Faculty of Medicine

Public Health (31505291) العامةالصحة Lecture 17

The global health impact of Cardiovascular Diseases , Diabetes and Obesity

By

Hatim Jaber MD MPH JBCM PhD

30 - 7-2018

1

1. The global health impact of mental health and mental diseases. Drug abuse and Addictive substances

1. Global overview of communicable diseases 2. Global overview Non- Communicable Diseases(NCDs) 3. The global health impact of Hepatitis, Tuberculosis and HIV/AIDS

4. The global health impact of Cardiovascular Diseases , Diabetes and Obesity

1. Health service delivery in developing countries 2. Health policy, Health priorities 3. Health systems and financing 4. Quality of care and effectiveness in different health services systems; 5. Health policies and management within a global health perspective 1. Violence and Injuries 2. Migration and Travelers' health

Presentation outline

Time

Introduction of concepts 09:15 to 09:25

Epidemiology of CVD: globally and locally

09:25 to 09:35

Epidemiology of Diabetes : globally and locally

09: 35 to 09:40

Epidemiology of obesity : globally and locally

09:40 to 09:50

Prevention strategies 09:50 to 10:15

3

25

50

%

Communicable diseases,

maternal and perinatal

conditions and nutritional

deficiencies

Injuries

DALYs, by broad cause group 1990 - 2020

in Developing Countries (baseline scenario)

DALY = Disability

adjusted life-year

1990

2020

Source: WHO, Evidence, Information and Policy, 2000

Noncommunicable

conditions

5

The different types of CVDs

1. CVDs due to atherosclerosis: • ischaemic heart disease or coronary artery disease (e.g.

heart attack) • cerebrovascular disease (e.g. stroke) • diseases of the aorta and arteries, including hypertension

and peripheral vascular disease. 2. Other CVDs • congenital heart disease • rheumatic heart disease • cardiomyopathies • cardiac arrhythmias.

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Public Health Significance

- Leading cause of mortality in developed countries and a rising tendency in developing countries (disease of civilization)

- A major impact on life expectancy

- Significantly contributes to morbidity and death rates in the middle aged population:

- potential life years lost,

- common cause of premature death,

- labor force (economic costs),

- family life

- Morbidity: nearly 30% of all disability cases

- Contributes to deterioration of the quality of life 7

8

Reasons For Worldwide Increase

In Cardiovascular Disease

Malnutrition

Infection

Smoking

BMI

CVDs are responsible for over 17.3 million deaths per year and are the leading causes of death in the world

10

Descriptive Epidemiology I. Distribution Patterns in the World---KEY FACTS

• CVDs are the number 1 cause of death globally: more

people die annually from CVDs than from any other cause.

• An estimated 17.5 million people died from CVDs in 2012, representing 31% of all global deaths. Of these deaths, an estimated 7.4 million were due to coronary heart disease and 6.7 million were due to stroke .

• Over three quarters of CVD deaths take place in low- and middle-income countries.

• Out of the 16 million deaths under the age of 70 due to noncommunicable diseases, 82% are in low and middle income countries and 37% are caused by CVDs.

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KEY FACTS • Most cardiovascular diseases can be prevented by

addressing behavioral risk factors such as: • tobacco use, • unhealthy diet and obesity, • physical inactivity • and harmful use of alcohol using population-wide

strategies. • People with cardiovascular disease or who are at high

cardiovascular risk (due to the presence of one or more risk factors such as hypertension, diabetes, hyperlipidaemia or already established disease) need early detection and management using counseling and medicines, as appropriate

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Descriptive Epidemiology . AGE

Question: What is the relative amount of CVD in death rates in different age groups?

- Early lesions of blood vessel, atherosclerotic plaques: around 20 years - adult lifestyle patterns usually start in childhood and youth (smoking, dietary habits, sporting behavior, etc.)

- Increase in CVD morbidity and mortality: in age-group of 30-44 years

- Premature death (<64 years of age, or 25-64 years): in the elderly population more difficult to interpret death rate due to multiple ill health causes

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Descriptive Epidemiology SEX Question: What is the relative amount of CVD in death rates

in women and men?

