The New Challenges for Obstetricians. The Prevention of NCDs L. Cabero Roura Barcelona

Non communicable diseases Disease that is not transmitted by another person, a vector, or the environment.

NCDs Diabetes Obesity Hypertension Isquemic CVD Ictus Rheumatic diseases Cancer Others

Global Causes of Death Noncommunicable diseases Communicable diseases, maternal and perinatal conditions, and nutritional deficiencies Injuries Source: WHO, World Health Report 2000—Health Systems: Improving Performance (Geneva: WHO, 2000).

NCDs : leeding cause of mortality

A vicious circle may ensue: poverty exposes people to behavioural risk factors for NCDs and, in turn, the resulting NCDs may become an important driver to the downward spiral that leads families towards poverty

Low economic growth Poverty Poor health NCDs MM

The scope Mortality and morbidity data reveal the growing and disproportionate impact of the epidemic in lower resource settings. Over 80% of cardiovascular and diabetes deaths, and almost 90% of deaths from chronic obstructive pulmonary disease, occur in low- and middle-income countries. More than two thirds of all cancer deaths occur in low- and middle-income countries

Trends in Death in Developing Areas Deaths (millions) NCDs Comm. Dis. Injuries Global Burden of Disease

Vulnerable Population Groups Impact -Humanitarian -Social -Economic Non Communicable Diseases (NCDs)

Vulnerable Population Groups Impact -Humanitarian -Social -Economic Non Communicable Diseases (NCDs)

Total deaths around the world: 58 million

Total deaths around the world: 58 million Deaths from noncommunicable diseases around the world: 35 million

Total deaths around the world: 58 million Deaths from noncommunicable diseases around the world: 35 million Deaths from noncommunicable diseases in developing countries: 28 million

Total deaths around the world: 58 million Deaths from noncommunicable diseases around the world: 35 million Deaths from noncommunicable diseases in developing countries: 28 million Deaths from noncommunicable diseases in developing countries which could have been prevented: an estimated 14 million

MOTHER FETUS NEWBORN ADULT VITAL EVOLUTION ENVIROMENTAL FACTOS GENETIC FACTORS

Many diseseases of maturity have their origins early in life

MOTHER FETUS NEWBORN ADULT NUTRITION ANEMIA TOBACCO DIABETES HYPERTENSION INFECTIONS STRESS OBESITY DRUGS

MOTHER FETUS NEWBORN ADULT NUTRITION ANEMIA TOBACCO DIABETES HYPERTENSION INFECTIONS STRESS OBESITY DRUGS IUGR PREMATURITY PPH POSTPARTUM INFECTIONS IUGR PREMATURITY PPH POSTPARTUM INFECTIONS MORTALITY SDR GROWTH NEUROLOGIC DEFICIENCIES MORTALITY SDR GROWTH NEUROLOGIC DEFICIENCIES WHO Definition Hb <9,5g/l WHO Definition Hb <9,5g/l HYPERTENSION CARDIOVASCULAR DISEASES ARTERIOSCLEROSIS OBESITY HYPERTENSION CARDIOVASCULAR DISEASES ARTERIOSCLEROSIS OBESITY

MOTHER FETUS NEWBORN ADULT NUTRITION ANEMIA TOBACCO DIABETES HYPERTENSION INFECTIONS STRESS OBESITY DRUGS CONGENITAL DEFECTS IUGR PREMATURITY MACROSOMIA FETAL INFECTIONS CONGENITAL DEFECTS IUGR PREMATURITY MACROSOMIA FETAL INFECTIONS HYPERTENSION CARDIOVASCULAR DISEASES ARTERIOSCLEROSIS DIABETES OBESITY HYPERTENSION CARDIOVASCULAR DISEASES ARTERIOSCLEROSIS DIABETES OBESITY MORTALITY SDR NEUROLOGIC PROBLEMS NUTRITIONAL PROBLEMS IMMUNE COMPETENCES MORTALITY SDR NEUROLOGIC PROBLEMS NUTRITIONAL PROBLEMS IMMUNE COMPETENCES OVER UNDER OVER UNDER

Epidemiological studies show importance of development: Smaller babies have higher adult risk of : Hypertension Altered plasma lipids Raised plasma fibrinogen and CRP Impaired glucose tolerance, type 2 diabetes and central obesity Endothelial dysfunction

Greater Mismatch; Inadequate response to environment; Greater risk of disease Quality of developmental environment Too poor Too rich

Greater Mismatch; Inadequate response to environment; Greater risk of disease Quality of developmental environment Too poor Too rich Socioeconomic development Even poorer rural economies Migrants to cities consume high fat, high GI diet, less physical activity

