The Effects of Globalisation on Cardiovascular Disease in India. Prof. K. Srinath Reddy President Public Health Foundation of India New Delhi, India

Transcription

1 The Effects of Globalisation on Cardiovascular Disease in India Prof. K. Srinath Reddy President Public Health Foundation of India New Delhi, India

2 Global Deaths by Cause (1000s) HIV/AIDS TB Malaria CVD Cancer Chronic Respiratory Diabetes Preventing chronic diseases : a vital investment : WHO global report

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4 Increasing CHD in India Prevalence (%) CVD Deaths Urban Rural Number of deaths (millions) Cardiovascular diseases Gupta R. CSI Cardiology Update. Ed. Manjuran RJ. 2003

5 YEARS OF LIFE LOST DUE TO CVD IN POPULATIONS Aged Years India China Russia USA PPYLL IN 2030 PPYLL IN 2000 S. Africa Portugual NUMBER IN MILLIONS PPYLL= Potentially Productive Years of Life Lost

6 Individual Susceptibility (genes; fetal and early life programming) Urban-Rural & Migrant Studies; Time Frame of Transition Environment Cardiovascular Disease

7 INTERHEART STUDY About 90% of CHD Risk ( PAR ) can be explained by 9 Risk Factors: Smoking Dyslipidemia ( Apo A/ Apo B Ratio) High BP Diabetes Abdominal Obesity Psychosocial Factors Fruits & Vegetables Exercise Alcohol

8 GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL Development (stage and speed) Distribution (equity) Demand- Supply (trade) Perceptions (cultural) Priorities (socio-economic) Pathways (availability, access) Beliefs Behaviours Biology

9 From Global Policy to Individual Health Global : - Trade Policies (insensitive to public health) Nations : - Caged Policies (due to debt trap) - Limited Resources (inadequate health system response) Individuals : - Illusory Choices (limited availability, affordability and access) Information Gaps (limited health literacy) CARDIOVASCULAR DISEASE

10 THE POOR AMONG COUNTRIES AND THE POOR WITHIN COUNTRIES ARE INCREASINGLY THE VULNERABLE VICTIMS OF THE ADVANCING GLOBAL CVD EPIDEMICS

11 SES GRADIENT:ORDER OF REVERSAL FOR CVD RISK FACTORS Tobacco Blood Pressure Plasma Cholesterol Physical Activity Obesity Health Transition Reddy KS et al (PNAS, 2007)

12 The Nutrition Transition in Developing Countries Shift in diet structure towards a high fat and refined sugar Western Diet Accelerating rate of change in diet Shift in activity patterns Link between diet and activity changes and increases in obesity Popkin, 2001

13 Globalisation and CVD: The Case of Edible Oils Cheap and plentiful edible oil a major source of increased energy intake and a key contributor to obesity in the developing world (Drewnowski and Popkin, 1997). Many of the edible oils consumed are quite unsafe for human health and are linked with direct effects on a range of cancers and heart disease.

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15 Trade Policy in India Edible Oils Despite accounting for 9.3% of world oilseed production, about 43% of edible oil in India is imported. India is the second-biggest buyer of vegetable oils after China Liberalization policies adopted in India 1994 Edible Oil first partially de-canalized; no longer in the negative list of imports March 1994 Import of refined palm oil put under OGL (open general license: when the item can be imported without seeking any approval). April 1995 Other edible oils put under OGL. Originally, duty on both refined and non-refined edible oil was 65 per cent slashed to 30%, then to 20% (1996) and 15% ( ). December 1999 Duty on refined oil fixed at 27.5% and that on crude oil fixed at 16.5% 2008 Current duty on refined oil is 7.5% and that on crude oil is zero

16 Rising Consumption of Edible Oils in India Consumption (in tonnes) Consumption (Kg/capita/yr) Consumption (kcal/capita/day) 3.9 mill ton 5.8 mill ton 10.5 mill ton Source: FAOSTAT, Food and Agricultural Organization, The UN, 2008

17 URBANIZATION: WEIGHT GAIN + BULGING BELLY Category Urban (Delhi) (% prevalence) Rural (Haryana) (% prevalence) Male Female Male Female Overweight (BMI 25) Overweight (BMI 23) Central Obesity (Age Group = years; Period = ) Reddy et al, Obesity Reviews (2002)

18 Stages of the Nutrition Transition Urbanization, economic growth, technological changes for work, leisure, & food processing, mass media growth Pattern 3 Receding Famine Pattern 4 Degenerative Disease Pattern 5 Behavioral Change starchy, low variety, low fat,high fiber labor-intensive work/leisure increased fat, sugar, processed foods shift in technology of work and leisure reduced fat, increased fruit, veg,cho,fiber replace sedentarianism with purposeful changes in recreation, other activity MCH deficiencies, weaning disease, stunting obesity emerges, bone density problems reduced body fatness, improved bone health Slow mortality decline accelerated life expectancy, shift to increased DR-NCD, increased disability period extended health aging, reduced DR-NCD Source: Popkin, Public Health Nutrition, 2002

