The Drivers of Non- Communicable Diseases

Transcription

1 The Drivers of Non- Communicable Diseases Susan B. Shurin, MD NCI Center for Global Health Consortium of Universities for Global Health, Boston MA 27 March 2015

2 Declaration of Interests For the past decade, I have been employed by the National Institutes of Health : NHLBI as a federal employee 2014-present: NCI as a contractor Before that, I was a Professor of Pediatrics and Oncology at Case Western Reserve University in Cleveland I have no financial conflicts, and pitifully few financial interests I will not be discussing treatment of anything 2

3 NCDs: Non-Communicable Diseases A. Are chronic diseases which produce substantial disability with economic and social costs & contribute to premature death B. Are often communicable (some cancers, lung & heart diseases have infectious causes; obesity spreads through social networks) C. Is a term now used to refer to cardiovascular & pulmonary disease, diabetes & cancer, with overlapping causal factors D. Does not include mental, neurologic or substance abuse, violence, trauma, inherited diseases 3

4 Causes of death globally 4

5 India Leading Causes of Death in the 21 st Century China 1. Coronary heart disease 1. Stroke 2. Diarrheal diseases 2. Lung disease 3. Lung disease 3. Coronary heart disease 4. Stroke 4. Lung cancer 5. Influenza & pneumonia 5. Liver cancer 5

6 Focus of This Discussion: Gaps What DO we know about NCDs? Major contributors to DALYS and premature (<70 years) death worldwide Environmental factors contribute heavily Nutrition Pollution of air & water Behaviors with profound biological, social &emotional context What do we NEED to know to take intelligent action? How to engage sectors other than the health care system in matters of health How to assess and project economic impact How to run health care systems How to improve nutrition, make people stop smoking, polluting and drinking to excess 6

7 Causation Pathway for Chronic Non-communicable Disease Environmental risk factors Behavioral risk factors Biological risk factors Chronic noncommunicable disease Globalisation Tobacco use High blood glucose Heart disease Urbanisation Unhealthy diet High blood pressure Stroke Poverty Physical Abnormal serum Cancer Low education inactivity lipids Chronic lung disease Stress High waist-hip Type 2 Diabetes ratio/obesity Adapted from: The Lancet 2011; 377:

8 Developmental Origins of Chronic Disease Hanson M, Gluckman P. Am J Clin Nutr. 2011;94:1754S-1758S 8

9 Obesity: About 3.6% of the global burden of cancer is attributable to high BMI Males BMI>25 kg/m 2 associated with increased risk of cancer Assumed 10-year lag between high BMI and cancer occurrence, numbers of new cancer cases attributable to high BMI estimated Globally 3.6% of all new cancers associated with excess BMI (1.9% in men; 5.4% in women). Females 9 Arnold M et al., Lancet Oncol, 2014

10 About 15.3% of Global burden of cancer is attributable to infectious agents Sub-Saharan Africa 31.3 Eastern Asia 22.7 Central Asia 19.2 Pacific Islands 19.2 Total world 15.3 Southern America Northern Africa and Western Asia Europe Helicobacter pylori Hepatitis B/C Virus Human PapillomaVirus Other infectious agents Northern America Australia / New Zealand Updated from de Martel et al. Lancet Oncol

11 Epidemiology Gaps Scientific Gaps Detailed incidence and prevalence data in countries Geography Gender Socioeconomic status Ethnicity Genetic/genomic factors specific to a population Specific exposure factors Environmental Behavioral/cultural Some Possible Approaches Improved surveillance and reporting Risk factors Diseases Population-level genomic studies Population-level data on exposures across time Air, water, food quality Alcohol, tobacco, substance use Infectious agents associated with disease: Hep B/C, papillomavirus, H. pylori, HIV Nutritional data 11

12 Pathophysiology Gaps Scientific Gaps Mechanisms of geneticexposure interactions Molecular impact of multiple environmental exposures on cells/organs Life course issues: levels of exposures, nutritional factors, across the entire life cycle and generations Some Possible Approaches Valid animal models for development of human disease across lifespan Effective measures of exposure of individuals and populations Measures of nutritional status across development Measures of body composition (leanness, fat) of individuals & populations 12

