1. Global Burden of Chronic Disease : Focus on CVD
Ramachandran S. Vasan, MD
Vanessa Xanthakis, PhD
NHLBI’s Framingham Heart Study
Boston University School of Medicine

2. Global Burden of CVD
Background
Present
Future
Causes
Prevention
Future Directions

3. Global Burden of CVD Background Basic concepts What is CVD
What is ‘Burden’
WHO subregions
Broad causes of death

4. CVD
The WHO includes the following broad disease categories under ‘CVD’
CHD: coronary artery disease
Cerebrovascular disease
Rheumatic heart disease
Hypertensive heart disease
Inflammatory heart disease
Other CVD

5. DALY = YLL + YLD Burden of Disease: Concept of DALYs i i i
DALY is a health ‘gap’ measure that summates
potential years of life lost due to premature death &
the years of ‘healthy’ life lost due to states
of less than full health (broadly termed ‘disability’)
1 DALY = 1 year of healthy life lost; Japanese life expectancy serves as standard

6. GBD investigators divided the world into regions based on
EUR
AMR
EMR
SEAR
AFR
WPR
GBD investigators divided the world into regions based on
levels of child (under 5) and adult (15-59) mortality for WHO member states

7. Causes of Deaths: Groups I, II and III
Group I includes communicable, maternal, and perinatal causes and nutritional deficiencies.
Group II includes the non-communicable causes including cancers, diabetes, cardiovascular disorders and chronic respiratory diseases.
Group III includes unintentional and intentional injuries.

8. 3 kinds of transitions determine global health
Epidemiological transition
Omran’s stages: epidemics, receding pandemics, NCD
Demographic transition
From high birth and death rates to low birth rates and death rates
Nutritional transition
Processed foods with added sugar, saturated fats and sodium

9. Epidemiologic Transition
Age
Pestilence and famine
Receding pandemics
Degenerative “man-made” diseases
Delayed degenerative diseases
Predominant CVD
Rheumatic
heart disease
Hypertension-
related
diseases
CHD, stroke, diabetes at young ages
CHD, stroke at older ages
% of deaths due to CVD
5-10
10-35
35-65
<50
Current examples
Sub-Saharan
Africa
Rural China
Rural India
Urban India
North America, Australasia
From S Yusuf et al. Circulation 2001;104:

10. Burden of CVD in Developing Countries
Background
Present
Future
Causes
Prevention
Future Directions

11. Global Health- the Good News
Huge health gains in the past century
increased life expectancy
decrease in infant mortality
Likely contributors
Economic growth
Social development
Medical advances

13. McKeown T. Determinants of Health

14. Death Rates due to Rheumatic Fever in US Time Trends
Classification of Streptococci
Introduction of Sulfonamides
Introduction of Penicillin
Gordis L, Circulation 1985;72:1155

15. Global Health- Bad News
There is an ongoing epidemic of NCD (Grp II: CVD, stroke, diabetes, metabolic diseases, & cancer) world-wide
Cumulative national losses>$1 trillion (China, $558 billion; Russia, $303 billion; India, $237 billion)

16. Global Burden of NCD: The Present
World-wide NCD account for:
36 million deaths annually
63% of deaths
48% of DALYs lost

18. Global Burden of NCD: The Present
NCD accounts for 63% of deaths world-wide
80% of these deaths in developing countries
NCD is leading cause of death in all parts of the world other than SSA
17. 1 million deaths annually due to CVD, 7.1 million deaths annually due to cancer, 4 million deaths due to diabetes

19. Global Burden of NCD: The Present
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.
NCDs also kill at a younger age in low- and middle-income countries, where 29% of NCD deaths occur among people under the age of 60, compared to 13% in high-income countries.

