K R Thankappan MD,MPH Professor and Head Achutha Menon Centre for Health Science Studies Sree Chitra Tirunal Institute for Medical Sciences and for Medical Sciences and Technology, Trivandrum, India Community Based Interventions to Reduce Tobacco, unhealthy diet and physical inactivity in Kerala, India

Outline Global Burden of Disease NCD burden in Kerala, the most advanced Indian State in Epidemiological Transition Health Expenditure pattern Challenges for prevention Way forward

RANKCauses of Death Ischemic heart disease 2Stroke 3Lower respiratory infectionsCOPD 4 Lower respiratory infections 5DiarrheaLung cancer 6TuberculosisHIV/AIDS 7Preterm birth complicationsDiarrhea 8Lung cancerRoad injury 9MalariaDiabetes 10Road injuryTuberculosis Lozano et al, Lancet 2012;380: Top 10 Causes of Death in the World Ranked in 1990 and 2010

RANK DISORDER Lower respiratory infectionsIschemic heart disease 2DiarrheaLower respiratory infections 3Preterm birth complicationsStroke 4Ischemic heart diseaseDiarrhea 5StrokeMalaria 6 HIV/AIDS 7COPDPreterm birth complications 8Protein–energy malnutritionRoad injury 9TuberculosisCOPD 10Neonatal encephalopathy Years of life lost in the world (YLLs) ranked in 1990 and 2010 Lozano et al, Lancet 2012;380:

Disability adjusted life years lost due to 10 leading risk factors in 1990 & 2000 Rank Childhood underweightHigh Blood Pressure 2Household air pollution from solid fuels Tobacco smoking including SHS 3 Alcohol use 4High Blood PressureHousehold air pollution from solid fuels 5Suboptimal breastfeedingDiet low in fruits 6Alcohol useHigh Body Mass Index 7Diet low in fruitsHigh fasting plasma glucose 8Ambient particulate matter pollution Childhood underweight 9High fasting plasma glucoseAmbient particulate matter pollution 10Iron deficiencyPhysical inactivity and low physical activity Lim SS et al. Lancet 2012;380:

IndicatorsKeralaIndia Infant Mortality Rate 1244 Crude Birth Rate Crude Death Rate Life Expectancy Selected Health Statistics for Kerala and India SRS SRS based life tables , GOI 2008

Diabetes Mellitus % (15-64 years) ResidenceMenWomenTotal Urban Rural Slum Kerala Thankappan K R et al. Indian J Med Res 2010; 131: 53-63

Awareness, Treatment and Control of Diabetes ResidenceAwareTreatedControl Urban Rural Slum Kerala Adequate control of Diabetes (< 126 mg /dl)

Hypertension % (15-64 years) ResidenceMenWomenTotal Urban Rural Slum Kerala Hypertension = SBP > = 140 mm of Hg, DBP > = 90 mm of Hg or under medication for hypertension.

Awareness, Treatment and Control of Hypertension (%) ResidenceAwareTreatedControlled* Urban Rural Slum Kerala Control = SBP < 140 and DBP < 90

Comparison of Age adjusted Death Rates (per 100,000) for CHD, Stroke and Total CVD in Kerala & selected countries. a USA 2005China (rural, 1999) Russia 2002 Scotland 2004 Japan 2004 Kerala. b CHD Men Women Stroke Men Women Total CVD Men Women Source: Soman et al. Asia Pac J Public Health 2010; May 10 doi: /

CountriesHealth expenditure (as % of GDP) TotalGovt.% by Govt. India China Sri Lanka US UK Canada Health Expenditure of Selected countries Source: World Health Report 2005

States% Kerala90.3 Uttar Pradesh86.9 Rajasthan75.6 Karnataka71.9 India78.0 Private Health Expenditure in Selected Indian States Kumar AKS et al. Lancet 2011; 377:

Issues in Privatization of Health Care High provider induced demand for procedures and drugs One example is the increased proportion of cesarean sections Difficult to quantify the magnitude of unnecessary care

Prevention is generally undervalued and underused-1 The right knowledge is often not in the right hands Visible Sick Patients – rule of rescue Irrational use of invasive procedure Gains of prevention are illusive and often invisible

Prevention is generally undervalued and underused-2 Powerful commercial interests obstruct policy change Health professionals favor treatment Media highlights new cures, obscure treatments

A Pilot Study on Community Based Interventions to reduce risk factors of NCDs in Kerala

Chirayinkeezhu Delayed Intervention Area 18

Interventions and their possible effects in the Community

Posters on Diet

Few Posters on Tobacco

A poster outside a major intervention health centre

Posters Posters are likely to remain in all the intervention and delayed intervention institutions for a long time. They are likely to be replaced by new ones subsequently by many of the Institutions. The messages in the posters are likely to have positive effects on tobacco control, healthy diet and physical activity among children, adults and their families

High Demand for Posters From a branch of one of our industries from a neighboring state From Health Department, Government of Kerala From officials, elected representatives and representatives of youth club

Students performing a street play for WNTD 2009

Effects of the Skit on Tobacco Control The students and staff involved in preparing the skit substantially improved their knowledge on tobacco control. This was a very effective media of communication to the school children on the bad effects of tobacco. An incentive for other students to prepare similar skit for healthy diet and physical activity promotion.