- Widespread idea: CVD is often thought to be a disease of middle-aged men.

- Cardiovascular mortality (fatal cases) are more common among men. However, CVD affect nearly as many women as men, albeit at an older age

Women: special case (WHO, 2004)

a., Higher risk in women than men (smoking, high triglyceride levels)

b., Higher prevalence of certain risk factors in women (diabetes mellitus, depression)

c., Gender-specific risk factors (risks for women only) (oral contraceptives, hormone replacement therapy, polycystic ovary syndrome)

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Prevalence of Coronary Heart Diseases by Age and Sex NHANES :1999-2002

Source: CDC/NCHS and NHLBI.

0.01.4

3.0

16.8

0.31.6

3.6

11.611.5

6.3

10.3

0.20

5

10

15

20

20-34 35-44 45-54 55-64 65-74 75+

Ages

Pe

rc

en

t o

f P

op

ula

tio

n

Men Women

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CVD in Men and Women

• CVD mortality in men is holding steady; in women it is increasing

• Women have comparable CVD rates about 10-15 years later than men, but the gap diminishes with age

• 82% of coronary events in women are attributable to unhealthy diet, lack of activity, cigarette use, and overweight

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Deaths due to heart attacks, strokes and other types of CVDs as a proportion of total cardiovascular deaths for

males and females

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Descriptive Epidemiology TIME and PLACE

SDR: Standardized Death Rate

Premature death rates for comparison purposes (<64 years of age)

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Descriptive Epidemiology World Trends

Developed countries: decreasing tendencies (e.g, USA: 30% between 1988-98, Sweden: 42%)

- improvement of lifestyle factors, for example, a decrease of smoking and a higher level of health consciousness in many developed countries

- better diagnostic and therapeutic procedures (e.g., bypass surgeries, hypertension screening, pharmacological treatment of hypertension and hypercholesterinaemia, access to health care)

Developing countries: increasing tendencies

- increasing longevity, urbanization, and western type lifestyle

21

22

Cardiovascular disease in Europe: epidemiological update 2016

Nick Townsend, Lauren Wilson, Prachi Bhatnagar, Kremlin Wickramasinghe, Mike Rayner, Melanie Nichols; Cardiovascular disease in Europe: epidemiological update 2016. Eur Heart J 2016; 37 (42): 3232-3245. doi: 10.1093/eurheartj/ehw334 23

Descriptive Epidemiology

International Comparisons

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NCD deaths by cause in some Arab countries

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NCD deaths by cause in some Arab countries

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Global distribution of CVD mortality rates in males (A) and females (B), age-standardized per 100,000.

Chapter: Epidemiology and prevention of cardiovascular disease Author(s): Nathan D. Wong From: Oxford Textbook of Global Public Health (6 ed.) Downloaded from Oxford Medicine Online.Reproduced with permission from Mendis S, Puska P, and Norrving B (eds), Global Atlas on Cardiovascular Disease Prevention and Control, World Health Organization, Geneva, Switzerland, Copyright © 2011, available from

http://www.who.int/cardiovascular_diseases/publications/atlas_cvd/en/. 28

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Major Risk Factors

• Cigarette smoking (passive smoking?)

• Elevated total or LDL-cholesterol

• Hypertension (BP 140/90 mmHg or on antihypertensive medication)

• Low HDL cholesterol (<40 mg/dL)†

• Family history of premature CHD

– CHD in male first degree relative <55 years

– CHD in female first degree relative <65 years

• Age (men 45 years; women 55 years)

† HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.

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Other Recognized Risk Factors

1. Obesity: Body Mass Index (BMI)

– Weight (kg)/height (m2)

– Weight (lb)/height (in2) x 703

• Obesity BMI >30 kg/m2 with overweight defined as 25-<30 kg/m 2

• Abdominal obesity involves waist circumference >40 in. in men, >35 in. in women

2. Physical inactivity: most experts recommend at least 30 minutes moderate activity at least 4-5 days/week

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"the causes of the causes”

• There are also a number of underlying determinants of CVDs or "the causes of the causes".

