From Science to Integrated NCD Prevention

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From Science to Integrated NCD Prevention

• Ruitai Shao MD
• Noncommunicable Disease Prevention and
• Health Promotion
• World Health Organization

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Outlines
Time to take action
Challenges and opportunities

• What do we know?

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Researches and studies

• CD Vs NCDs (Disease pattern changed)
• Epidemiological, health transition
• Measurement of diseases and health
• Mortality, morbidity, etc. ? DALYs, etc.
• Epidemiological studies
• Descriptive epidemiological study
• Observational study
• Case-control study
• Cohort study
• Experimental study
• Quasi-experimental study

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Global burden of disease 1990 - 2020 by disease
group in developing countries
1990
2020 (baseline scenario)
Communicable diseases, maternal and
perinatal conditions and nutritional deficiencies
Noncommunicable Conditions
Neuropsychiatric Disorders
Injuries
Source WHO, Evidence, Information and Policy,
2000
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Epidemiological Study

• Coronary heart disease in seven countries -
  Finland, Greece, Italy, Japan, Netherlands, USA
  and Yugoslavia
• Framingham heart study
• Stanford 3 5 cities study
• North Karelia Project
• MONICA Project
• Multiple Risk Factor Intervention Collaborative
  Trials

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Multiple Risk Factor Intervention Collaborative
Trials
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The benefits of reducing blood cholesterol by 10
(0.6 mmol/ld)
10 reduction of blood cholesterol produces
20-30 decline in CHD deaths
60 of decline in CHD deaths is accounted by
dietary factors
Law et al., BMJ, 1994, 308 367
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Coronary heart disease mortality risk factors in
Finland Men aged 35-64
Vartiainen E
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Use of butter for cooking
Use of vegetable oil for cooking (men age 30-59)
Use of vegetable oil for cooking (men age 30-59)



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The interlinking of physical inactivity and
dietary effects on obesity and its related
chronic diseases
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WHAT DRIVES THE DECLINE IN MORTALITY?MONICA10
YEARS EXPERIENCE

• MONICA Results heterogenous
• Populations in which the CHD mortality is
  increasing (mainly Eastern Europe) differ from
  the rest
• In populations in which the CHD mortality is
  declining, changes in event rates contribute 2/3
  and changes in case-fatality contribute 1/3
• Tunstall -Pedoe H et al., Lancet 19993531547-57

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Commonality of Risk Factors
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PRINCIPLES OF RISK

• Risk operates across a continuum - not
  thresholds
• (Blood Pressure Cholesterol overweight
  Smoking)
• More events arise from the main body of the
• distribution than from the upper tail, for
  any risk
• factor
• The risk is multiplicative when many risk factors
  co-
• exist risk factors often cluster together
• Majority of events arise in individuals with
  modest
• elevations of many risk factors than from
  marked
• elevation of a single risk factor

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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

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CHD mortality decline in Finland and North
Karelia 1971-2001 Men 35-64
3,2/year
North Karelia
1,5/year
1,1/year
3,8/year
Finland
6,0/year
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NCD INTERVENTION MAURITIUS

• ?FIVE YEAR HEALTHY LIFESTYLE PROGRAMME
• ?CROSS-SECTIONAL CLUSTER SURVEYS
  (1987-1992)25-74 YEARS.
• -RESULTS MEN WOMEN
• HT PREVALANCE 15 ? 12.1 12.4 ? 10.9
• CIGARETTE SMOKING 58 ? 47.2 6.9 ? 3.7
• HEAVY ALCOHOL CONSUMPTION 38.2 ? 14.4 2.6
  ? 0.6
• MODERATE LTPA 16.9 ? 22.1 1.3 ? 2.7
• MEAN POPULATION SERUM CHOLESTEROL 5.5mmol/l
  ?4.7mmol/l
• OVERWEIGHT/OBESITY ? GLUCOSE INTOLERANCE -NS
• Dowse et al BMJ, 1995

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Explaining the Decline in Coronary Heart Disease
Mortality in Finland 1982-1997
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Whats the big picture?
Health care
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Genetics
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Behavior
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Environment
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Social
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USA, Mc Ginnis 2003 Meeting in Helsinki
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Summary What we know?

