Global Response

What is being done to combat the inequity seen in NCDs?

It’s clear to see that inequity is rife in regards to NCDs across the globe. As such there have been several key responses that have been implemented by the United Nations (UN) and the World health Organisation (WHO) to combat the inequity seen across the globe in regards to noncommunicable diseases. These strategies have been coordinated by the United Nations interagency task force on the prevention and control of NCDs and are largely operated and controlled by the WHO.

NCD Global Monitoring Framework1

• In 2013, a framework comprising of 9 voluntary global targets and 25 key indicators was presented to member states of the UN.1
• The aim of this framework is to encourage nations to combat mortality associated with NCDs within their own countries.
• The main outcome adopted by the assembly was to reduce NCD associated mortality by 25% by 2025.1

Reducing the economic impact of NCDs in low and middle income countries

• The WHO released a report in 2011 with the aim of addressing the economic problems and inequality associated with NCDs.
• Several risk factors are presented in the report with accompanying cost-effective interventions.
• The total cost for these “best buy” interventions for low income countries stood at US$1 per capita per annum, which constitutes only 4$ of total health expenditure in these countries.2
• These are the potential benefits from the proposed interventional investments:
• Health
• Prevention of around 30 million premature deaths between 2006 and 2015.2
• An average saving of 3 million lives per year.2
• Economics
• A saving of US$25 billion a year.2
• A reduction in economic losses as a result of these diseases of US$377 billion between 2011 and 2025.2

Minor Health Advocacy Organisations

Whilst the activities of WHO are vital for implementation of global change; approaching this issue at a global level means that many individuals remain ignorant of the impact of NCDs within their daily lives. Smaller, local corporations are thus vital to increasing health advocacy at a community level.

EAT

Stordalen Foundation, EAT combines government’s, leading research universities and institutions, philanthropic foundations, non-government actors and organisations to communicate the value of sustainable, nutritious food sources in improve global health. Current goals; including establishing practical guidelines as to the components of a modern health diet; are communicated through global collaborative forums and regional
seminars.  In combination with annual presentations; EAT have established a sizable web presence, with an array of educational media being made available.3

SDI

Dwellers International (SDI) are an association of community-based
organisations serving to combat the cost of urbanisation of those within
developing nations within Africa, Asia and Latin America. They provide locals
with the tools to improve their living environment. Assisting their engagements
with local authorities and governing powers; to survey local communities and generate
detailed development plans based on the local socio-economic profiles.  Organisation of developments in this manner means that they remain sustainable; properly facilitated and safe to live in.  Examples of current projects  include housing an infrastructure upgrading in Peru and the Nungua Zongo Communal Water Project.4

NCD Free

A local organisation, NCD free are a growing voice within the global media. Publishing articles within The Age and PLOS their current aim in to increase global awareness of the
contributing factors in NCD development. Informing readers as to the effect of
diet, alcohol, tobacco use and exercise on disease development; their message
is targeted towards all socioeconomic groups. Importantly NCD free are trying
to abolish the misconception that NCDs only affect those in first world
countries. In fact the majority of their recent publications have been
emphasized the role of NCDs in LMIC’s.

Beyond online journal publications; their presence on Twitter, Facebook and
Instagram means that they are in constant communication with their audience.5
The link below gives a brief over view of their approach to health advocacy
https://player.vimeo.com/video/100172370

So what else needs to be done?
These strategies are a step in the right direction in combating the growing problem of inequity in NCDs; however it’s clear that we need to do more.

1.    There needs to be a global increase in public awareness of both the causes and the extent of the problems associated with NCDs, particularly in low and middle economic countries (LMIC). Education plays a vital role in controlling many of these diseases and as such more input is needed from governments to assist people in learning about preventing and managing the problem. Simply increasing input into anti-smoking and healthy eating campaigns in LMICs would be a great start.

2.    Although health spending in developing countries has tripled in recent years6, a huge gap remains between what is being provided and what is necessary. This is particularly true in the case of NCDs, with only a small fraction of health expenditure being placed in this area.6 Additionally, funding for NCDs currently sits at a mere 1.2% of the international financial assistance provided via the Development Assistance for Health (DAH).7

3.    It is also apparent that the importance of the targets set under the WHO action plan are not being emphasised enough. Although the framework is having a positive impact on the issues associated with NCDs, the voluntary nature of the targets makes it difficult to monitor and enforce them. The framework needs to be more stringently enforced and include compulsory aspects of each target that must be undertaken by nations.

