Faculty of Medicine. Lecture 17 The global health impact of Cardiovascular Diseases, Diabetes and Obesity. Hatim Jaber MD MPH JBCM PhD

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Faculty of Medicine الصحة العامة (31505291) Health Public Lecture 17 The global health

1 Faculty of Medicine الصحة العامة ( ) Health Public Lecture 17 The global health impact of Cardiovascular Diseases, Diabetes and Obesity By Hatim Jaber MD MPH JBCM PhD

2 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

3 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

% DALYs, by broad cause group 1990-2020 in Developing Countries (baseline scenario) 50 1990 2020 25 DALY = Disability adjusted life-year Communicable

4 % DALYs, by broad cause group in Developing Countries (baseline scenario) DALY = Disability adjusted life-year Communicable diseases, maternal and perinatal conditions and nutritional deficiencies Injuries Noncommunicable conditions Source: WHO, Evidence, Information and Policy, 2000

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6 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. 6

7 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

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9 Reasons For Worldwide Increase In Cardiovascular Disease Malnutrition Infection Smoking BMI

10 CVDs are responsible for over 17.3 million deaths per year and are the leading causes of death in the world 10

11 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 lowand 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. 11

12 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 12

13 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 agegroup of years - Premature death (<64 years of age, or years): in the elderly population more difficult to interpret death rate due to multiple ill health causes 13

14 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) 14

15 Percent of Population Prevalence of Coronary Heart Diseases by Age and Sex NHANES : Ages Men Women Source: CDC/NCHS and NHLBI. 15

17 CVD in Men and Women CVD mortality in men is holding steady; in women it is increasing Women have comparable CVD rates about 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 17

18 Deaths due to heart attacks, strokes and other types of CVDs as a proportion of total cardiovascular deaths for males and females 18

19 Descriptive Epidemiology TIME and PLACE SDR: Standardized Death Rate Premature death rates for comparison purposes (<64 years of age) 19

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21 Descriptive Epidemiology World Trends Developed countries: decreasing tendencies (e.g, USA: 30% between , 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

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Cardiovascular disease in Europe: epidemiological update 2016 Descriptive Epidemiology International Comparisons Nick Townsend, Lauren Wilson, Prachi Bhatnagar, Kremlin

23 Cardiovascular disease in Europe: epidemiological update 2016 Descriptive Epidemiology International Comparisons Nick Townsend, Lauren Wilson, Prachi Bhatnagar, Kremlin Wickramasinghe, Mike Rayner, Melanie Nichols; Cardiovascular disease in Europe: epidemiological update Eur Heart J 2016; 37 (42): doi: /eurheartj/ehw334 23

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25 NCD deaths by cause in some Arab countries 25

26 NCD deaths by cause in some Arab countries 26

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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.

28 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 28

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30 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. 30

31 Other Recognized Risk Factors 1. Obesity: Body Mass Index (BMI) Weight (kg)/height (m 2 ) Weight (lb)/height (in 2 ) x 703 Obesity BMI >30 kg/m 2 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 31

32 "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. 32

33 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 , Copyright 2008 American Heart Association, Inc. All rights reserved. 33

34 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 34

35 Risk Factor Concepts in Primary Prevention 1. Nonmodifiable risk factors include age, sexc, race, and family history of CVD, which can identify highrisk 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. 35

36 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. 36

37 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 37

38 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.. 38

39 Global action plan for the prevention and control of NCDs 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

40 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. 40

41 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 secondhand smoke reduce the cardiovascular risk and thereby help to prevent CVDs. 41

42 The Decrease in CVD Mortality 25% is due to primary prevention 75% is due to behavioral changes affecting risk factors or improvements in treatment 42

43 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

44 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

46 Emerging Risk Factors Lipoprotein (a) Homocysteine Prothrombotic factors Proinflammatory factors Impaired fasting glucose Subclinical atherosclerosis 46

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48 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 48

49 World Health Day 2016: Beat diabetes World Diabetes Day 2016 World Diabetes Day November

51 Global burden of diabetes Globally, an estimated 422 million adults were living with diabetes in 2014, compared to 108 million in 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.

52 Global burden of diabetes Diabetes caused 1.5 million deaths in 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

53 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

54 VOLUNTARY GLOBAL TARGETS FOR PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES TO BE ATTAINED BY2025

55 PERCENTAGE OF ALL-CAUSE DEATHS ATTRIBUTED TO HIGH BLOOD GLUCOSE, BY AGE AND COUNTRYINCOME GROUP, a 2012(A) MEN, (B) WOMEN

56 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

57 In million adults had diabetes HIGH BLOOD GLUCOSE AGE-STANDARDIZED MORTALITY RATES PER BY WHO REGION, AGE 20+

58 ESTIMATED PREVALENCE AND NUMBER OF PEOPLE WITH DIABETES (ADULTS 18+ YEARS) Diabetes prevalence has doubled since 1980

59 TRENDS IN PREVALENCE OF DIABETES, , BY COUNTRY INCOME GROUP

60 TRENDS IN PREVALENCE OFDIABETES, , BY WHO REGION

61 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

62 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

63 Obesity/Unhealthly Lifestyles

64 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

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

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

69 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]

70 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)

73 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

74 Dementia = type 3 diabetes Risk of incident dementia by baseline glucose (no diabetes) Source: Crane et al NEJM :6 (pp540-8)

75 Coronary mortality (deaths per 100,000) as a function of saturated fat intake Source: Kromhout et al Seven Countries Study, 1995 Prev Med

Sleep, Obesity and T2 Diabetes 43% increased risk of incident diabetes for every quartile of Obstructive Sleep Apnea severity (Botros, 2009) 125-193% Risk

76 Sleep, Obesity and T2 Diabetes 43% increased risk of incident diabetes for every quartile of Obstructive Sleep Apnea severity (Botros, 2009) % Risk of future obesity in short sleepers (Gangwisch 2005) % Greater risk of short sleepers for developing type 2 diabetes (Gangwisch 2007 & Gottlieb 2005)

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.

77 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

Faculty of Medicine. Lecture 16 The global health impact of Cardiovascular Diseases, Diabetes and Obesity. Hatim Jaber MD MPH JBCM PhD

Faculty of Medicine. Lecture 16 The global health impact of Cardiovascular Diseases, Diabetes and Obesity. Hatim Jaber MD MPH JBCM PhD Faculty of Medicine الصحة العامة (31505291) Health Public Lecture 16 The global health impact of Cardiovascular Diseases, Diabetes and Obesity By Hatim Jaber MD MPH JBCM PhD 12-7-2017 1 1. The global health