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.

What is Cardiovascular Disease?

Cardiovascular disease (CVD) is an umbrella term that encompasses a variety of common conditions affecting the heart and blood vessels, including coronary artery disease and stroke. Many of these conditions can be directly linked to atherosclerosis (a build-up of plaque in arterial walls), however they can also stem from infection, particularly in developing countries.⁴   

The process of plaque formation leading to Atherosclerosis
http://mouseclique.jax.org/wp-content/uploads/Atherosclerosis1.jpg

What’s the problem?
With the frequency of cardiovascular disease skyrocketing; global health organisations are have begun serious discussions regarding management of this disease. Notably, in the last 10 or so years, CVD has become the primary cause of death worldwide. Responsible for 30% of global deaths and 50% of deaths attributable to non-communicable diseases.³ Traditionally, CVD was perceived an affliction of the wealthy; and thus only found in developed nations. Only recently have efforts been made to correct this misconception - shared by both the general public and world leaders. 

It is now well known that 80% of deaths worldwide, attributable to CVD, occur within middle to lower income countries.⁵ Notably those living in poverty within first world nations, including Australia, are also at a greater risk of CVD. Analysis of the distribution of CVD within established nations causes one to question how these people are slipping under the radar. The Aboriginal and Torres Strait Islander population of Australia are a prime example. In 2011 population studies found that Australian Aboriginal and Torres Strait Islander's had a 70% higher mortality rate than non-Aboriginal Australians in addition to exhibiting increased rates of circulatory problems. These statistics show that CVD is pertinent to all; as transcending both cultural and socio-economic boundaries. 

Deaths from cardiovascular disease by proportion from each country

http://www.worldmapper.org/display_extra.php?selected=451

Why is it happening?

Lifestyle factors such as diet, smoking and exercise are strong predictors of an individual’s risk of  CVD development. In affluent countries such as Australia, the USA and the UK people are increasingly making poor lifestyle choices, developing poor eating habits and leading more sedentary lifestyles. With an ever increasing array of fast food and disproportionate health education,  it’s easy to see how CVD has escalated globally. 

However, the obvious question arises - if this is mostly related to diet and lifestyle why are developing countries seeing a surge in CVD?

In recent times, there has been a transition towards urbanisation and industrialisation in many developing nations. With urbanisation of course comes access too cheaper, fast foods  and longer working hours, observed in their first world neighbors ⁴. Furthermore, these nations are still affected by many communicable diseases, which has previously been the primary cause of CVD. In regards to causation in Aboriginal Australians, the aetiological features are multifaceted and complex, existing at both individual and community levels. Several key issues are similar however, including sedentary behaviour, diet and smoking. This is highlighted by the fact that Aboriginal Australians are 2.4 times more likely to smoke and are 13% more likely to exhibit low levels of exercise than non-Aboriginal Australians.⁴

It’s clear that health inequality is widespread in respect to CVD both around the globe and locally. So in order to combat this issue, we will need to make changes of a global scale - starting with education and health literacy....

National Heart Foundation – Cardiovascular Disease Factsheet

http://www.heartfoundation.org.au/SiteCollectionDocuments/Factsheet-Cardiovascular-disease.pdf


Calculate your own risk of risk of developing cardiovascular disease
http://www.cvdcheck.org.au/

References

1. Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander Health Survey: First Results 2012-13. 2013 [cited 2015 Mar 16]; ABS cat. no. 4727.0.55.001. Available from: http://www.abs.gov.au

2. Australian Institute of Health and Welfare. Expenditure on health for Aboriginal and Torres Strait Islander people 2006–07 [Internet]. 2009 [cited 2015 Mar 16]; AIHW cat. no. HWE 48. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468323

3. Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, Feigl AB, Gaziano T, Mowafi M, Pandya A, Prettner K, Rosenberg L, Seligman B, Stein AZ, Weinstein C. The Global Economic Burden of Non-communicable Diseases. Geneva: World Economic Forum; 2011 Sep.

4. Celermajer DS, Chow CK, Marijon E, Anstey NM, Woo KS. Cardiovascular Disease in the Developing World : Prevalences, Patterns, and the Potential of Early Disease Detection. J Am Coll Cardiol. 2012 Oct;60(14):1207-1216.

5. Gershl BJ, Sliwa K, Mayosi BM, Yusuf S. The epidemic of cardiovascular disease in the developing world: global implications. Eur Heart J. 2010 Feb;31:642-8.

So where are we going with this....