• These are a reflection of the major forces driving social, economic and cultural change – globalization, urbanization and population ageing.

• Other determinants of CVDs include poverty, stress and hereditary factors.

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Estimated 10-year CHD risk in 55-year-old adults according to levels of various risk factors: Framingham Heart Study.

Chapter: Epidemiology and prevention of cardiovascular disease Author(s): Nathan D. Wong From: Oxford Textbook of Global Public Health (6 ed.) Downloaded from Oxford Medicine Online.Source: data from Wilson PWF et al., Prediction of Coronary Heart Disease Using Risk Factor Categories, Circulation, Volume 97, pp. 1837–1847, Copyright © 2008 American Heart Association, Inc. All rights reserved. 33

Approaches to Primary and Secondary Prevention of CVD

• Primary prevention involves prevention of onset of disease in persons without symptoms.

• Primordial prevention involves the prevention of risk factors causative o the disease, thereby reducing the likelihood of development of the disease.

• Secondary prevention refers to the prevention of death or recurrence of disease in those who are already symptomatic

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Risk Factor Concepts in Primary Prevention

1. Nonmodifiable risk factors include age, sexc, race, and family history of CVD, which can identify high-risk populations

2. Behavioral risk factors include sedentary lifestyle, unhealthful diet, heavy alcohol or cigarette consumption.

3. Physiological risk factors include hypertension, obesity, lipid problems, and diabetes, which may be a consequence of behavioral risk factors.

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Population vs. High-Risk Approach

• Risk factors, such as cholesterol or blood pressure, have a wide bell-shaped distribution, often with a “tail” of high values.

• The “high-risk approach” involves identification and intensive treatment of those at the high end of the “tail”, often at greatest risk of CVD, reducing levels to “normal”.

• But most cases of CVD do not occur among the highest levels of a given risk factor, and in fact, occur among those in the “average” risk group.

• Significant reduction in the population burden of CVD can occur only from a “population approach” shifting the entire population distribution to lower levels.

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Materials Developed for Community Intervention Trials

• Mass media, brochures and direct mail • Events and contests

• Screenings • Group and direct education • School programs and worksite interventions • Physician and medical setting programs • Grocery store and restaurant projects • Church interventions • Policies

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How can the burden of cardiovascular diseases be reduced

• “Best buys” or very cost effective interventions that are feasible to be implemented even in low-resource settings have been identified by WHO for prevention and control of cardiovascular diseases.

• They include two types of interventions: population-wide and individual,

which are recommended to be used in combination to reduce the greatest cardiovascular disease burden.

• Examples of population-wide interventions that can be implemented to reduce CVDs include:

• - comprehensive tobacco control policies

• - taxation to reduce the intake of foods that are high in fat, sugar and salt

• - building walking and cycle paths to increase physical activity

• - strategies to reduce harmful use of alcohol

• - providing healthy school meals to children.

• .

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Global action plan for the prevention and control of NCDs 2013-2020

• The sixth target in the Global NCD action plan calls for 25% reduction in the global prevalence of raised blood pressure. Raised blood pressure is one of the leading risk factors of cardiovascular disease

• Reducing the incidence of hypertension by implementing population-wide policies to reduce behavioural risk factors, including harmful use of alcohol, physical inactivity, overweight, obesity and high salt intake, is essential to attaining this target

• The eighth target in the Global NCD action plan states at least 50% of eligible people should receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes. Prevention of heart attacks and strokes through a total cardiovascular risk approach is more cost-effective than treatment decisions based on individual risk factor thresholds only and should be part of the basic benefits package for pursuing universal health coverage..

• In 2015, countries will begin to set national targets and measure progress on the 2010 baselines reported in the "Global status report on noncommunicable diseases 2014". The UN General Assembly will convene a third high-level meeting on NCDs in 2018 to take stock of national progress in attaining the voluntary global targets by 2025.