References

1. Global action plan for the prevention and control of noncommunicable diseases [Internet]. Geneva:  World Health Organization; 2013 [cited 2015 Apr 7]. NLM classification: WT 500. Available from: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf

2. From Burden to “Best Buys”: Reducing the Economic Impact of Non-Communicable Diseases in Low- and Middle-Income Countries [Internet]. Geneva:  World Health Organization; 2013 [cited 2015 Apr 7]. Available from: http://www.who.int/nmh/publications/best_buys_summary.pdf?ua=1'

3.EAT Forum [Internet] 2013 [updated 2015 April 8; cited 2015 Apr 9]. Available from: http://www.eatforum.org/

4.Shack/ Slum Dwellers International [Internet] 2009 [updated 2015 March 25; cited 2015 Apr 9]. Available from: http://www.sdinet.org/about-what-we-do/

5.NCD Free [Internet] 2014 [updated 2015 April 8; cited 2015 Apr 9]. Available from: http://ncdfree.org

6. Health at a Glance 2013: OECD Indicators [Internet]. Paris: OECD Publishing; 2014 [cited 2015 Apr 7]. Available from: http://dx.doi.org/10.1787/health_glance-2013-en

7. Financing Global Health 2013: Transition in an Age of Austerity [Internet]. Seattle: Institute for Health Metrics and Evaluation; 2014 [cited 2015 Apr 7]. Available from: http://www.healthdata.org/sites/default/files/files/policy_report/2014/FGH2013/IHME_FGH2013_Full_Report.pdf

Diabetes

Diabetes, like many other NCDs, is on the rise.  Classifiable into one of two main categories, 90% of the 328 million people currently living with the disease are diagnosed with type 2 diabetes. 

Diabetes occurs when the body is no longer able to manage its own blood glucose levels, due to insufficient insulin production diabetes may be classified according to one of two types. Diabetes mellitus type 1 is an endocrine disorder resulting in an absolute insulin deficiency due to the destruction of insulin producing (beta cells) of the pancreas.¹ Often developing in childhood, sufferers of diabetes mellitus type 1 are unable to metabolize carbohydrates, proteins and fats normally results in hyperglycemia.  Acute hyperglycaemia results in polyuria (excessive urine excretion), polydipsia (thirst), constant hunger, weight loss, altered vision and a fatigued state and eventual diabetic ketoacidosis and hyperosmolar hyperglycemia state.^1-3,5 In contrast type 2 diabetes occurs when the body exhibits varying degrees of resistance or deficiency in circulating insulin. ⁴ Formally known as adult onset diabetes; this condition is directly correlated with obesity and physical inactivity. Sufferers exhibit similar symptoms to type 1, with a more gradual onset, taking a number of years to manifest.^1,5

Causal factors 

Type 1

Selective beta cell destruction is the result an autoimmune response, driven by the presence of auto antibodies to either islet cells; insulin, GAD65 or tyrosine phosphatises.  Antibody driven destruction of beta cells is accredited to a combination of polygenic susceptibility and environmental exposure.^2,3 Approximately 50% of genetic susceptibility is accredited to presence of HLA on chromosome 6.³ Environmental triggers including diet, viral exposure and vitamin D deficiency; which may occur in utero or postnatally; are through to precipitate onset in genetically susceptible individuals.³

Type 2

Metabolic risk factors associated with development of diabetes mellitus type 2 include; obesity (defined as having a BMI exceeding 30), prediabetes (the presence of higher than average fasting glucose levels) metabolic and polycystic ovary syndrome as well as gestational diabetes.⁵ Lifestyle risk factors include a diet high in processed meat and high GI foods in addition to a sedentary life style and smoking.  Lower socioeconomic status is also closely correlated with its development, with more than 80% of cases occurring in low income countries.^5-7

Interactive Plot avalible at
http://healthintelligence.drupalgardens.com/content/prevalence-diabetes-world-2013

A few facts too put this all into perspective

Currently 347 million people have diabetes worldwide and is set to become the 7^th leading cause of death by 2030.²

In 2012 along, 1.5 million people died of diabetes, 80% of which was in low and middle income countries.²

Type 2 diabetes makes up 90% of cases; which means that most of these cases are preventable.²

Previously prevalence of type 2 in children was rare; currently almost half of all new diagnosis are in children.²

Not only is it causing premature death; diabetes is a leading cause of blindness, amputation and kidney failure.

The majority of causes of type 2 are preventable with moderate intensity physical activity, and a healthy diet.²

Within developing countries...

