Global Health - Stephen T McGarvey, PhD, MPHProfessor of Epidemiology & AnthropologyDirector, International Health Institute
• Health Transition
• Global Burden of Mortality and Disease
• Overnutrition
• Translational Perspectives & Research
Terms: Epidemiologic Transition
Gaziano 2005
Stage 1 Malnutrition and infectious diseases are the leading causes of mortality and morbidity
Stage 2 Improved nutrition and public health leads to increase in CNCDs
Stage 3 Increased fat and caloric intake, widespread tobacco use, CNCD deaths surpass deaths from infections and malnutrition
Stage 4 CVD and cancer are the leading causes of morbidity and mortality; primary and secondary prevention efforts lead to declines in age-adjusted CVD
Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.
Disability Adjusted Life Years (DALYs)
Mortality – years of life lost due to the disease
Disability - decrease in healthy or functional years of life due to disease or injury (Experts decide based on previous research that some domain of function is reduced by some percent over so many years due to disease/injury.)
DALYs, thus, are estimates of health lost due to death and disability.
Cause-specific Mortality
Population Reference Bureau (Cohn 2007)
Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.
Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.
Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.
Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.
Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.
Unipolar depression – major source of disability in all income groups
Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.
WHO: Facts related to chronic diseases; Yach 2004, Strong 2005
Global Burden of NCDs• Chronic Non-communicable diseases (NCDs) are the
major cause of death and disability worldwide (except in South Asia and Sub-Saharan Africa)
• NCDs now account for 59% of all deaths and 48% of the global burden of disease
• Death rates for NCDs are higher in the developing world compared to the developed world
• Top diseases:– Cardiovascular disease – Cancer– Chronic respiratory diseases– Type 2 Diabetes– Obesity – Mental health and psychiatric conditions
Increase in ‘Dual Burden’ in LMIC• Low and middle income countries (LMIC) are now
and will suffer increasingly from the dual presence of both infectious/communicable diseases and NCDs
• Child survival to age 5 years• TB, HIV, malaria• Adult, esp age 40-80 yrs, hypertension, obesity,
type 2 diabetes, coronary artery disease• Risk behaviors – tobacco use, excess alcohol
use, risky sexual exposures
• Impact on design of health care systems, both clinical and public health
• Need for broader range of clinical specialists, esp for NCDs
Health Inequalities
Health Inequities
Marmot 2005. Social determinants of health inequalities Lancet 365: 1099–104
Leading Causes of Under Five Morbidity & Mortality in Developing World
• Infectious Diseases leading cause of death among children (about half)
• Undernutrition – Potentiating effects on infectious diseases– Related to poor learning and cognitive function
• Perinatal (extreme prematurity, stillbirth etc)
Infectious Diseases in Under 5’s• Many vaccine preventable
– Expanded Program of Immunization (EPI) established 1974– Has significantly reduced polio, neonatal tetanus, and measles
• Parasitic diseases-treatment available for almost all– Malaria major killer in sub-saharan Africa (1 million per year) and
extensive morbidity extensive ---> severe anemia, undernutrition– Helminth infections ---> anemia, undernutrition, cognitive
• HIV/AIDS
• Acute lower respiratory tract infections (number 1)
• Diarrheal illnesses - highlight precarious state of children
Nutrition TransitionPart of the Health Transition – occurs with the demographic and epidemiologic transitions.
Diets high in complex carbohydrates and fiber change to more varied diets with higher proportions of fat, saturated fats and sugars.
Assumption that it is due almost solely to the invasion by western foods into traditional regions.
Changes in modes of subsistence and occupations leads to decreased physical activity
BMI Classifications and Disease Risks
BMI Groups NCD Risks*
Underweight = <18.5 ?• Normal weight = 18.5-24.9 Standard• Overweight >25 • Pre-obese (Overwt) = 25-29.9 Increased• Obesity I = 30 – 34.9 High• Obesity II – 35 – 39.9 Very High• Obesity III - >40 Extremely High
* - NCD – non-communicable diseases,
e.g., Type 2 diabetes, hypertension, & CVD
Prevalence of Overweight & Obesity in Women 15-49 yr
0
5
10
15
20
25
30
S Asia SSAfrica
LatAmer
CEE/CIS ME/NAfr
USA
% Ovwt
% Obese
Overweight & Obesity in the US- age adjusted prevalence
0
10
20
30
40
50
60
Men25-29
Women25-29
Men>=30
Women>=30
Men>=25
Women>=25
BMI Groups
NHES 1960-62NHANES 1971-74NHANES 1976-80NHANES 1988-94
Coexistence of overweight and underweight in developing societies
1. Rapid urbanization and nutrition transition – reliance on energy dense diets and physical inactivity
2. Co-distributions of underweight and overweight individuals is conditional on stage of economic development and age distribution of households
3. Intrahousehold food allocation influences the under/over weight phenomenon
Am Samoa Market 1976
Fast Food & Vehicles Am Samoa – Now
Prevalence of Obesity, BMI >32 kg/m2, in American Samoa Adults 1976-2002
25
35
45
55
65
75
All Men M 45-54 y All Women W 45-54 y
1976-7819902002
Type 2 diabetes, FSG>126 mg/dl, Dx & Rx, by Age in American Samoa Adults
1990-2002
0
5
10
15
20
25
30
M 25-34 M 35-44 M 45-54 W 25-34 W 35-44 W 45-54
19902002
Overweight & Obesity, in American Samoa Children & Adolescents Girls – 1976-78 and 2002
0
10
20
30
40
50
60
70
80
90
100
G 6-8 y G 9-11 y G 12-14 y G 15-17 y
1976-78 Ovwt/Obese1976-78 Obese2002 Ovwt/Obese2002 Obese
Hypothesis
ECONOMIC DEVELOPMENT CONTINUUM Early: Samoa Middle: A. Samoa Advanced: US/UK
CV
D R
ISK
FA
CT
OR
S,
MO
RB
IDIT
Y &
MO
RT
AL
ITY
Socioeconomic Status
Diet and BMI
inSamoa1961-2010
Poverty & Obesity: energy density & costs
• Strong negative or inverse association in the US and other developed nations between BMI, overweight and SES
• WHY? • Nutritional health literacy• Food costs & availability • Food insecurity - limited/uncertain
availability of affordable and nutritionally acceptable or safe foods
Poverty & Obesity: energy density & costs
• In US women food insecurity is associated with overweight: 58% overweight from food insecure households vs 47% non-insecure households
• Theory – low income households first consume less expensive foods to maximize caloric intake relative to the cost of food
Poverty & Obesity: energy density & costs
• Due to changes in food production by food corporations, energy dense foods are more abundant and cheaper than ever before.
