TRANSITION FROM INFECTIOUS
AND NON-COMMUNICABLE CAUSES MEXICO 1950-2010
0
100
200
300
400
500
600
1950 1960 1970 1980 1990 2000 2010
Infectious ampparasitic NCDs
Bobadilla et al In Jamison ed Disease Control
Priorities in DC Oxford UP WB 1993
bullMassive total deaths
bull Large absolute and
proportionate in NCDs
bull Large absolute infectious diseases
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
THE CVD EPIDEMICS THE THREE TRANSITIONS
BURDEN OF DISEASE SHIFTS
EARLY LIFE MIDLIFE
RISK BEHAVIOURS RISK FACTORS
EARLY ADAPTER LATE ADAPTER
(HIGH SES) (LOW SES)
DEMOGRAPHIC
LIVING HABITS
SOCIO -ECONOMIC
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Risk factors tobacco use on the rise in developing countries
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
The Nutrition Transition in Developing Countries
Shift in diet structure ndash 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
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Mean Plasma Cholesterol Values in China
0
50
100
150
200
250
mg
dl
1958 1981 1997 2003
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED ge 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mill
ions 2000
2025
Source Global Burden of Diabetes 1995-2025 King H etal Diabetes Care19
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
OECD countries Obesity rates in women aged 15-64 (age-adj)
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Trends in Obesity amp Overweight Mexico
143 181 216 233361 36959
87 69 92
249324
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
ObesityOverweight
33
14
14
202268
285325
610
693
66094 ppyr
4057 ppyr
8312 ppyr
Fernald et al 2007
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Major risk for chronic diseases in Middle East
Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)
669 674563
812 764
539
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Perc
ent
Hypertension in the EMR Based on STEPwise Surveillance
255 26 288246
334
236
404
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
DM in the EMR (STEPwise Surveillance)
104
16179
199167 165
192
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
Low Physical Activity
567
79
338 329
554 504
868
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
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 Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Q How Is Cardiovascular Health Linked to Development
Poor CV Health Development (-) Development (+)
bull darrProductivity
bull uarr Poverty
bull uarrHealth Care Costs
bull Unhealthy Living
Habits (Urbanization)
bull Marketing of
Unhealthy Products
(Globalization)
bull Education amp
Communication
(uarr Awareness)
bull Income
(uarr Access To Healthier
Products amp Services)
HINDERS DEVELOPMENT
DAMAGES CV HEALTH
PROMOTES CV HEALTH
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
(not numbers) of CVD deaths by age group 2000-2030 assuming stable risks
0
10
20
30
40
50
60
70
US Russia S Africa Brazil
lt4545-6465-7475 +
Note how deaths from CVD in the US occur principally at ages gt75+ while in developing economies
they occur at younger ages
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years
PPYLL= Potentially Productive Years of Life Lost
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Lost National Income due to IHD Stroke and Diabetes (2005-2015)
0
200
400
600
China
Russia
IndiaBraz
il UK
Pakist
an
Inte
rnat
iona
l $ (b
illio
ns)
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
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 countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
CVDs THE SOCIAL GRADIENT
As socio-economic and health transitions advance within each countryhelliphellip
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 GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
darr Physical Activity
Obesity
Health Transition
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Tanzania Smoking amp HT uarr in low SES BMI uarr 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 stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE
- Heeley E et al Stroke 2009 402149-5
bull OOPE from Stroke pushed 37 of
patients and their families below
the poverty line 62 without
insurance went into poverty
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)
(Harikrishnan 2010)
bull Catastrophic Health Expenditures (729)bull Distress Financing Common (50)
bull 40 of CVD patients lost sources of income
bull 82 did not have health insurance
bull 13 could not continue medication due to cost factors
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Response to Health Transition
Low Risk High Risk
POPULATIONS
Demographic and Social Determinants
Public Health Interventions
Low Risk High Risk
INDIVIDUALS
Biology + Beliefs + Behaviors
Clinical + Behavioral Interventions
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL
Development(stage and speed)
Distribution(equity)
Demand- Supply(trade)
Beliefs
Behaviours
Biology
Perceptions(cultural)
Priorities(socio-economic)
Pathways(availability access)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
POLICY APPROACHES(Global National Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUALFAMILY
NEIGHBORHOOD COMMUNITY
Enhancement of Knowledge Motivation and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONPr
even
tive
Dia
gnos
tic
Ther
apeu
tic
Reh
abili
tativ
e Se
rvic
es
HEA
LTH
CA
RE
DEL
IVER
Y
WIDER SOCIETY
DET
ERM
INA