In 2013 the countries with the highest prevalence of diabetes; 
Tokelau (37.5%), Federated States of Micronesia (35%), Marshall Islands (34.9%), Kiribati (28.8%), Cook Islands (25.7%), Vanuatu (24%), Saudi Arabia (23.9%), Nauru (23.3%), Kuwaite (23.1%) and Quatar (22.9%).²

Most of these countries are located within the Western Pacific, Middle East or Northern African region.²

In Africa, diabetes is responsible for 76% of deaths occurring under the age of 60.²

Furthermore 1 in 10 adults in both Northern Africa and the Middle east have diabetes (34,571 people).²

Within the western pacific regions, 138 195 people are diagnosed with diabetes; a prevalence of 8.6%.² 

In contrast Europe has the highest prevalence of type 1 diabetes in children.²

References

1. Atkinson MA, Eisenbarth GS, Michels AW. Type 1 diabetes. Lancet 2014;383(9911):69-82.

2. IDF. IDF Diabetes Atlas sixth addition [Internet] 2013.  [cited 2015 Mar 26] Available from:http://www.idf.org/diabetesatlas

3. Redondo MJ, Jeffrey J, Fain PR, Eisenbarth GS, Orban T. Concordance for islet autoimmunity among monozygotic twins.N Engl J Med. 2008; 359(26):2849.

4. Hu G1, Lindström J, Valle TT, Eriksson JG, Jousilahti P, Silventoinen K, Qiao Q, Tuomilehto J. Physical activity, body mass index, and risk of type 2 diabetes in patients with normal or impaired glucose regulation. Arch Intern Med. 2004; 164(8):892-6.

5. Paneni F, Beckman JA, Creager MA, Cosentino F. Diabetes and vascular disease: pathophysiology, clinical consequences, and medical therapy: part I. Eur Heart J.2013;34(31):2436-2443.

6. Kumari M1, Head J, Marmot M. Prospective study of social and other risk factors for incidence of type 2 diabetes in the Whitehall II study. Arch Intern Med. 2004;164(17):1873-80.

7. Wannamethee SG1, Shaper AG, Lennon L, Morris RW. Metabolic syndrome vs Framingham Risk Score for prediction of coronary heart disease, stroke, and type 2 diabetes mellitus. Arch Intern Med. 2005; 165(22):2644-50.

8. Perreault L, Pan Q, Mather KJ, Watson KE, Hamman RF, Kahn SE; Diabetes Prevention Program Research Group. Effect of regression from prediabetes to normal glucose regulation on long-term reduction in diabetes risk: results from the Diabetes Prevention Program Outcomes Study. Lancet. 2012;379(9833):2243-51.

9. Stringhini S1, Tabak AG, Akbaraly TN, Sabia S, Shipley MJ, Marmot MG, Brunner EJ, Batty GD, Bovet P, Kivimäki M. Contribution of modifiable risk factors to social inequalities in type 2 diabetes: prospective Whitehall II cohort study. BMJ. 2012;345.  

Defining COPD

Chronic Obstructive Pulmonary Disease (or COPD as it is commonly known) is a term used to describe a variety of lung related diseases that limit airflow into the lungs. Sufferers usually complain of shortness of breath, wheezing, a chronic cough and tightness in the chest. As this problem is chronic (long term) and progressive, these symptoms can range from being relatively mild to severe once the disease has developed over time. COPD affects an enormous amount of people both in Australia and worldwide and contributes significantly to the global burden of disease.¹

Causal Factors

There are several factors that have contributed to the development and prevalence of this disease. These factors are not only seen at an individual level but also at societal and global levels. Here are a few of the major risk factors;

Smoking (including secondhand smoking) is by far the most significant determinant of developing COPD.

Pollution can also contribute to this disease (fumes/chemicals and other harmful irritants in the community and workplace).²

Genetics also has a big influence on COPD, in particular a deficiency in a protein called alpha-1 antitrypsin that protects the lung from damage.²

The British Lung Foundation has developed an interactive pathway showing the life of a COPD sufferer from symptom recognition to end of life:

http://copdpathway.blf.org.uk/

A person’s socioeconomic status (wealth, education, occupation etc.) also plays a large part in the development of COPD.³ In poorer countries, the proportion of smokers and the degree of exposure to pollution in both the community and the workplace are far higher than in wealthy countries.⁴ As such, it’s easy to see why these less developed countries are suffering from a higher prevalence of the disease than countries such as Australia. The following table⁵ highlights the correlation between smoking and socioeconomic status.

Accessible at:
http://www.aihw.gov.au/publication-detail/?id=32212254712&libID=32212254712&tab=2

Fast facts

Here are some facts that give you a quick snapshot into the reality of COPD and its consequences both in Australia and worldwide.