19 Diabetes, strokes, heart disease, cancers arthritis The impact of inappropriate Western diets on most of the world's susceptible populations: health systems already overwhelmed Inadequate health care system Reduced fertility; CVD, HT Cancers Elderly Early onset Type 2 Diabetes Reduced capacity to care for baby Disordered foetal nutrition Woman o/w or obese Pregnancy Glucose intolerance/ diabetes Fat Baby High Birth Weight Rapid Abdominal obesity Inadequate obstetric care Normal/high growth weight gain Adolescent O/W-obese Reduced job opportunities Child overweight Untimely / inadequate Early Weaning Frequent fast foods Poor school conditions Inadequate physical activity Reduced play and social isolation Adapted by James, 2008 from James et al. SCN Millennium Rep. Food & Nutrition Bulletin, 2000, 21, 3S.

20 Nutritional profiling determining government policies throughout the food chain Who controls the food chain? Family and other small food companies Global Feed Companies Farmers (large Government subsidies) Global Food Companies Local markets, roadside stalls and farm shops Small food outlets Supermarkets: the "food consuming industry" GENERAL POPULATION Source: (From James, 2008) Corinna Hawkes, 200

21 Societal policies and processes influencing the population prevalence of obesity INTERNATIONAL FACTORS NATIONAL/ REGIONAL COMMUNITY LOCALITY WORK/SCHOOL /HOME INDIVIDUAL POPULATION Transport Public Transport Leisure Activity/ Facilities Globalisation of markets Development Media programs & advertising Urbanization Health Social security Media & Culture Education Public Safety Health Care Sanitation Manufactured/ Imported Food Labour Infections Worksite Food & Activity Family & Home Energy Expenditure Food intake : Nutrient density % OBESE AND OVER-- WEIGHT Food & Nutrition Agriculture/ Gardens/ Local markets School Food & Activity National perspective Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipathies V. IOTF website 1999:

22 INTERNATIONAL AGENCIES; TRANS-NATIONAL TRADE AND MEDIA GLOBAL COVENANTS, COMMERCE & COMMUNICATIONS NATIONAL POLICY FRAME WORK Political, Economic, Social Motivators MOULDING THE MARKETS INDUSTRY PRACTICES CONSUMER CONCIOUSNESS Health Professionals, Civil Society; Media Private-Public Partnerships; Health Dividend

23 COMMUNICATION TO CONSUMERS; MIS-MATCH BETWEEN SCIENCE AND COMMERCE Occasional Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candy Fast food (Burgers, pizzas etc.) IN MODERATION PLENTY NUTRITION PYRAMID?? ADVERTISING PYRAMID

24 Data from healthy, educated, urban employed Indians using comprehensive physical activity questionnaires, indicate that 61 % of males and 51 % of females are either sedentary or mildly active (Vaz and Bharathi, Indian Heart Journal, 2000) The PURE (Prospective Urban Rural Epidemiology) study- There are variable differences in dietary intakes, physical activity patterns and prevalence of chronic diseases among urban and rural populations. There is some evidence of positive behavioral shift in higher SES urban for adopting more physically active lifestyles. In rural areas with a high penetration of urban influences, degenerative phase of nutrition transition is well underway (Vaz et al, SAJCN, 2005)

25 Upside of Globalisation Shared knowledge Changing stereotypes and role models Increased Global cooperation and joint action towards health goals etc. Sharing of technologies, drugs, devises etc.

26 Some Barriers Proprietary science Commercially motivated use of technology

27 Implications for the future.. Both genetic, physiological as well as environmental factors involved, but latter most evident and changeable Biomedical and epidemiological research contribute to knowledge but are incomplete because they exist in silos Scope for more transdisciplinary research on Gene-Environment interactions

28 TRADITIONAL WAY OF LIVING MODERN WAY OF LIVING POST-MODERN WAY OF LIVING NEGATIVE IMPACT OF URBANIZATION - GLOBALISATION POSITIVE IMPACT OF URBANIZATION - GLOBALISATION PRESERVING CV HEALTH UNDERMINING CV HEALTH PROMOTING CV HEALTH

29 Policy Needs: Interdisciplinary Research Enlightened policy needs Scientific credibility (evidence & rationale?) Financial feasibility (cost effective? affordable?) Operational stability (sustainable? scalable?) Political viability (is the community ready & receptive?) Aided by Biomedical & Epidemiological research Health economics research Health systems research Social sciences research