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primary prevention

The worldwide potential for primary prevention of most CVD is established by several salient facts:

• (a) the large population differences in CVD incidence and death rates; CVD is rare in many countries and common in others;

• (b) dynamic national trends in CVD deaths, both upward and downward;

• (c) rapid changes in CVD risk among migrant populations;

• (d) the identification of modifiable risk characteristics for CVD among and within populations; and

• (e) the positive results of preventive trials.

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Tobacco: The totally avoidable risk factor of CVDs

KEY MESSAGES

• Tobacco use is a principal contributor to the development of heart attacks, strokes, sudden death, heart failure, aortic aneurysm and peripheral vascular disease.

• Smoking cessation and avoidance second-hand smoke reduce the cardiovascular risk and thereby help to prevent CVDs.

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The Decrease in CVD Mortality

• 25% is due to primary prevention

• 75% is due to behavioral changes affecting risk factors or improvements in treatment

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Benefits of Risk Factor Reduction

• 50-70% lower risk in former vs current smokers within 5 years of cessation

• 2-3% decline in risk for each reduction of 1% serum cholesterol

• 2-3% decline in risk for each reduction of 1 mm Hg in diastolic blood pressure

• 35-55% lower risk for those who maintain desirable body weight as compared to those 20%+ above

43

Benefits of Risk Factor Reduction

• 45% lower risk for those who maintain an active lifestyle compared with a sedentary lifestyle

• 35% lower risk in aspirin users compared with nonusers

44

Emerging Risk Factors

• Lipoprotein (a)

• Homocysteine

• Prothrombotic factors

• Proinflammatory factors

• Impaired fasting glucose

• Subclinical atherosclerosis

46

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Cardiovascular disease (including heart attacks and stroke) is the world's biggest killer. The good news? WE CAN reduce the risk through: -Protecting people from tobacco smoke -Healthy diets -Physical activity -Avoiding harmful use of alcohol

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World Health Day 2016: Beat diabetes

• World Diabetes Day 2016

World Diabetes Day 2016- 14 November

Global burden of diabetes

• Globally, an estimated 422 million adults were living with diabetes in 2014, compared to 108 million in 1980.

• The global prevalence (age-standardized) of diabetes has nearly doubled since 1980, rising from 4.7% to 8.5% in the adult population. This reflects an increase in associated risk factors such as being overweight or obese.

• Over the past decade, diabetes prevalence has risen faster in low- and middle-income countries than in high-income countries.

Global burden of diabetes

• Diabetes caused 1.5 million deaths in 2012. Higher-than-optimal blood glucose caused an additional 2.2 million deaths, by increasing the risks of cardiovascular and other diseases.

• Forty-three percent of these 3.7 million deaths occur before the age of 70 years.

• The percentage of deaths attributable to high blood glucose or diabetes that occurs prior to age 70 is higher in low- and middle-income countries than in high-income countries

Global burden of diabetes

• Overweight and obesity are the strongest risk factors for type 2 diabetes

• Diabetes can damage the heart, blood vessels, eyes, kidneys and nerves, leading to disability and premature death

• People with diabetes are more likely to incur catastrophic personal health expenditure

• Diabetes is 1 of 4 priority NCDs targeted by world leaders

VOLUNTARY GLOBAL TARGETS FOR PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES TO BE

ATTAINED BY2025

PERCENTAGE OF ALL-CAUSE DEATHS ATTRIBUTED TO HIGH BLOOD GLUCOSE, BY AGE AND COUNTRYINCOME GROUP, a

2012(A) MEN, (B) WOMEN

43% of all deaths due to high blood glucose occur before the age of 70

In 2014 422 million adults had diabetes

• HIGH BLOOD GLUCOSE AGE-STANDARDIZED MORTALITY RATES PER 100 000 BY WHO REGION,

AGE 20+

ESTIMATED PREVALENCE AND NUMBER OF PEOPLE WITH DIABETES (ADULTS 18+ YEARS)