20. 48%
63%

21. Deaths by Broad Cause Group within WHO Region (2000)
Developing countries contribute substantially more in terms of absolute numbers % 75 50 25
AFR
EMR
SEAR
WPR
AMR
EUR
Noncommunicable
conditions
Communicable diseases, etc.
Injuries
Source: WHO, World Health Report 2001

22. 48%
61%

23. Global Burden of CVD: The Present
CVD accounts for 30% of deaths world-wide
80% of these deaths in developing countries
CVD is leading cause of death in all parts of the world other than SSA

24. Deaths due to CVD within WHO Regions (2000)
Strokes
Heart attacks
AFR
EMR
EUR
SEAR
WPR
AMR 10 20 30
% Deaths
Source: WHO, World Health Report 2001
Developing countries contribute substantially more in terms of absolute numbers

25. Global Burden of CVD: The Present
CVD accounts for 10% of DALYs world-wide
86% of these DALYs lost in developing countries

27. Estimated number of people (millions) at High CVD Risk
by WHO subregion
29 m
34 m
28 m
14 m
31 m
12 m
4 m
26 m
3 m
9 m
4 m
12 m
1 m
3 m
A: very low child and adult mortality
B: low child and adult mortality
C: low child, high adult
D: high child, high adult
E: high child, very high adult

28. Global Burden of CVD
Background
Present
Future
Causes
Prevention
Future Directions

29. Global CVD- More Bad News
The epidemic of CVD, Stroke, diabetes and metabolic diseases will hit the poor nations (low-and-middle income ) and in 2020 they will carry:
80% of the mortality from CVD
85% of the burden of disease

31. Projected Global Burden Of CVD Deaths (1990-2020)
20% ↑
110% ↑
B. Neal et al. Eur. Heart J 2002

32. Global Burden of Disease in Developing Countries
(DALYs)
1990
2020 (baseline scenario)
Communicable diseases,
maternal and perinatal
conditions and
nutritional deficiencies
Noncommunicable Conditions
Injuries
Source: WHO, Evidence, Information and Policy, 2000

33. Global Burden of NCD: The Future
The estimated percentage increase in cancer incidence by 2030, compared with 2008, will be greater in low- (82%) and lower-middle-income countries (70%) compared with the upper-middle- (58%) and high-income countries (40%).

34. Global CVD- Some Good News A Silver lining
We know what are the major risk factors
Epidemiology & clinical trials
We have successfully stemmed the epidemic in developed countries
CCUs in hospitals
Public health

35. Global CVD- Some Bad News Dynamics of epidemic in developing countries
Compressed time frame
Early exposure to tobacco and high BP
Societal response lags
Setting of poverty & international debt
Dual burden
Paucity of epidemiological data
Individual responses limited by low education, modest personal resources
We have successfully stemmed the epidemic in developed countries
Public health

36. Global Burden of CVD
Background
Present
Future
Causes
Prevention
Future Directions

37. Global health risks: mortality and burden of disease attributable to selected major risks. WHO 2009

38. Global health risks: mortality and burden of disease attributable to selected major risks. WHO 2009

39. BP, Smoking, Dyslipidemia
Diet, Obesity, Phys. Inactivity

40. Risk Factors & CVD Risk: Some Principles
Continuous gradient across values
No threshold (e.g., BP, Chol, glucose)
More cases arise from ‘body’ than ‘tail’ of distribution
A substantial % of CVD occurs in people with modest elevations of one or more risk factors (compared to marked elevations of a single risk factor).
Risk factors cluster and interact multiplicatively

41. Global Burden of CVD Risk Factors
AFR
AMR
EUR
SEAR
WPR
EMR
World
Blood Pressure
Mean SBP, mm Hg
128
126
134
125
123
127
% SBP>140 27 21 36 19 23
Cholesterol
Mean, mmol/l
4.3
5.3
5.5
5.1
4.9
4.8
% >6 mmol/l (232 mg/dl) 8 28 34 17 15 22
Glucose
Mean glucose, mmol/l
5.4
5.6
% with fpg>7mmol 4 10 12 7 11
Global Health Risks: WHO (2009)