13 Primary Prevention Gaps Scientific Gaps Optimal nutrition Undernutrition Overnutrition Micronutrient deficiency Lifecourse issues underfeeding girls Reduce toxic environmental exposures Decrease tobacco in LMICs Vaccine prevention of cancers Some Possible Approaches Develop better biomarkers of nutritional status Develop better biomarkers of environmental exposures Economic & cultural studies of tobacco markets, determinants of use Economic and cultural studies on use of vaccines against hepatitis & papillomavirus 13

14 Prevention works but takes time lung and cervix Lung, men Cervix uteri 14

15 Secondary Prevention Gaps Scientific Gaps Cancer: How to best use early detection to minimize morbidity and mortality CVD: Population approaches to management of hypertension, cholesterol T2DM: Population approaches to management of obesity and T2DM Pulmonary: effective approaches to smoking cessation Some Possible Approaches Cancer: Develop better data on screening for breast & prostate cancer who, when, how integrate screening for cervical, oral & colorectal cancer into care systems CVD, lung, T2DM: better interventions in the health care system and social supports for interventions 15

16 Cultural and Behavioral Gaps Scientific Gaps How to effectively change the behavior of individuals in society Prevention & management of addictive substances such as tobacco & alcohol Cultural issues in diet, food preparation, use of psychoactive substances (nicotine, alcohol, others) Some Possible Approaches Realistic examination of relative impact of interventions targeted at economics, cultural & individual behaviors. Understand biology of addiction Understand cultural aspects of foods, cooking practices, psychoactive substances 16

17 Treatment Gaps Scientific Gaps Scaling & implementing therapies of varying efficacy and impact How to build effective health systems to facilitate primary & secondary prevention &treatment How to encourage investments of known high impact which don t make a profit Some Possible Approaches Build global capacity in implementation science Coordinated global programs in health care delivery with meaningful short and long-term outcomes. Engagement of politicians & advocates in setting research priorities 17

18 Some system issues to consider: funding Research on prevention, public health & implementation of knowledge is relatively neglected. Not sexy Doesn t pay off quickly Pays off in costs avoided, not in profits Those most likely to benefit are poor, voiceless, & often have short term concerns Requires a team 18

19 Some system issues to consider: setting priorities Biomedical researchers tend to focus on health care systems. Many of the causes of NCDs are outside the health care system. Other economic sectors see changes as likely to cut into profits by decreasing revenue or increasing costs. Politicians are not rewarded for advancing the common good. 19

20 Resources matter: CVD in the U.S Accidental Injuries Heart Disease Cancer Stroke Age-adjusted death rates from heart disease and stroke have fallen >30% since 1950 Multiple factors contribute 0 Alzheimer s Data source: New York Times, April 24,

21 Less Pollution = Better Lungs Levels of Pollutants/time Children s Lung Function Gauderman WJ et al. N Engl J Med 2015;372:

22 Leadership matters! NYC banned : Smoking in commercial establishments 2011: Smoking in public spaces 2013: Cigarette sales to those under : Sales of "flavored" tobacco products 2013: Smoking e-cigarettes in public spaces 2013: Cigarette in-store displays 2010: High Sodium levels in processed foods : Illegal guns 2006: Trans-fats in restaurants 2013: Commercial music over 45 decibels 2013: Loud headphones 2012: Sodas larger than 16 ounces 2008: Chain restaurant menus without calorie counts 2013: Non-hurricane-proof buildings in coastal areas Under Mayor Bloomberg 22

23 For Discussion How can the biomedical research community take leadership addressing NCDs? Be objective about what we know? Communicate risks and uncertainties? Engage other sectors in research? Share control of research priority-setting? 23

24 Center for Global Health (CGH) Contact Information Website: Telephone number: h.gov Twitter Street address: 9609 Medical Center Drive, Rockville, MD (near Shady Grove Adventist Hospital) 24

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