1. 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 Email: kavumpurathu@yahoo.com kavumpurathu@yahoo.com Prevention and Control of NCDs: Need for Reducing major Risk Factors

2. Outline Global Burden of Disease NCD Risk Factors in Gujarat and India Health Expenditure pattern Challenges for prevention Way forward Conclusions

3. RANKCauses of Death 19902010 1Ischemic 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;380:2095-128 Top 10 Causes of Death in the World Ranked in 1990 and 2010

4. RANK DISORDER 19902010 1Lower 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;380:2095-128

5. Disability adjusted life years lost due to 10 leading risk factors in 1990 & 2000 Rank19902010 1Childhood 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;380:2224-60

6. IndicatorsGujaratIndia Infant Mortality Rate 3842 Crude Birth Rate 21.121.6 Crude Death Rate 6.67.0 Natural Growth Rate 14.414.5 Selected Health Statistics for Gujarat and India SRS Bulletin 2013.

7. Current Tobacco Use: Gujarat and India (% of males aged 15 years and above) Type of TobaccoGujaratIndia Any Tobacco Use46.247.9 Smoking Only14.815.0 Smokeless only26.423.6 Both forms05.009.3 GATS India 2009-10

8. Current Tobacco Use: Gujarat and India (% of females aged 15 years and above) Type of TobaccoGujaratIndia Any Tobacco Use11.320.3 Smoking Only00.301.9 Smokeless only09.817.3 Both forms01.201.1 GATS India 2009-10

9. Alcohol Use: Gujarat and selected States (% of males and females 15-49 years) StatesMalesFemales Gujarat16.00.8 Rajasthan19.10.2 Jammu and Kashmir12.50.0 Andhra Pradesh47.26.8 Kerala45.20.7 National Family Health Survey -3, 2005-06

10. Fruit Consumption: Gujarat and selected States (% of males and females 15-49 years) StatesMalesFemales Gujarat48.449.6 Rajasthan31.022.9 Jammu and Kashmir57.449.6 Andhra Pradesh56.047.6 Kerala79.665.7 National Family Health Survey -3, 2005-06

11. Overweight /Obese: Gujarat & selected States (% of males and females 15-49 years) StatesMalesFemales Gujarat11.316.7 Rajasthan06.208.9 Jammu and Kashmir06.216.7 Punjab22.229.9 Kerala17.828.1 National Family Health Survey -3, 2005-06

12. Hypertension Prevalence in a District in Gujarat (15-64 Years) Hypertension (%)UrbanRural Male37.317.9 Female27.319.9 Total29.118.4 Bhagyalaxmi A, Atul T, Shikha J. 2013; 31:78-85

13. Risk factor prevalence among doctors in Trivandrum City, Kerala Risk factorsMen (N=86)Women (N=60) Overweight 55.840.0 Abdominal obesity52.351.7 Diabetes34.921.7 Hypertension24.420.0 Dyslipidemia26.718.3 Current tobacco use18.60.0 Current Alcohol use40.70.0 Patra L, Mini GK, Mathews E, Thankappan KR. Br J Sports Med 2013; June 14.

14. CountriesHealth expenditure (as % of GDP) TotalGovt.% by Govt. India6.11.321 China5.82.034 Sri Lanka3.71.849 US14.66.645 UK7.76.483 Canada9.66.770 Health Expenditure of Selected countries Source: World Health Report 2005

15. States% Kerala90.3 Gujarat79.2 Rajasthan75.6 Karnataka71.9 India78.0 Private Health Expenditure in Selected Indian States 2004-05 Kumar AKS et al. Lancet 2011; 377: 668-79

16. 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

17. 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

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

19. 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

20. 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

21. 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.

22. Way forward -2 National accountability involves monitoring and reviewing progress and appropriate response to accelerate progress with appropriate institutional mechanisms.

23. Conclusions Global burden of disease has shifted to chronic non-communicable diseases NCD risk factors are high in Gujarat In most developed countries except the US public sector provides most of the health care In India and Gujarat 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.