Health Transition Global Burden of Mortality and Disease Overnutrition

1. 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

3. Terms: Epidemiologic Transition Gaziano 2005

4. Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.

6. 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.

7. Cause-specific Mortality Population Reference Bureau (Cohn 2007)

9. Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.

10. Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.

11. Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.

12. Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.

13. 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.

14. Projections of Global Mortality and Burden of Disease from 2002 to 2030. Mathers & Loncar. PLoS Med November 2006 | Volume 3 | Issue 11 | e442.

15. 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 WHO: Facts related to chronic diseases; Yach 2004, Strong 2005

16. 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

25. Health InequalitiesHealth Inequities

28. Marmot 2005. Social determinants of health inequalities Lancet 365: 1099–104

29. 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)

30. 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

33. Nutrition Transition Part 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

35. BMI Classifications and Disease Risks BMI GroupsNCD 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

36. Prevalence of Overweight & Obesity in Women 15-49 yr

37. Overweight & Obesity in the US- age adjusted prevalence

38. Coexistence of overweight and underweight in developing societies • Rapid urbanization and nutrition transition – reliance on energy dense diets and physical inactivity • Co-distributions of underweight and overweight individuals is conditional on stage of economic development and age distribution of households • Intrahousehold food allocation influences the under/over weight phenomenon

40. Am Samoa Market 1976

41. Fast Food & Vehicles Am Samoa – Now

42. Prevalence of Obesity, BMI >32 kg/m2, in American Samoa Adults 1976-2002

43. Type 2 diabetes, FSG>126 mg/dl, Dx & Rx, by Age in American Samoa Adults 1990-2002

44. Overweight & Obesity, in American Samoa Children & Adolescents Girls – 1976-78 and 2002

45. Hypothesis

46. Diet and BMI in Samoa 1961-2010

47. 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

48. 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

49. 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 $$.

50. 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