42. Burden of disease due to high cholesterol (% lost healthy life years in each subregion)

43. Burden of disease due to high BP (% lost healthy life years in each subregion)

44. Stroke & blood pressure in different populations
Diastolic blood pressure

45. Total cholesterol (mmol/l)
Continuous risks: blood pressure, cholesterol and the risk of coronary heart disease
Blood pressure
Cholesterol
4.0
% people
% people
2.0
Risk of CHD
% population
HTN
1.0
Dyslipidemia
0.5
4.0
5.0
6.0
7.0
8.0
Systolic blood pressure (mmHg)
Total cholesterol (mmol/l)
Risks continue well below common thresholds, such as “hypertension”
Most people have suboptimal levels of blood pressure and cholesterol

46. Global Burden of CVD
Background
Present
Future
Causes
Prevention
Future Directions

47. Drivers Of The CVD Epidemic
Globalization = greater intercountry dietary dependance
Foreign direct investment in foods & beverages in developing economies = less healthy food products
MNC marketing influences persons in developing economies to prefer Western products as incomes rise
Technological change speeds all these processes
Technological change favors inactive lifestyle, and locus of food consumption shifts away from home
Stuckler D. Milbank Quarterly 2008;86:

48. Drivers Of The CVD Epidemic
Health Transition
Urbanization
Global trade and marketing developments
Tobacco industry
Physical inactivity
Tobacco use, inappropriate diet and physical inactivity (expressed through unfavourable lipid profiles, overweight and raised BP) explain at least 75% of new CHD cases

49. World Health in Transition
Epidemiological
Chronic disease replacing infectious disease; dual burden in developing countries
Demographic
Aging of the population
Summary slide which focuses on the 4 major drivers of these phenomenae

50. World Health in Transition
Nutritional
- Shifting dietary pattern
-high fiber low fat replaced by energy-dense high sat fat
-complex CHO replaced by refined CHO
Sedentary life style
decreasing leisure-time activity
Economic & Social
- Globalization of time, trade & travel
Summary slide which focuses on the 4 major drivers of these phenomenae

51. Nutritional Transition

52. Nutritional Transition
Increased caloric consumption in a milieu of reduced energy expenditure
Sedentary lifestyle
Motorized transport
Labor-saving devices
Reduced leisure time physical activity

53. Stone Agers on a Fast Lane ? Paleolithic versus Modern Diet
Man
Modern
Protein, % 30 12
Fat, %
20-25 42
Fiber, gm 86
10-20
Sodium, mg
604
3400
Potassium, mg
6970
2400
Potassium: sodium
12:1
0.7:1
Eaton SB, J Nutr 1996;126:732-40

54. Diet & CVD

55. The real weapons of mass destruction?
3 behavioral Risk factors  50% of global mortality

57. DEMOGRAPHIC TRANSITIONS?:
Temporal Trends in Obesity Prevalence for Low vs High income regions
Finucane et al. Lancet 2011:

58. Global epidemic of obesity
1.5 billion
Age 15+
1.1 billion
Age 18+
414 million
300 million

59. The potential future of nutritional risks

60. Obesity

61. Obesity & the Global Economy
Shifting dietary patterns
Industrialization
Economic development
Globalization of markets

63. Global Trends in Nutrition
Reduced intake of fruit and vegetables
Increase intake of fats and sugars
Decrease intake of fiber

64. Global Trends in Nutrition

65. Obesity in Developing Countries
Urbanization
Lifestyle changes
Diet
Physical activity
Genetics
Early life

68. Global Physical activity

70. Changes in physical activity
In Us they have exmine

71. Prevalence of Diabetes in Adults (millions of people, by WHO Region)
Source: World Health Report, 1997

72. Global projection for the diabetes epidemic: 2003-2025 (millions)
48.4
58.6
21% ↑
23.0
36.2
57% ↑
39.3
81.6
108% ↑
43.0
75.8
76% ↑
19.2
39.4
105% ↑
14.2
26.2
85% ↑
7.1
15.0
111% ↑
Ref: Diabetes Atlas second edition, IDF 2003
World = 194 million = 5.1% of adult population
2025 = 333 million = 6.3% of adult population
Increase 72%