Australia

A staggering 1 in 20 Australians (5.7% of the population or 310,700 people) aged 55 and over suffer from COPD.⁶

In 2012, COPD was the fifth leading cause of death in Australia behind heart disease, stroke, dementia and lung cancer - that’s 4% of all deaths.⁶ $929 dollars was spent on COPD alone in 2008-2009 (1.3% of all disease expenditure).⁷ 

It is the 2^nd leading cause of avoidable hospital admissions.⁷

In spite of the associations between smoking and COPD, 20% of COPD sufferers have never smoked.⁸

The self-reported prevalence of COPD is 2.5x greater in Aboriginal Australians in comparison to non-Aboriginal Australians.⁹ 

Around 4% of adult Aboriginals report suffering from COPD.⁹



Worldwide

65 million people worldwide currently suffer from moderate to severe COPD.¹⁰

An astounding 90% of all deaths attributable to COPD occur in low to middle income countries.¹⁰

In 2012, COPD represented 6% of all global deaths (more than 3 million people).¹⁰

74% of those who are affected by COPD remain untreated, with the majority of this figure being made up from people of low income countries.¹⁰

References

1.   Prevention and control of noncommunicable diseases: guidelines for primary health care in low resource settings [Internet]. Geneva:  World Health Organization; 2012 [cited 2015 Mar 26]. NLM classification: W 84.6. Available from: http://apps.who.int/iris/bitstream/10665/76173/1/9789241548397_eng.pdf

2.    Global Strategy for the Diagnosis, Management, and Prevention of COPD [Internet]. Global Initiative for Chronic Obstructive Lung Disease; 2013 [cited 2015 Mar 26]. Available from:  http://www.goldcopd.org/uploads/users/files/GOLD_Report_2015_Feb18.pdf

3.   Kanervisto M, Vasankari T, Laitinen T, Heliövaara M, Jousilahti P Saarelainen S. Low socioeconomic status is associated with chronic obstructive airway diseases. Resp Med [Internet]. 2011 [cited 2015 Mar 26];105(8):1140-6. Available from: http://www.sciencedirect.com/science/article/pii/S0954611111000965

4.   Hiscock R, Bauld L, Amos A, Fidler JA, Munafò M. Socioeconomic status and smoking: a review. Ann N Y Acad Sci [Internet]. 2012 [cited 2015 Mar 26]; 1248:107-23. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1749-6632.2011.06202.x/full

5.   Australian Institute of Health and Welfare. National Drug Strategy Household Survey: survey report [Internet]. 2011 [cited 2015 Mar 26]; AIHW cat. no. PHE 145. Available from: http://www.aihw.gov.au/publication-detail/?id=32212254712&libID=32212254712&tab=2

6.   Australian Institute of Health and Welfare. Australian Centre for Asthma Monitoring [internet]. 2011 [cited 2015 Mar 26]; AIHW cat. no. ACM 22. Available from : http://www.aihw.gov.au/publication-detail/?id=10737420159

7.   Page A, Abrose S, Glover J ,Hetzel D. Atlas of Avoidable Hospitalisations in Australia: ambulatory care-sensitive conditions [Internet]. Adelaide:   Adelaide PHIDU. University of Adelaide; April 2007. Available from: https://www.adelaide.edu.au/phidu/publications/pdf/2005-2009/avoidable-hospitalisations-aust-2007/avoidable_hospitalisations_full.pdf

8.   Lamprecht B, McBurnie MA, Vollmer WM, Gudmundsson G, Welte T, Nizankowska-Mogilnicka E, Studnicka M, Bateman E, Anto JM, Burney P, Mannino DM, Buist SA. COPD in Never Smokers: Results From the Population-Based Burden of Obstructive Lung Disease Study. Chest [Internet]. 2011[cited 2015 Mar 26]; 139(4):752-63. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1087839

9.   Australian Institute of Health and Welfare. Coronary heart disease and chronic obstructive pulmonary disease in Indigenous Australians [internet]. 2014 [cited 2015 Mar 26]; AIHW cat. no. IHW 126. Available from : http://www.aihw.gov.au/publication-detail/?id=60129547716

10. Global surveillance, prevention and control of chronic respiratory diseases [Internet]. Geneva:  World Health Organization; 2007 [cited 2015 Mar 26]. NLM classification: WF 140. Available from: http://whqlibdoc.who.int/publications/2007/9789241563468_eng.pdf?ua=1

The next biggest killer ...