• NCD a priority
• Major NCDs CVD, Cancer, COPD and Diabetes
• Main NCD share common risk factors
• Tobacco use, Unhealthy Diet, Physical inactivity,
  Alcohol abuse
• Prevention is a key
• Population approach
• Integrated NCD prevention

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Challenges and opportunitiesin developing world
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Double burden of disease in middle/low income
countries
DALYs
India SSA
Communicable, Maternal and Perinatal Conditions
Nutritional Deficiencies Noncommunicable
Conditions
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Trend of main causes of Death in urban area,
China (1954-1999)
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Increasing burden of noncommunicable diseases and
injuries change in rank order of DALYs for the 15
leading causes (baseline scenario)
1999 Disease or Injury
2020 Disease or Injury
1. Acute lower respiratory infections 2.
HIV/AIDS 3. Perinatal conditions 4.
Diarrhoeal diseases 5. Unipolar major
depression 6. Ischaemic heart disease 7.
Cerebrovascular disease 8. Malaria 9. Road
traffic injuries 10. Chronic obstructive
pulmonary disease 11. Congenital
abnormalities 12. Tuberculosis 13. Falls 14.
Measles 15. Anaemias
1. Ischaemic heart disease 2. Unipolar major
depression 3. Road traffic injuries 4.
Cerebrovascular disease 5. Chronic obstructive
pulmonary disease 6. Lower respiratory
infections 7. Tuberculosis 8. War 9.
Diarrhoeal diseases 10. HIV 11. Perinatal
conditions 12. Violence 13. Congenital
abnormalities 14. Self-inflicted injuries 15.
Trachea, bronchus and lung cancers
DALY Disability-adjusted life year
Source WHO, Evidence, Information and Policy,
2000
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Global progress in developing and
implementing National Nutrition Plans and
Policies (192 countries)
1993-2002
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Challenges and opportunities GAPS

• Vast scientific knowledge but not enough
  
• sufficient policy development and action
• Limited resource and actual needs in
• NCD prevention and health promotion

KNOWLEGE
ACTION
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Percentage of Countries With National Policies
Plans
AFR AMR EMR EUR SEAR WPR All Public
Health Policy 82 82 65 80 89 65
77 NCD Policy 13 37 59 59
44 58 43 CVD Plan 8 30 53 50
50 40 35 Tob. Control Plan 13 27
50 43 75 68 39 Diab. Control Plan
13 41 50 54 56 64 43 Cancer Control
Plan 15 50 56 62 78 64 48
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What constrains Progress?

• Double burden of diseases, resource competition
• Confusions
• Personal Behaviours Vs Public health problem
• Treatment Vs Prevention
• Ageing(natural) population Vs Young population
• Modernization, globalization ( Rich) Vs local
  problem (poor)
• Future Vs present problem
• Measurement of NCDs Vs CD
• Myths about impact
• Under-estimation of intervention effectiveness
• Commercial pressure
• Institutional inertia
• Post September 11 impact

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National capacity for NCD prevention and control

• 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

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Summary Challenges and opportunities in
developing world

• NCD mortality is increasing but relative
• lower than that in developed world.
• Challenged by double burden of diseases but
• different population influenced
• Behaviour is changing but not formed fully
• Influenced by globalization, modernization
• but it is beginning, a long way to go
• Very few successful case but experiences
  
• Lessons in the developed world

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Time to take action
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What are our prevention priorities? CVD, CANCER
AND CHRONIC RESPIRATORY DISEASES RISK FACTORS

• Non-modifiable
• Risk Factors
• Age
• Sex
• Genes

• Coronary heart
• disease
• Stroke
• Peripheral vascular
• disease
• Several cancers
• COPD/emphysema
• Health, wellbeing

End Points
Intermediate Risk Factors

• Behavioural
• Risk Factors
• Tobacco
• Diet
• Physical Activity
• Alcohol

Socio-economic, Cultural EnvironmentalCondition
s, and Modernisation, Mechanisation, Urbanisation,
Globalisation
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Epidemiologic Transition
POPULATIONS
Low Risk
High Risk
Public Health Interventions
Epidemiologic Transition
INDIVIDUALS
Low Risk
High Risk
Clinical Interventions
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Integrated NCD prevention

• Strong Evidences
• Scientific knowledge, Experiences from the
  countries, and Cost-effective
• Main NCDs
• Common risk factors
• Common strategies
• In cooperation, coordination with related sectors

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NCD Prevention Priorities for Action
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NCD Prevention Priorities for Action
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Summary Time to take action

• Increase awareness
• Marketing NCD prevention and advocacy
• National strategy and policy
• National initiatives and programmes
• Capacity building and training
• Networking
• Technical support
• Cooperation and coordination

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THANK YOU