73. Diabetes Top Three Countries in the world 1995 2025 57 million
King et al, Diabetes Care, 1998

74. Tobacco Over 1 billion smokers worldwide
500 million people alive today will eventually die of tobacco-related causes, including 250 million children
Half of all smokers die in middle age (35-65)
We are all familiar with the health consequence of tobacco. Here in this country great progress has been made in controlling tobacco use. As a result, the tobacco industry has shifted its attention to countries with less regulation. Our success in controlling tobacco has led to an explosion of tobacco use in much of the developing world. As consumption increases, so too do tobacco-related disease such as cancers of the lung, esophagus and bladder.
Smoking prevalence rates among men in China have risen to 65 percent. By 2025, 1 million lung cancer deaths a year are projected.
Less than $100 million per year is spent on international tobacco control, excluding the US, Canada and Australia. This year, nearly $2 billion will be spent in the US alone.
If we can cut adult consumption in half by the year 2020, we can save nearly 200 million lives over the next 50 years.

75. Distribution of world’s smokers
2000
2025
fctc.org/mercosurasociados05/Tom.ppt
WHO World Health Report 1999.

77. Smoking in developing world

78. How serious is the global tobacco epidemic?
Tobacco kills almost 5 million people / yr.
Tobacco killed 100 million in the last century
It is projected to kill 1 billion this century
By 2030, it will kill 10 million a year, and
70% of these deaths will be in developing countries.
The tobacco epidemic is rapidly spreading to the world’s most vulnerable populations.

79. Tobacco deaths in the Industrialized and Developing World, 2000 and 2030
While tobacco-related deaths will only increase slightly in the industrialized world during the next 30 years, they will more than triple in the developing world.
Industrialized countries
Developing countries
fctc.org/mercosurasociados05/Tom.ppt

80. How Did Tobacco Use Become Epidemic?
Nicotine, a potent addicting agent
Risks are not immediate
Produced at tremendous profit by a powerful, multinational industry
Advertising makes it appealing and targets children
Governments profit from tobacco
health.osf.lt/downloads/news/STILLMAN-Origin-and-evolution-pandemic.ppt

81. The ‘Global Smoker’ Cognitive Globalization
Social norms promote smoking with a globally shared culture of smoking;
Western cigarettes as the norm (as opposed to national brands, etc);
Western ideas of freedom, independence, economic success, choice (esp. emerging markets).
More insidiously, the industry has succeeded in cognitive globalization through these efforts. The tobacco cartels have established a globally shared cultural norm of smoking. Western brands and imagery emphasizing social and economic success as well as “freedom to choose” are well know themes to the attendees of this conference.
health.osf.lt/downloads/news/STILLMAN-Origin-and-evolution-pandemic.ppt

82. Is Tobacco Use a Global Infectious Disease?
Host
Government
and People
Vector
Tobacco Industry
Agent
Advertising
Movies and Media
Political Influence
In an ideal world, goods and services that cross borders in response to open markets should have beneficial effects for the marketer and the purchaser. In the case of tobacco, we must consider it not as a publicly traded good, but rather as a publicly traded bad. More like a marketed infectious disease in which there is an agent of distribution (advertising, etc), a host (people and governments), and an environment in which cognitive globalization of tobacco can occur. This is not a perfect market, in that political influence, economic influence, and what is know as information asymmetry distort the market, making it look more like an infectious disease problem than simply a problem of trade and market balance.
health.osf.lt/downloads/news/STILLMAN-Origin-and-evolution-pandemic.ppt