Cancer, accounting for 8.2 million deaths globally in 2012, is recognized as the second most prevalent NCD worldwide.¹

 

Despite the scale of this disease, cancers frequently arise from mutations in a single or a small group of cells. These mutations affect either the cell’s DNA or the cellular mechanisms regulating its DNA sequence, resulting in abnormal growth, duplication and eventual tumour formation.^2,3 Notably, the severity of cancer depends greatly on its metastatic potential – whether or not it has the ability to spread too and infect other distant body regions.  For further explanation click here.³

Cancer infographic accessed at
http://www.infographicszone.com/health/top-10-cancer-infographics

Cancer causing mutations may be inherited, however they frequently arise from exposure to physical (UV light or ionizing radiation), chemical (asbestos, tobacco smoke and arsenic) or biological (infection with certain viruses or bacteria) carcinogens.^2,3,4  Various lifestyle factors also have a huge impact on an individual’s risk of cancer development.  Notably, 30% of cancers are preventable.⁴ These are cancers arising from a single or combination of factors including; a poor diet, tobacco use, physical inactivity and harmful use of alcohol or exposure to cancer-related infections such as helicobacter pylori (stomach cancer), HBV (liver cancer) and HPV (cervical cancer).⁴

Notably, cancer remains the leading cause of death in developing countries and is predicted to cause 2/3 of the deaths in these regions by 2020.^4-7  The growing rates of cancer within these lower socioeconomic regions are partly due to the increase in life expectancy due to gains made against infectious diseases, which have subsequently increase child survival beyond the age of 5.^5-7 However, now there exists a high incidence of malignant (metastatic) tumours arising from communicable diseases. These 2 million deaths are almost solely due to a lack of disease control and screening services within low- resource communities.  Urbanisation has also been a major contributor to the increase in lung, breast and colorectal cancers, as it has lead to increased tobacco consumption, calorie intake and alcohol abuse within low socioeconomic communities. Of all those listed above, tobacco causes 20% of both cancer related deaths within these communities, making it the highest contributing factor in cancer development within these communities.^5,6

Cancer incidence worldwide in 2012
Avalible at http://www.cancerresearchuk.org/cancer-info/cancerstats/world/

So what is being done to help?

Lack of access to both screening and treatment is responsible for the majority of cancer related deaths within low-socioeconomic communities.^5,6,8 In many middle and low income countries, access to trained professionals, palliative care, oral morphine and medication is limited. Furthermore the majority of those living in low socioeconomic communities do not have access to the screening facilities required to make an early cancer diagnosis. In the past, the global health agenda has focused solely on the treatment of infectious diseases and disease outbreak control. As the health burdens associated with commutable diseases diminishes, attention is hoped to turn towards treatment of NCDs.  With this in mind, WHO, in their 2008 report proposed that cost effective cancer interventions need to be designed which stretch across four broad categories; primary prevention and control, early detection, treatment and palliative care. It is hoped that in implementing these plans there will be a marked reduction in the number of cancer associated deaths within middle and low socioeconomic communities over the next 10 years.⁸

References

1.The NCD Alliance. Cancer [Internet] 2014 [updated  2012; cited 2015 Mar 18]. Available From: http://www.ncdalliance.org/node/40.

2. National Cancer Institute. What Is Cancer? [Internet] 2015 [updated  2015 Feb; cited 2015 Mar 19]. Available From: http://www.cancer.gov/cancertopics.

3.Biodigital. What is Cancer? New York City; Biodigital: 2008 

4. World Health Organisation. Cancer Fact Sheet [Internet] 2015 [updated  2015 Feb; cited 2015 Mar 19]. Available From: http://www.who.int/mediacentre/factsheets/fs297/en /

5. World Health Organisation. Cancer Mortality and morbidity [Internet] 2012 [updated  2012; cited 2015 Mar 20]. Available From: http://www.who.int/gho/ncd/mortality_morbidity/cancer/en/.

6. Koh H, Massin-Short S, Elqura L, Judge C. Poverty, Socioeconomic Position, and Cancer Disparities: Global Challenges and Opportunities. Geo. J. on Poverty L. & Pol’y. 2008; 15: 663

7. World Health Organisation. Cancer Mortality; age-standardised death rate per 100 000 population, both sexes 2012 [Internet] 2012 [updated  2012; cited 2015 Mar 19]. Available From: http://gamapserver.who.int/mapLibrary/Files/Maps/Global_NCD_mortality_cancer_2012.png

8.World Health Organisation. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Switzerland: WHO press; 2013. 91p.