The Burden of Chronic Diseases in the Developing World Stephen J. Spann, M.D., M.B.A. Professor and Chairman Department of Family and Community Medicine

The Global Burden of Non- Communicable Diseases (NCDs) 36/57 million (63%) global deaths in 2008 were due to NCDs: Cardiovascular diseases: 17 million Diabetes mellitus: 1.3 million Cancers: 7.6 million Chronic respiratory diseases: 4.2 million NCD deaths are expected to increase globally by 15% between 2010 and 2020

Major Causes of Global Mortality (WHO 2005) “Other conditions” comprises communicable diseases, maternal and perinatal conditions and nutritional deficiencies

The Burden of NCDs in the Developing World Nearly 80% of NCD deaths occur in middle and low income countries NCDs are most common cause of death in most countries (except Africa) In middle and low income countries 29% of NCD deaths occur in people below age 60, compared to 13% in high income countries Global status report on non-communicable diseases. WHO, 2010.

The Burden of NCDs in the Developing World Country Income LevelAge-standardized NCD mortality, males Age-standardized NCD mortality, females Middle/Low756/100,000565/100,000 High458/100,000307/100,000 % Difference65%85% Global status report on non-communicable diseases. WHO, 2010.

Total Death by Broad Cause Group, by WHO Region, World Bank Income Group, and by Gender, 2008

Proportion of Global NCD Deaths Under the Age of 70, by Cause of Death, 2008

Most Frequently Diagnosed Cancers by Country, Males, 2008

Most Frequently Diagnosed Cancers by Country, Females, 2008

Age-standardized Incidence Rates of All Cancers by Type of Cancer per 100,000 Population for Both Genders, by World Bank Income Groups, 2008

Age-standardized Prevalence of Diabetes in Adults Age 25+ Years, by WHO Region and World Bank Income Group, Comparable Estimates, 2008

Major Lifestyle Risk Factors Contributing to NCDs Globally Tobacco: 6 million deaths/year Insufficient physical activity: 3.2 million deaths/year Harmful use of alcohol: 2.3 million deaths/year Unhealthy diet: 2.8 million deaths/year from overweight/obesity

Age-standardized Prevalence of Daily Smoking in Adults 15+ Years, by WHO Region and World Bank Income Group, Comparable Estimates, 2008

Age-standardized Prevalence of Insufficient Physical Activity in Adults 15+ Years, by WHO Region and World Bank Income Group, Comparable Estimates, 2008

Total Adult (15+ Years of Age) Consumption of Pure Alcohol (liters) by Both Sexes, by WHO Region and World Bank Income Group, Projected Estimates, 2008

Availability of Total Fat and Saturated Fatty Acids (As% Dietary Energy Supply) for , by WHO Region and World Bank Income Group

Major Metabolic/Physiological Risk Factors Contributing to NCDs Globally Elevated BP: 7.5 million deaths/year Overweight/obesity: 2.8 million deaths/year Elevated cholesterol: 2.6 million deaths/year

Age-standardized Prevalence of Elevated Blood Pressure in Adults 25+ Years, by WHO Region and World Bank Income Group, Comparable Estimates, 2008

Age-standardized Prevalence of Overweight in Adults 20+ Years, by WHO Region and World Bank Income Group, Comparable Estimates, 2008

Age-standardized Prevalence of Obesity in Adults 20+ Years, by WHO Region and World Bank Income Group, Comparable Estimates, 2008

Age-standardized Prevalence of Elevated Total Cholesterol in Adults 25+ Years, by WHO Region and World Bank Income Group, Comparable Estimates, 2008

“Best Buys” in Population-based Interventions to Prevent NCDs

“ Best Buys” in Individual-based Interventions to Prevent NCDs

Impact and Cost of Medical Interventions for Preventing Cardiovascular Disease in Developing Countries Multidrug regimen: a statin, ASA, and two antihypertensive medications, given in 23 developing countries Over 10 year period, 17.9 million deaths could be averted Annual cost: U$ for lower income countries, and U$ for middle income countries Sim SS et al. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs. Lancet 2007; 370: 2054–62.

The Vicious Cycle of Poverty and NCDs

The Importance of Primary Health Care in Prevention, Detection and Treatment of NCDs Integrated primary care vs. silos Importance of the primary health care team Importance of doctor/team/patient relationship over time Importance of basic diagnostic and treatment infrastructure

Availability of Laboratory Tests and Basic Technologies in Primary Care, by WHO Regions, 2010

Availability of Laboratory Tests and Basic Technologies in Primary Care, by World Bank Income Group, 2010

The Chronic Care Model Adapted with Permission from Wagner EH. Chronic Disease Management: What Will it Take to Improve Care for Chronic Illness? Effective Clinical Practice. 1998;vol. 1(1):2-4. Wagner EH. Chronic Disease Management: What Will it Take to Improve Care for Chronic Illness? Effective Clinical Practice. 1998;vol. 1(1):2-4.

References Except where noted otherwise, cited material comes from : Global status report on non-communicable diseases. WHO, 2010.

A 60 Year Old Woman With Hypertension BP 180/90. Asymptomatic. No obvious end organ damage Followed sporadically at Baylor Shoulder- to-Shoulder clinic in rural Honduras. Takes antihypertensive medications when she has them. Can’t afford to buy on her own How can she be maintained on chronic antihypertensive medication?

A 55 Year Old Woman With Type 2 Diabetes Mellitus Lives in poverty in rural Honduras BMI 26, active, walks several miles daily Limited food choices (beans and corn tortillas) Fasting FSBS 230 Current meds: sulfonylureas when she can get them No HbA1c, lipid panel, LFTs, urine microalbumin/creatinine tests available

What Are the Major Barriers to Preventing and Treating Chronic Diseases in Resource Poor Settings?

How Can These Barriers Be Overcome?

Implementing the Chronic Care Model in Your Practice: Clinical Practice Guidelines for Decision-support

Implementing the Chronic Care Model in Your Practice:Physician/Patient Reminders, Chronic Disease Registries Last Name, First Name Postal Address City, State, Zip Phone Number (H) Phone Number (W) Best call time Address (with patient’s permission) Primary Care Physician Date of last visit Key Clinical Data (below are examples, keep it simple) For Diabetes Date of last foot exam Date of last eye exam Last BP and date Last HbA1c and date Last LDL and date Latest Self Mgmt goal and date