NTS
Globalization
Acce
ss
to C
are
Syst
ems
Infr
astr
uctu
reH
ealth
W
orkf
orce
Qua
lity
of C
are
Dru
gs amp
Te
chno
logi
es
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
As the definition of lsquonormalrsquorsquooptimalrsquo BP moves from lt16095 to lt14090 lt12080(or even lt11575 as WHO now says)
Drug Therapy of lsquoPatientsrsquo Has Less Impact
Than Dietary Changes (egSalt Reduction)
Across The Whole Population
Individual lsquoRisk Factorrsquo Becomes A lsquoSocial
Causersquo
Clinical Medicine Merges Into Public Health
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
ldquoDo we not always find the diseases of the populace traceable to defects in societyrdquo
ldquoIf disease is an expression of individual life under unfavourablecircumstances then epidemics must be indicative of mass disturbancesrdquo
- Rudolf Virchow (1821-1902)
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
PUBLIC HEALTH INTERVENTIONS
Policy Interventions Educational Interventions
Enabling Environment Health Beliefs and Behaviours(Financial Social Physical) (Community Individual) Desired
Change
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
TOBACCOEvidence is available from many countries
(including LMIC) that
- Taxation- Ad Bans- Smoke Free Policies- Health Warnings
ARE EFFECTIVE 481 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
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
POWER OF POLICY FOR CHRONIC DISEASE PREVENTION
DIETbull 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 Initiativesbull Food Labelingbull Reduced Salt in Processed Foodsbull Ban on Trans-Fatsbull Advertising Restrictions
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Salt Reduction Strategy Tobacco Reduction Strategy
- 85 Million Deaths - 55 Million Deaths
In 23 Low amp Middle Income Countries (During 2006-2015)
- Asaria P et al Lancet 2007
+
138 Million Deaths Averted
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
ldquoHealth leaps out of science and
draws nourishment from the society
around itrdquo
-Gunnar Myrdal (Swedish Economist
Nobel Laureate)
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
COMMUNITYLOCALITY
AgricultureGardens
Local markets
Health Care
PublicSafety
PublicTransport
ManufacturedImported
Food
Sanitation
Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg
POPULATION
OBESE
AND OVER--WEIGHT
WORKSCHOOL HOME
SchoolFood ampActivity
Infections
Labour
Worksite Food amp Activity
LeisureActivityFacilities
Family ampHome
INDIVIDUAL
EnergyExpenditure
Food intake
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL REGIONAL
Education
Food amp Nutrition
Urbanization
Health
Social security
Transport
Media ampCulture
Nationalperspective
INTERNATIONAL FACTORS
Development
Globalizationof
markets
Media programs
amp advertising
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
NUTRITION PYRAMID ADVERTISING PYRAMID
Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)
COMMUNICATION TO CONSUMERS MIS-MATCH BETWEEN SCIENCE AND COMMERCE
Occasional
IN MODERATION
PLENTY
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
MOULDING
THE
MARKETS
INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA
GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS
INDUSTRY PRACTICES
Private-Public Partnerships Health Dividend
CONSUMER CONCIOUSNESS
NATIONAL POLICY FRAME WORK
Political Economic Social Motivators
Health Professionals Civil Society Media
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
CONVERGENCE OF CONCERNS
In The Policy Arenahellip
Common Determinants Link
bull NCDs and Environment
bull NCDs and Zoonotic Pandemics
bull NCDs and Food Security
bull NCDs and Human Rights
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
CONVERGENCE IN RECOMMENDATIONS
bull Protection of Environment bull Chronic Disease Prevention
Sustainable Development Needs
bull Urban environments which reduce vehicular congestion promote physical activity and energy efficiency
bull Diets which promote appropriate nutrient intake through sustainable consumption patterns at the population level
bull RemovalReduction of pollutants amp toxic chemicals from the environment
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
TOBACCO AND THE ENVIRONMENT
l Deforestation due to - lsquoFlue Curingrsquo- Packaging
l Subsoil Water Depletionl Soil Erosionl Pesticide Usel Forest Firesl Litterl Environmental Tobacco Smoke
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
INDUSTRIAL SCALE LIVESTOCK BREEDING
ObesityCVDCancer
Climate Change(uarr Methane Deforestation)
Food Crisis(Grain Diversion)
Pandemics (Zoonotic Diseases rising)
Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050
+ +
WATER
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake
- Howard Nemerov(ldquoTo the Congress of the United States
Entering Its Third Centuryrdquo) 1989
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM EPIGENETICS
bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized
bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects
bull 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
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
ldquoShould 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 allrdquo
- Rudolf Virchow (1821-1902)
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
SUSTAINABLE DEVELOPMENT
PUBLIC HEALTH
MEDICINE20th Century
21st Century
Persons
PeoplePopulations
PLANET
Persons
PeoplePopulations
PLANET