Effects of Healthy diet promotion in the Canteens Introduction of healthy food options in the canteens is likely to continue Some of the employees are likely to replicate this in their homes also Incentive for organizing healthy food options in meetings and seminar organized in these Institutions Display of POD prompts in front of canteen is likely to remind the healthy food choices.

Canteen POD prompts

Healthy cooking session at a major intervention health centre

Effects of Cooking Classes Those who attended these classes were given information on healthy and tasty cooking options. One of the key challenges is resource persons for cooking classes addressing healthy cooking practices.

Vegetable garden training

Effects of Vegetable Garden Training Vegetables are becoming very costly in the State and most of the vegetables are imported from neighboring State of Tamil Nadu Pesticide fear is another issue that people are concerned This training helped people to have their own vegetable gardens in what ever land they had and with locally available manure and no pesticides.

POD prompts for taking the stairs

Effects of Physical Activity (PA) Promotion Display of POD prompts in front of elevators in the major hospital has an effect on the employees as well as patients and their by-standers. They are constantly being made aware of the importance of physical activity

Sports kit distribution by the Honorable minister for Education, Mr M A Baby

Effects of Sports Goods Distribution Minister for Education of the Government of Kerala distributing the sports goods to various organizations had a big impact in the community. The sports goods are likely to be replenished by the Institutions and the physical activity in these communities are likely to increase A message is given to the society regarding the importance of regular physical activity

Inauguration of cycle training for girls

Effects of bicycle Training for Girl Students Many of the girl students are likely to purchase bicycles The message that girls can also ride bicycles and they are interested Physical activity is least among girls and women in the Kerala Society and this is likely to change among these school girls

Health projects for Prevention of NCD risk factors taken up by Local Self Governments and Youth welfare board This is likely to make the CIH activities sustainable in the communities. Networking with several sectors outside the Health department which is the key in prevention and control of NCDs. Effects of Community Coalition

Collaboration and networking Asian Collaboration for Excellence in non- Communicable Diseases (ASCEND) the millennium promise award from the Fogarty International Centre of the US NIH. Kerala Diabetes Prevention Program Grant by the National Health and Medical Research Council, Australia

Comprehensive Framework for Cardiovascular and Respiratory Health, Cancer and Diabetes Control Poverty, inequities and unfavourable environment Adverse behaviour patterns Major risk factors First event/ sudden death Disability and recurrence Complication and pain Positive social and economic environment Health promoting behavioural patterns Low population risk Few events/ rare deaths Full functional capacity/ low recurrence Good quality of life until death Behaviour change Risk factor detection and control Acute care management Chronic care and rehabilitation End-of-life care Macro-economic and environmental change Current deployment of resources Source: WHO

Comprehensive Framework for Cardiovascular and Respiratory Health, Cancer and Diabetes Control Poverty, inequities and unfavourable environment Adverse behaviour patterns Major risk factors First event/ sudden death Disability and recurrence Complication and pain Positive social and economic environment Health promoting behavioural patterns Low population risk Few events/ rare deaths Full functional capacity/ low recurrence Good quality of life until death Behaviour change Risk factor detection and control Acute care management Chronic care and rehabilitation End-of-life care Macro-economic and environmental change Giving emphasis to prevention, promotion Source: WHO

Way forward -1 Strong leadership by heads of state and governments needed to meet national commitments to the UN Political declaration on non-communicable diseases (NCD) and to achieve the goal of 25% reduction of premature NCD mortality by 2025 A simple, phased national response to the political declaration needs three steps: planning, implementation and accountability. Bonita R et al. Lancet 2013

Kerala Needs to Lead the Rest of India in NCD prevention and Control “A Statewide Community Intervention addressing risk factors of NCDs in Kerala, India was led by senior officials of the department of health and education, the chief of local governments and managing directors of major industries: their combined efforts ensured good commitment and resources”. The Lancet 2013.

Conclusions Global burden of disease has shifted to chronic non-communicable diseases Rest of India is likely to follow the Kerala pattern of high NCD burden In most developed countries except the US public sector provides most of the health care In India and Kerala private sector is the predominant health care provider Prevention is the key Strong leadership is required to meet national commitments to the UN political declaration on NCDs. Kerala could lead the rest of India in this.