Diabetes prevalence has doubled since 1980

TRENDS IN PREVALENCE OF DIABETES, 1980–2014, BY COUNTRY INCOME GROUP

TRENDS IN PREVALENCE OFDIABETES, 1980–2014, BY WHO REGION

BURDEN AND TRENDS IN THE COMPLICATIONS OF DIABETES

• Lower limb amputation rates are 10 to 20 times higher among people with diabetes

• Adults with diabetes historically have a two or three times higher rate of cardiovascular disease (CVD) than adults without diabetes

• Diabetic retinopathy caused 1.9% of moderate or severe visual impairment globally and 2.6% of blindness in 2010

• Pooled data from 54 countries show that at least 80% of cases of end-stage renal disease (ESRD) are caused by diabetes, hypertension or a combination of the two

PREVENTING DIABETES

Type 2 diabetes is largely preventable.

• Actions to address overweight and obesity are critical to preventing type 2 diabetes

• Policies that increase the price of foods high in fat, sugar and salt can decrease their consumption

• Interventions that promote healthy diet, physical activity and weight loss can prevent type 2 diabetes in people at high risk

• Much type 2 diabetes results from risk factors that can be reduced using a combination of approaches at population and individual levels

Obesity/Unhealthly Lifestyles

More than1 in 3 adults were overweight and more than 1 in 10 were obese in 2014

• PREVALENCE OFBEING OVERWEIGHT (BMI 25+) IN ADULTS OVER18 YEARS, 2014, BYS EXAND WHO REGION

PREVALENCE OF BEING OVERWEIGHT (BMI 25+) IN ADULTS OVER 18 YEARS, 2014, BY SEX AND COUNTRY

INCOME GROUP

Obesity

• It is estimated by the WHO that globally, over 1 billion (16%) adults are overweight and 300 million (5%) are obese.

The Global Obesity Crisis…

Centers for Disease Control and Prevention has declared that obesity is

the No. 1 health threat in the United States today.

[65 percent of U.S. adults are considered overweight with 38.8 million American adults classified as obese]

Generational transmission of diabesity

• Low birth weight, combined with weight gain in adulthood, increases risk of CVD, diabetes, some cancers

• Maternal obesity amplifies the risk of diabetes in pregnancy, birth defects, childhood obesity and type 2 diabetes

• Maternal obesity increases early death (before age 60) by 35% in the offspring (BMJ 2013)

Various theories : FOOD Global pandemic diabesity since 1980 and

the hunt for culprit foods New foods: cheap calories and processing

• Fats

• Fructose

• Portion size drift

• Availability, affordability and the social gradient

Dementia = “type 3 diabetes” Risk of incident dementia by baseline glucose (no diabetes)

Source: Crane et al NEJM 2013 369:6 (pp540-8)

Coronary mortality (deaths per 100,000) as a function of saturated fat intake

Source: Kromhout et al Seven Countries Study, 1995 Prev Med

0

200

400

600

800

1000

1200

1400

0 5 10 15 20 25

Sleep, Obesity and T2 Diabetes

125-193% Risk of future obesity in

short sleepers (Gangwisch

2005)

50-150% Greater risk of short sleepers for developing type 2

diabetes (Gangwisch 2007 & Gottlieb 2005)

43% increased risk of incident diabetes for every quartile of Obstructive Sleep Apnea severity (Botros, 2009)

Myths: 1. It mostly high income countries 2. Low/Middle income countries should focus

on infectious disease vs. chronic disease 3. It affect mainly rich people 4. It primarily affect older people 5. It primarily affect men 6. It are the results of unhealthy lifestyles 7. Chronic disease cannot be prevented 8. Chronic disease prevention is too expensive 9. 1/2 truths: “my grandfather smoked and

was overweight and he lived to be 96, therefore I do not need to worry

10. Everyone needs to die of something

Reality: 1. FALSE 2. FALSE 3. FALSE 4. FALSE 5. FALSE 6. FALSE 7. FALSE 8. FALSE 9. ½ FALSE 10. True…but ideally not

slowly and painfully