• Energy dense foods (high fat & sugar) are less costly but have high hedonic properties and produce less satiety, also long shelf life
• Energy density and energy cost are inversely related through deliberate choices of food-insecure or low income households to save $$.
Poverty & Obesity: energy density & costs
• Low cost, high pleasure & low satiety=
overconsumption, and chronic positive energy balance.
• In the US portion sizes have increased and proportions of macronutrients have changed: increase in CHO
• Marketing of energy dense foods by large food corporations and widespread availability in stores
NCD Control Common Myths• Myth: “Chronic diseases are diseases of
affluence” – 80% of deaths from chronic disease are in low-income
and middle-income countries. – Chronic disease affects economic development.
• Myth: “People must die of something” – Certainly everyone has to die of something, but death
does not need to be slow, painful, or premature. – In low-income and middle-income countries, where
people tend to develop disease at younger ages, suffer longer— often with preventable complications—and die sooner than those in high-income countries.
– Death is inevitable, but a life of protracted ill health is not.
NCD Control Common Myths• Myth: “Chronic diseases develop over a lifetime so effective
prevention will take generations”– Risk factor reduction can lead to surprisingly rapid health gains. – The effect of tobacco control is almost immediate leading to decreases in
tobacco use, rates of cardiovascular disease, and hospital admissions.
• Myth: “Interventions for chronic disease are less cost-effective”– Many chronic disease interventions are cost-effective and inexpensive
throughout the world, including sub-Saharan Africa. – They include salt reduction, changes in oil and produce consumption,
tobacco taxation and advertising bans, and combination drug therapy for individuals at high risk.
Population vs individual approaches to health and disease
• Personal/individual• Family• School• Work• Social organizations such as religious groups• Neighborhoods• Community• Regional• Governments• Health care systems
Population vs individual approaches to reducing the burdens of disease and health
promotion
Importance of Structural Factors
• Political & economic context
• Role of public policies and laws
• Enfranchisement of individuals
• Empowerment of community
Translation & Implementation Research• Need to translate fundamental knowledge of biological and
behavioral processes - to clinical settings - to communities of free-living individuals
• Requires implementing program delivery into communities - with strong attention to socio-cultural, economic and
historical variations
• Avoid the invidious distinction between basic and applied scholarship
• Implementation research offers the opportunity to produce generalizable knowledge about design and delivery of programs.
• Global health inequalities and evidence about how risk factor exposures lead to disease and ill health, translating and implementing is a required step
Translation & Implementation Research• As anthropologists, we must critically think and teach our students
and the public about - evidence for linkages among poverty, health and mortality - identify hidden or poorly specified assumptions involved - avoid easy refuge of imprecise evolutionary concepts about relative
survival and mortality and a too-easy acceptance of inequalities.
• Our intellectual mission as anthropologists includes attempts: - to observe and measure human biocultural phenomena - with special attention to heterogeneities within & among communities - to develop & employ causal webs with factors operating at many
levels - to maintain unique biocultural, historical and population-based
perspectives
• Explicit interdisciplinary collaborations with biomedicine and public health probably required
• Assert primacy of community in such collaborations
Increase in ‘Dual Burden’ in LMIC• Low and middle income countries (LMIC) are now
and will suffer increasingly from the dual presence of both infectious/communicable diseases and NCDs
• Child survival to age 5 years• TB, HIV, malaria• Adult, esp age 40-80 yrs, hypertension, obesity,
type 2 diabetes, coronary artery disease• Risk behaviors – tobacco use, excess alcohol
use, risky sexual exposures
• Impact on design of health care systems, both clinical and public health
• Need for broader range of clinical specialists, esp for NCDs
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