Unhealthy childhood body comp., metabolism & cardiovascular function Mismatch between induced phenotype & post-natal environment Healthy childhood body comp., metabolism & cardiovascular function Match between induced phenotype & post-natal environment Mother’s body composition & nutrition Epigenetic modification of gene expression Fetal and Infant growth & developmental adaptations The Future HEALTH DISEASE

Premature death and morbidity Obesity Insulin resistance Gestational diabetes Enriched postnatal environment due to nutritional transition Large babies Stunting low birth weight Very poor postnatal environment Women malnourished Low pregnancy weight gain Maternal morbidity Suboptimal fetal development The Recurring Nightmare: Cycles of Disease with a Poor Start to Life Modified from Gluckman and Hanson 2005 Large babies Fat mothers

MOTHER FETUS NEWBORN ADULT NUTRITION ANEMIA TOBACCO DIABETES HYPERTENSION INFECTIONS STRESS OBESITY DRUGS FETAL DEFECTS FETAL GROWTH ANOMALIES FETAL-NEONATAL DEATH NEONATAL MORBIDITY PREMATURITY/SDR OBESITY INFANT AND ADULT DIABETES CARDIOVASCULAR DISEASES SCHIZOPHRENIA FETAL DEFECTS FETAL GROWTH ANOMALIES FETAL-NEONATAL DEATH NEONATAL MORBIDITY PREMATURITY/SDR OBESITY INFANT AND ADULT DIABETES CARDIOVASCULAR DISEASES SCHIZOPHRENIA

MOTHER FETUS NEWBORN ADULT NUTRITION ANEMIA TOBACCO DIABETES HYPERTENSION INFECTIONS STRESS OBESITY DRUGS PREECLAMPSIA IUGR MATERNAL DEATH FETAL-NEONATAL DEATH NEONATAL MORBIDITY PREMATURITY/SDR ADULT HYPERTENSION CARDIOVASCULAR DISEASES PREECLAMPSIA IUGR MATERNAL DEATH FETAL-NEONATAL DEATH NEONATAL MORBIDITY PREMATURITY/SDR ADULT HYPERTENSION CARDIOVASCULAR DISEASES

MOTHER FETUS NEWBORN ADULT NUTRITION ANEMIA TOBACCO DIABETES HYPERTENSION INFECTIONS STRESS OBESITY DRUGS FETAL DEFECTS FETAL GROWTH ANOMALIES MATERNAL DEATH FETAL-NEONATAL DEATH NEONATAL MORBIDITY PREMATURITY/SDR ADULT DIABETES ADOLESCENT/ADULT OBESITY CARDIOVASCULAR DISEASES HYPERTENSION FETAL DEFECTS FETAL GROWTH ANOMALIES MATERNAL DEATH FETAL-NEONATAL DEATH NEONATAL MORBIDITY PREMATURITY/SDR ADULT DIABETES ADOLESCENT/ADULT OBESITY CARDIOVASCULAR DISEASES HYPERTENSION

MOTHER FETUS NEWBORN ADULT NUTRITION ANEMIA TOBACCO DIABETES HYPERTENSION INFECTIONS STRESS OBESITY DRUGS Strong IMPACT

MOTHER FETUS NEWBORN ADULT NON COMUNICABLE DISEASES VITAL CICLE

MOTHER FETUS NEWBORN ADULT NON COMUNICABLE DISEASES VITAL CICLE

Good news Effective interventions are available, and abundant evidence now demonstrates their clear and measurable impact in a range of resource settings.

Behavior Change Successes Reducing malnutrition (micronutrient initiatives) Reducing maternal obesity Diagnose and treat the diabetes during pregnancy Preventing anemia (iron supplements) Preventing malaria (insecticide-treated bednets) Helping children survive (breastfeeding) Improving maternal health (safe motherhood movement, emergency obstetric care) Making family planning a norm (worldwide efforts) Combating HIV/AIDS (Uganda program)

Sumary A well-constructed alliance between the NCD and maternal and women’s health fields has the potential to strengthen both. It is time to overcome the words and make the facts¡¡¡

Castells Humans

Key messages The majority of noncommunicable diseases can be averted through interventions and policies that reduce major risk factors. Many preventive measures are cost-effective, including for low-income countries. Some preventive actions can have a quick impact on the burden of disease at the population level. Interventions that combine a range of evidence-based approaches have better results. Comprehensive prevention strategies must emphasize the need for sustained interventions over time.

Many things we need can wait, the child cannot. Now is the time his bones are being formed, his blood is being made, his mind is being developed. To him we cannot say tomorrow. His name is today. Gabrielle Mistral, Su Nombre es Hoy