83. The ‘Global Smoker
fctc.org/mercosurasociados05/Tom.ppt

84. The ‘Global Smoker
fctc.org/mercosurasociados05/Tom.ppt

85. The ‘Global Smoker
fctc.org/mercosurasociados05/Tom.ppt

90. Global trends in HTN Prevalence

91. Global Burden of CVD
Present
Future
Causes
Prevention
Future Directions

92. Commonality of Risk Factors
Cardiovascular
Cancers
Diabetes
Chronic Respiratory Diseases
Osteoporosis
Oral Health
Mental Health
Tobacco
Diet
Physical Activity
Alcohol
Source:

93. Optimal & Actual BP Distributions in Populations
Global health risks: mortality and burden of disease attributable to selected major risks. WHO 2009

94. Population-based & High-Risk Strategies for CVD Prevention

95. The Global NCD Strategy Focus on Integration
WHA endorsed framework for the integrated prevention and control of NCD’s – May 2000
However…Member State capacities pose challenges for supporting an integrated NCD agenda
High level UN meeting in Sept 2011 on Global NCD

96. NCD Control: Public Health Policy
Comprehensive health programs led by primary care
Appropriate balance between primary and secondary prevention
Particularly population approaches (Only 5% in wealthy countries at ideal cholesterol, BP, weight)
Also high-risk approaches to primary prevention (although latter may increase inequalities)
Acute management and secondary prevention
Surveillance and monitoring

97. NCD Prevention And Control
94%
88%
88%
76%
65%
39%
WHO 2001

98. Comprehensive National Tobacco Control Policy
Fiscal policy
Increase price of all tobacco products beyond inflation, use part of the revenue for tobacco control
Information policy
Ban tobacco advertising and promotion; ensure effective health warnings are placed on all tobacco products; invest in counter-advertising and health education
Establish smoke-free public places
Provide tobacco dependence treatment
Ensure adequate institutional support
To tobacco control capacity building, applied research, routine surveillance and program evaluation
Work with the media
On the need for tobacco control, the availability of policies that work, and the role of the industry in thwarting implementation of “healthy” policies
Assist farmers to diversify out of tobacco

99. Examples of integrated NCD prevention projects
North Karelia Project, Finland
Tian-Jin Project, China
NCD prevention project, Mauritius
Coris project, South Africa
Mirame project, Chile
Isfahan Healthy heart Project, Iran

100. NCD Prevention: WHO

101. Summary
Tobacco: Almost 6 million people die from tobacco use each year, both from direct tobacco use and second-hand smoke.
By 2020, this number will increase to 7.5 million, accounting for 10% of all deaths.
Smoking is estimated to cause about 71% of lung cancer, 42% of chronic respiratory disease and nearly 10% of cardiovascular disease.

102. Summary
Insufficient physical activity: Approximately 3.2 million people die each year due to physical inactivity
Harmful use of alcohol: Approximately 2.3 million die each year from the harmful use of alcohol, accounting for about 3.8% of all deaths in the world. More than half of these deaths occur from NCDs including cancers, cardiovascular disease and liver cirrhosis.

103. Summary
Raised blood pressure: Raised blood pressure is estimated to cause 7.5 million deaths, about 12.8% of all deaths.
Overweight and obesity: At least 2.8 million people die each year as a result of being overweight or obese.
Raised cholesterol: Raised cholesterol is estimated to cause 2.6 million deaths annually

105. Challenges Double burden of diseases, resource competition Myths:
Personal Behaviours vs. Public health problem
Treatment vs. Prevention
Ageing (natural) population vs. Young population
Modernization ( Rich) vs. local problem (poor)
Future vs. present problem
Measurement of NCDs vs. CD
Under-estimation of intervention effectiveness
Commercial pressure
Institutional inertia

106. Developing Countries: Challenges
Few clear policies and strategies
Limited resources
Fragmented and uncoordinated care
Low commitment to prevention
Lack of surveillance systems
Inadequate treatment guidelines
PHC capacity to deal with NCDs is poor
Severe lack of investment in research

108. Thank you