Non-communicable diseases A global overview David Leon

2 Outline Definition Non-communicable disease mortality worldwide The Epidemiological Transition Global Burden of Disease Study Major risk factors –Blood pressure –Cholesterol –Smoking Infection and non-communicable diseases

3 What are non- communicable diseases?

4 Classifying deaths and diseases (WHO) Communicable diseases [Group I] –Those where death is directly due to the action of a communicable agent Non-communicable diseases –Diseases [Group II] Cancer, diseases of various organ systems (eg respiratory, cardiovascular etc.), diabetes, mental health etc. –External causes (injuries, poisonings and violence) [Group III]

5 Importance of non- communicable diseases mortality

6 A global problem In 2004 there were 59 million deaths world-wide Non-communicable diseases accounted for 60% of these deaths and injuries and violence 10%. By 2020 it is estimated that non- communicable disease will account for 73% of all deaths GBD 2004 Update, 2008

7 The epidemiologic transition (Omran, 1971) Change in the balance of disease in a population from communicable diseases to non-communicable disease

8 Decline in proportion of total mortality due to infectious diseases England & Wales, , by age Males Females

9 Different countries at different stages of the epidemiological transition

10 Non-communicable diseases as % of all deaths by global region (all ages ) WORLDWIDE59% N.America; W Europe88% China, W Pacific, + some SE Asia75% Latin America + Caribbean67% S E Asia including India51% Sub-Saharan Africa21%

11 Urbanisation

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13 Urbanisation

14 Drivers of the epidemiological transition in low and middle income countries Population ageing Major socio-economic changes (especially urbanisation) –changes in risk factors such as diet, physical activity, smoking etc.

15 Global Burden of Disease (GBD) Study

16 GBD 2001 mortality estimates 107 countries had collected “useable” information on cause of death from registration systems 55 countries (42 in sub Saharan Africa) no information on adult mortality Estimates based on many assumptions and extrapolations

17 Global Burden of Disease Study First GBD study started in 1992 by World Bank. Second GBD study (in collaboration with WHO) conducted 2001 Extensive synthesis of all available data to give set of mortality estimates by age, sex, region and cause worldwide – for the first time 2001 GBD study covers 135 causes of death, 17 sub-regions, based on aggregation of country-level information

Global Burden of Disease 2004 Update (published 2008) al_burden_disease/GBD_report_2 004update_full.pdf 18

Distribution of deaths in the world by sex, GBD report 2004 update, 2008

Mortality rates among men and women aged 15– 59 years, region and cause-of-death group, GBD report 2004 update, 2008

Projected global deaths for selected causes, 2004– GBD report 2004 update, 2008

Effect of key risk factors on mortality 22

Combining data … Prospective studies collaboration 23

Prospective Studies Collaboration Established chiefly to investigate associations of blood pressure and cholesterol with cause-specific mortality Individual data on participants without any previous history of vascular disease from 61 prospective cohort studies vascular deaths ( ischaemic heart disease [IHD], stroke, other)

Blood pressure and cardiovascular mortality 25

December Cardiovascular mortality: Age-specific effects for 20 mmHg lower usual SBP deaths at ages 40-89

Cholesterol and cardiovascular mortality 27

Age at risk UDV3:[VEP.PSC.FIGURES.TCHOL ]ihd-by-agesex-hettrend.ctrl: 24-SEP :47:08.14 Usual total cholesterol (mmol/L) 4·05·06·07·08·0 0· Hazard ratio ( 95% CI) Ischaemic Heart Disease mortality ( deaths) and total cholesterol

Different for stroke 29

UDV3:[VEP.PSC.FIGURES.TCHOL ]stroke-by-agecause-trend.ctrl: 24-SEP :47:18.56 Usual total cholesterol (mmol/L) 4·05·06·07·08· Age Hazard ratio (& 95% CI) Stroke mortality ( deaths) and total cholesterol by age

31 Smoking

32 % of deaths aged years attributable to smoking in 2000 MenWomen Belarus33%0% Russia33%3% Ukraine32%3% Central Asia (8)23%4% Estonia31%3% Latvia30%2% Lithuania29%0% United Kingdom25%21% Germany29%11% Source :

33 Risk of myocardial infarction increases with every single cigarette smoked per day Number of cigarettes smoked per day Odds Ratio of Myocardial Infarction Never >=21 Source : K. K. Teo et al Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study Lancet 368 (9536): , INTERHEART study 52 countries cases, controls

34 Smoking causes more deaths from cardiovascular disease than cancer Deaths attributed to smoking among men (all ages) in Russia, 2000 All cancers = 77,000 Cardiovascular disease = 148,000 Source :

35 Things are getting worse not better

36 Smoking in men in Russia is not declining Rural Urban St Petersburgh/Moscow Source : Perlman et al Tob.Control 16 (5): , 2007 Russian Longitudinal Monitoring Survey

37 Smoking in women in Russia is increasing Rural Urban St Petersburgh/Moscow Russian Longitudinal Monitoring Survey Source : Perlman et al Tob.Control 16 (5): , 2007

Giving up smoking reduces risk 38

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Some non-communicable diseases have infectious etiology 40

Trends in stomach cancer mortality 41 Source : WHO HFA database Age standardised mortality per 100,000

42 Helicobacter pylori bacterium - a causal factor for stomach cancer

43 Marshall BJ,.Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet 1984;1: Marshall BJ, Armstrong JA, McGechie DB, Glancy RJ. Attempt to fulfil Koch's postulates for pyloric Campylobacter. Med.J.Aust. 1985;142: The Helicobacter pylori story …...

Summary Non-communicable diseases are now the most common cause of death world wide Increasing rates in low and middle income countries because of change in lifestyles (urbanisation) Key risk factors have very large effects Interventions are effective and can reduce burden The need to combine results and have large studies 44