1. Chronic Disease – Management Priorities in the 21st Century V.K. Barbiero, PhD, MHS George Washington University Department of Global Health

2. Setting the Stage…  Remember…averages mean squat…

3. Chronic Diseases

4. What Are Chronic Diseases  Cardiovascular (heart disease) (hypertension)  Cerebrovascular (stroke)  Cancer  Chronic Respiratory Disease  Diabetes  Mental disorders  Oral disease  Bone and joint  Genetic disorders

5. Characteristics of Chronic Diseases  Take time to become fully established  Have origins at young ages  Required long, systematic and often expensive approaches to treatment  Require integration with responses to acute, infectious diseases  Many opportunities for prevention  They are the leading cause of death in all regions except Africa

6. Eight Myths of Chronic Diseases  Wait until infectious diseases are controlled  Economic growth will improve all health conditions  Chronic diseases affect only the affluent  Chronic diseases are diseases of the elderly  Chronic diseases result from individual behaviors  Benefits of CD control are for individuals only  ID models apply to chronic diseases  Chronic diseases should only be addressed in the health sector Source: Merson, et. al., 2005

7. The Demographic Transition

8. The Epidemiologic Transition ~2005 Source: Omran, A.R., 1971. The Epidemiologic Transition Source: Omran, A.R., 1971. The Epidemiologic Transition.

9. The Nutrition Transition  Pre-processed foods  More food of animal origin  Fall in cereal and fiber intake  More sugar added to food  More alcohol  Urbanization Source: Popkin, BM, 2001. Journal of Nutrition; 131:871S-873S, 2001)

10. Pathways of the Nutrition Transition

11. Prevalence of Overweight (BMI >25) of Women by Income Strata Prevalence (%) of BMI >25 Source: WHO, 2005

12. The Urban Transition 2008 World 50% Urban

13. Four Stages of The Health Transition CVD = Cardiovascular disease; PVD = peripheral vascular disease

14. Ghana’s Days of Healthy Live Lost Measles other Preventable Non Preventable Adult Deaths Preventable Undernutrition DD, ARI Malaria Non Preventable Childhood Deaths Source: Merson, et. al., 2005 ADULTS CHILDREN

15. Disability-Death Model Birth PYLLs, HeaLYs, QALYys, DALYs High Case Fatality Disability Death Mortality Death The Ideal 90 Yrs Early Deaths 24-36 Months Continuing Early Deaths 2007 – Death/Disability 2025 – Disability/Death

16. Population/Family Planning the Development Imperative Billions of People

17. Pyramids Tell the Tale… China – 2000 & 2050 Population = 1.42B

18. Pyramids Tell the Tale… Nigeria – 2000 & 2050 Population = 307M

19. Chronic Diseases - Fact Sheet  35 million will die from chronic diseases in 2005  More people die from chronic diseases than infectious diseases worldwide 60% of all deaths are from chronic diseases  80% of chronic disease deaths occur in mid-low income countries  12 million die of heart attacks annually  50% of deaths are women  > 1 billion adults are overweight worldwide – 30% obese  Behavioral interventions are effective

20. Global Chronic Disease Profile Source: WHO, 2006 Total Deaths 2005 ~58 Million

21. Estimated Causes of Death Worldwide Source: WHO, 2002 Total Deaths 2005 ~58 Million

22. Projections of Future Deaths  There will be about 64 million deaths in 2015… 17 million from communicable diseases 41 million from chronic diseases ~6 million from injuries CVD and stroke will remain highest with ~20 million Source: WHO, 2002

23. Estimated DALYs By Condition Source: WHO, 2002

24. The Double Burden for the Poor…

25. Estimated Causes of Death by Income 2005 Source: WHO, 2002, vkb/extrapolated from World Bank graph Age Standardized Death Rates Per 100,000

26. Estimated DALYs by Income Source: WHO, 2002, vkb/extrapolated from World Bank graph

27. Elements & Progression of Chronic Diseases Underlying Social & Environmental Determinants Urbanization & Aging Population Source: vkb adapted from WHO, 2002 Modifiable Risk Factors Diet Activity Smoking Non-Modifiable Risk Factors Age Heredity Immediate Risk Factors Blood Pressure High Glucose Abdominal Fat Overweight Obesity Main Chronic Diseases Heart Disease Stroke Cancer COPD Diabetes

28. No Quick Fixes…No Magic Bullets…

29. Preventing and Managing Chronic Disease  Health Promotion (to shift distribution of risks)  Specific Prevention Programs Diet, smoking, exercise Environmental and Occupational Exposures e.g. Sexual Health (AIDS, HPV, etc) Retooling Health Service Programs  ‘Health Impact’ of ‘Non-Health Policy’ Food Safety Agriculture/Trade Urban Planning

30. Preventing and Managing Chronic Disease  WHAT TO DO IS THE EASY PART…  HOW TO DO IT IS ANOTHER STORY…

31. Policy to Action  Talk is free  Ink is cheap  Action takes a lot of money, time, commitment and effort…

32. Lessons to Date…  HIV/AIDS Prevention, Care and Treatment  Insurance Schemes and Tiered pricing  Training and Task Shifting Level of training, brain drain  DOTS and TB  Diagnosis and treatment?  Prevention…?..blah, blah, blah… do we know?...witness USA’s BMI…  Facility care, HBC, palliative care?

33. Conclusions  Chronic disease epidemiology is a worldwide issue  We need more thought and demonstration interventions on this issue  AIDS requires chronic disease management…what lessons can we learn?  Double and triple burden of disease in LDCs will cause millions to suffer  Action is required…we must begin…now…

34. THANK YOU