Non-Communicable
Diseases in LMICs:
Myths, Facts and
Opportunities
Gerald S.
B l o o mfi e l d , M D ,
MPH
DGHI,
Division of
C a r d i o lo g y,
D u ke U n i v e r s i t y
S e p te m b e r 2 01 3
OUTLINE




Trends in selected NCDs in LMICs
Epidemiologic transition
Data challenges
Approaches to NCD research in LMICs
CARDIOVASCULAR
DISEASE
CLASSIC TEACHING ON CARDIOVASCULAR
DISEASES IN SSA
 Common CVDs: Rheumatic, infectious, pericardial, high BP
 Heart failure is endemic in SSA
 Dilated cardiomyopathy: 48% of admissions
 Causes: RHD, Hypertension, Peripartum, Idiopathic
 Coronary heart disease “distinctly rare”
 Diagnostic limitations
 Lack of specialized investigations
 Viral, nutritional, familial, alcohol, immune, ischemia
 68% of ‘idiopathic’ can be mislabeled
RHD = Rheumatic Heart Disease
BP = blood pressure
1999
Watkins and Mayosi. Cardiovascular Journal of Africa 2009
Oyoo and Ogola. East African medical journal
Mokhobo. S Afr Med
History of chronic CVD in Africa
No change in
BP with age
Uganda. N= 1500
“High tension
pulses not often
met with”
Kenya.2 years,
1800 patients.
0% HTN,
arteriosclerosis
Uganda.2 years
0% HTN
Heavy Heart is
a Bad Heart
Ancient Egypt
1370 BC
1901 1920s
1941
“Africans are
immune to
heart/coronary
disease”
Kalahari
San. No
increase in
BP with age
40% hospital
admissions
with any CVD
Prev. HTN
Ghana 13%
Nigeria 25%
Lesotho 7%
1958-72: 8-11%
admissions due
to CVD
1960
1970s
1976-8 1980-90s
2010:CVD is the 2nd most common cause of death in SSA
LUO MIGRATION STUDY
 325 migrants, 267 controls followed for 24 months
 SBP changes over 24 months
Poulter BMJ 1990
PULMONARY DISEASE
DEATHS DUE TO PULMONARY DISEASE
3500000
3000000
2500000
2000000
ILD
Pneumoconioses
Asthma
COPD
1500000
1000000
500000
0
Developed Developed Developing Developing
1990
2010
1990
2010
www.healthmetricsandevaluation.org 2013
Adult Smoking Prevalence, 2009
Youth Smoking Prevalence, 2009
Tobacco Control Report from the Region
of the Americas 2011
http://www.who.int/tobacco/en/atlas19.pdf
PROPORTION OF PATIENTS WITH COPD WHO
ARE NON-SMOKERS
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
USA
Colombia Brazil
Salvi and Barnes. Lancet 2009
Chile
Mexico UruguayVenezuela
www.who.int/ceh/publications/en/map09b.jpg
HOUSEHOLD AIR POLLUTION
 85% of all global
particulate exposure occurs
indoors
 HAP levels are typically
higher than developed
world standards for
ambient air quality
 EPA Standard: 150
micrograms/cubed meter
 Households with HAP: 3003000
 During cooking 30,000
 50x more carbon monoxide
HAP in Nigeria
http://magazine.uchicago.edu/1102/investigations/in
door_air_pollution.shtml
DIABETES AND HIGH
BLOOD SUGAR
Leading causes of attributable global mortality and
burden of disease, 2004
Attributable Mortality
Attributable DALYs
%
1. High blood pressure
12.8
2. Tobacco use
8.7
3. High blood glucose
5.8
4. Physical inactivity
5.5
5. Overweight and obesity
4.8
6. High cholesterol
4.5
7. Unsafe sex
4.0
8. Alcohol use
3.8
9. Childhood underweight
3.8
10. Indoor smoke from solid fuels 3.3
%
1. Childhood underweight
5.9
2. Unsafe sex
4.6
3. Alcohol use
4.5
4. Unsafe water, sanitation, hygiene 4.2
5. High blood pressure
3.7
6. Tobacco use
3.7
7. Suboptimal breastfeeding
2.9
8. High blood glucose
2.7
9. Indoor smoke from solid fuels 2.7
10. Overweight and obesity
2.3
59 million total global deaths in 2004
1.5 billion total global DALYs in 2004
Health Statistics and Informatics
EPICENTERS OF DIABETES
Deaths from diabetes
Hu. Diabetes Care 2011
The Epidemiologic Transition
Description
Life
Expectancy
% deaths
from CV
Dominant CVDs
35 years
<10
•Infectious (RHD)
•Nutritional
50 years
10-35
•Infectious (RHD)
•Stroke-haemorrhagic
>60 years
35-65
•Ischemic heart disease (IHD)
•Stroke – haemorrhagic,
ischaemic
>70 years
40-50
•IHD
•Stroke – ischaemic
•CHF
Stage 1 Pestilence and Famine
•Malnutrition
•Infectious diseases
Stage 2 Receding pandemics
•Improved nutrition and public health
•Chronic disease
•Hypertension
Stage 3 Degenerative and man-made diseases
•High fat and caloric intake
•Tobacco use
•Chronic diseases > infectious, malnutrition
Stage 4 Delayed degenerative diseases
•Leading causes of mortality CV and
cancer deaths
•Prevention and treatment delays onset
•Age-adjusted CV death reduced
From Gersh et al. European Heart Journal 2010
THE PERFECT STORM OF CVD IN LMICS
LMICs: low- and middle-income countries
Gersh et al. EHJ 2010
Diet
Development
Sedentary lifestyle
Tobacco
Urbanization
Technology
Industry
Projected Deaths by Cause
Beaglehole and Bonita. Lancet 2008
WHERE DO WE GO FROM HERE?
PERCENT OF CVD STUDIES FROM SSA BY
COUNTRY/REGION, 1980 -2008
100%
90%
80%
70%
West Africa
Southern Africa
East Africa
Nigeria
South Africa
60%
50%
40%
30%
20%
10%
0%
1980-87
1987-94
1994-2000
2000-08
CONTEMPORARY CAUSES OF HEART
FAILURE IN SSA
Bloomfield et al. Curr Cardiol Reviews 2013
“FLTR” FOR NCDS
Current
scenario
Find
HOSPITA
L
Proposed
scenario
HOSPITA
L
Link
Health Center
Dispensary
Treat
Retain
COMMUNITY
COMMUNITY
Optimizing Linkage and Retention to Hypertension Care in Kenya:
LARK Hypertension Study. Slide courtesy of R. Vedanthan, Mt. Sinai
OPTIMIZING LINKAGE AND RETENTION
TO HYPERTENSION CARE:
LARK HYPERTENSION
AN OPPORTUNIT Y FOR PRIMARY
PREVENTION
Oxford Health Alliance
2006
THE GOOD NEWS: PREVENTION WORKS
http://www.ktl.fi
THANK YOU
Non-Communicable Diseases in LMICs: Myths,
Facts and Opportunities
Gerald S. Bloomfield, MD, MPH
Duke Global Health Institute
Division of Cardiology
Duke University