This brief presentation overviews the major NCDs affecting our global community. In the next few blogs the topics outlined in the presentation will be covered; firstly we will look into the major NCDs contributing to the global burden of health. 

What are NCDs?

Earlier this year, Oxfam proposed that if current financial trends persist, the richest 1% will earn more than the remaining 99% of the population1. Whilst staggering, to many of us this is just another meaningless statistic, easily ignored - forgotten.  What we fail to realise is that this escalating inequity is having a huge impact on global health. Unbeknownst to many, our economic divide is a key contributor to our leading cause of death. Which begs the question, what is the biggest killer globally? Whilst Ebola, HIV and TB all immediately spring to mind, none of these have mortality rates comparable to NCDs1.

Available from http://visual.ly/wealth-distribution-around-world

Non-Communicable Diseases (NCDs) kill 3 out of 5 people. Vastly more that HIV (1.4 million in 2013) or Ebola (3,800 in 2014). NDC’s include heart disease, cancer, diabetes, chronic lung disease and mental illness, all chronic diseases which, by definition, are not transmittable3. Notably whilst there is no apparent link between any of these diseases, they all arise from a combination of lifestyle and socio-economic factors including; poor diet, alcohol and tobacco use3,4.

Looking at the list above you may immediately assume that NCDs are diseases of the wealthy. This could not be further from the truth.  Approximately 80% of NCD’s exist in middle to low socioeconomic groups. Due to their chronic nature, these diseases are extremely costly3,4,5. The WHO (World Health Organisation) reported that 100 million sufferers (per year) will be driven into poverty by the extraneous costs associated with these diseases.

Total deaths based on  income group, nationality and sex taken (2010)5. 

So why do NCD’s have the greatest impact on those of low socioeconomic status? Two words, inequity and urbanisation. Whilst those in higher socioeconomic groups have naturally benefited from the economic boom, those within the middle and lower socioeconomic groups are suffering3,4,5. The resulting gross level of global inequity means that those in lower socioeconomic groups now have less control over their access to nutritious foods, education, quality healthcare, medication, and a safe working environment5,6. This means that the majority of those in middle and low income groups lead largely sedentary lifestyles, working long hours in high stress environments. Forced lifestyle choices are further exacerbated by the behaviours of exploitative global food production companies, manufacturing cheap, poor quality and nutritionally defunct foods targeted towards low socioeconomic groups3,5,6.  Redirection of marketing by global tobacco companies has also increased the tobacco usage within these populations.  In short, people from lower socioeconomic settings have limited access to healthcare due to both cost and location.

Risk factors associated with disease burden (2010)4.

This begs the question, what can be done? If urbanisation is the leading cause of these diseases, how do we overcome it? Recognition. To be fair this is easier said than done. Current developmental and social security agendas have been targeted towards combating starvation and infection disease within low-socioeconomic groups,  leaving lifestyle factors contributing to NCDs largely unattended. All too often these factors are considered the individuals responsibility. It is assumed that people should be educated to the traps of globalised marketing companies and the outcomes of poor health and nutrition. Notably cross-national correlations conducted in developing countries have shown a strong inverse association between education level and cardiovascular risk2,3,5. Based on this data various educational campaigns have been established within developed countries to educate their populations as to causal factors of NCDs. Furthermore, in order to rectify these major over sites; in 2011, the WHO launched a global response, involving 190 countries in their Global Action Plan. From 2013, the WHO established 9 voluntary global targets in order to reduce premature deaths from NCDs by 25% before 20255,6.

Whilst this is a great start there is a lot more that can be done. In terms of education, its all about making information available to the general population – essentially that’s what this blog is trying to achieve. Any difference is a start.

References

1. Hardoon  D. Having it all and wanting more. Oxfam international; 2015. 12p


2. Crooks  R. Wealth distribution around the world [Internet] 2011[updated 2011 May 20; cited 2015 Mar 6]. Available from http://visual.ly/wealth-distribution-around-world

3. Demanio A. The greatest health threat you've never heard of, but need to know about [Internet]. 2014[updated 2014 Oct 25; cited 2015 Mar5]. Available from http://blogs.plos.org/globalhealth/2014/10/greatest-health-threat-youve-never-heard-need-know/

4. Lim et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease study 2010. Lancet 2013;80(9859):2224-60.

5. World Health Organisation. Global status report of non-commutable disease. Geneva: WHO Press; 2011. 162p 

6.AIWH. Australias Health.  Canberra :AIWH:2004