1. Gerald S. Bloomfield, MD, MPH DGHI, Division of Cardiology, Duke University September 2013 Non-Communicable Diseases in LMICs: Myths, Facts and Opportunities

2.  Trends in selected NCDs in LMICs  Epidemiologic transition  Data challenges  Approaches to NCD research in LMICs OUTLINE

3. CARDIOVASCULAR DISEASE

4.  Common CVDs: Rheumatic, infectious, pericardial, high BP  Heart failure is endemic in SSA  Dilated cardiomyopathy: 48% of admissions  Causes: RHD, Hypertension, Peripartum, Idiopathic  Coronary heart disease “distinctly rare”  Diagnostic limitations  Lack of specialized investigations  Viral, nutritional, familial, alcohol, immune, ischemia  68% of ‘idiopathic’ can be mislabeled CLASSIC TEACHING ON CARDIOVASCULAR DISEASES IN SSA RHD = Rheumatic Heart Disease Watkins and Mayosi. Cardiovascular Journal of Africa 2009 BP = blood pressure Oyoo and Ogola. East African medical journal 1999 Mokhobo. S Afr Med J 1980

5. “Africans are immune to heart/coronary disease” Ancient Egypt 1370 BC Heavy Heart is a Bad Heart Kenya.2 years, 1800 patients. 0% HTN, arteriosclerosis Uganda.2 years 0% HTN Kalahari San. No increase in BP with age No change in BP with age Prev. HTN Ghana 13% Nigeria 25% Lesotho 7% History of chronic CVD in Africa 1920s194119601970s1976-81901 Uganda. N= 1500 “High tension pulses not often met with” 1958-72: 8-11% admissions due to CVD 1980-90s 40% hospital admissions with any CVD 2010:CVD is the 2 nd most common cause of death in SSA

6.  325 migrants, 267 controls followed for 24 months  SBP changes over 24 months LUO MIGRATION STUDY Poulter BMJ 1990

7. PULMONARY DISEASE

8. DEATHS DUE TO PULMONARY DISEASE www.healthmetricsandevaluation.org 2013

9. Adult Smoking Prevalence, 2009 Youth Smoking Prevalence, 2009 Tobacco Control Report from the Region of the Americas 2011

10. http://www.who.int/tobacco/en/atlas19.pdf

11. PROPORTION OF PATIENTS WITH COPD WHO ARE NON-SMOKERS Salvi and Barnes. Lancet 2009

12. www.who.int/ceh/publications/en/map09b.jpg

13.  85% of all global particulate exposure occurs indoors  HAP levels are typically higher than developed world standards for ambient air quality  EPA Standard: 150 micrograms/cubed meter  Households with HAP: 300- 3000  During cooking 30,000  50x more carbon monoxide HOUSEHOLD AIR POLLUTION HAP in Nigeria http://magazine.uchicago.edu/1102/investigations/in door_air_pollution.shtml

14. DIABETES AND HIGH BLOOD SUGAR

15. Health Statistics and Informatics Leading causes of attributable global mortality and burden of disease, 2004 % 1.High blood pressure 12.8 2.Tobacco use8.7 3.High blood glucose 5.8 4.Physical inactivity 5.5 5.Overweight and obesity 4.8 6.High cholesterol 4.5 7.Unsafe sex 4.0 8.Alcohol use3.8 9.Childhood underweight 3.8 10.Indoor smoke from solid fuels 3.3 59 million total global deaths in 2004 % 1.Childhood underweight 5.9 2.Unsafe sex4.6 3.Alcohol use4.5 4.Unsafe water, sanitation, hygiene 4.2 5.High blood pressure3.7 6.Tobacco use3.7 7.Suboptimal breastfeeding 2.9 8.High blood glucose 2.7 9.Indoor smoke from solid fuels 2.7 10.Overweight and obesity 2.3 1.5 billion total global DALYs in 2004 Attributable MortalityAttributable DALYs

16. EPICENTERS OF DIABETES Deaths from diabetes

17. Hu. Diabetes Care 2011

18. The Epidemiologic Transition DescriptionLife Expectancy % deaths from CV Dominant CVDs Stage 1 Pestilence and Famine Malnutrition Infectious diseases 35 years<10Infectious (RHD) Nutritional Stage 2 Receding pandemics Improved nutrition and public health Chronic disease Hypertension 50 years10-35Infectious (RHD) Stroke-haemorrhagic Stage 3 Degenerative and man-made diseases High fat and caloric intake Tobacco use Chronic diseases > infectious, malnutrition >60 years35-65Ischemic heart disease (IHD) Stroke – haemorrhagic, ischaemic Stage 4 Delayed degenerative diseases Leading causes of mortality CV and cancer deaths Prevention and treatment delays onset Age-adjusted CV death reduced >70 years40-50IHD Stroke – ischaemic CHF From Gersh et al. European Heart Journal 2010

19. THE PERFECT STORM OF CVD IN LMICS Gersh et al. EHJ 2010 LMICs: low- and middle-income countries

20. Development Diet Tobacco Sedentary lifestyle Technology Urbanization Industry

21. Projected Deaths by Cause Beaglehole and Bonita. Lancet 2008

22. WHERE DO WE GO FROM HERE?

23. PERCENT OF CVD STUDIES FROM SSA BY COUNTRY/REGION, 1980-2008

24. CONTEMPORARY CAUSES OF HEART FAILURE IN SSA Bloomfield et al. Curr Cardiol Reviews 2013

25. “FLTR” FOR NCDS  Find  Link  Treat  Retain HOSPITA L Health Center Dispensary COMMUNITY Current scenario Proposed scenario Optimizing Linkage and Retention to Hypertension Care in Kenya: LARK Hypertension Study. Slide courtesy of R. Vedanthan, Mt. Sinai

26. OPTIMIZING LINKAGE AND RETENTION TO HYPERTENSION CARE: LARK HYPERTENSION

27. Oxford Health Alliance 2006 AN OPPORTUNITY FOR PRIMARY PREVENTION

28. THE GOOD NEWS: PREVENTION WORKS http://www.ktl.fi

29. Non-Communicable Diseases in LMICs: Myths, Facts and Opportunities Gerald S. Bloomfield, MD, MPH Duke Global Health Institute Division of Cardiology Duke University THANK YOU