Burden of Disease Research Unit

Chronic Diseases in South Africaand Other Developing countries and Implications for the Public Service

Assoc Prof Debbie BradshawMRC Burden of Disease Research Unit

Indaba VII 21-23 October 2007

Overview of presentation

• What is the burden of disease in South Africa?

• How does it compare with other developing countries?

• What is the risk factor profile of South Africa?

• What does it mean for the public service?

SA National Burden of Disease Study (SA NBD)

• Followed the methodology developed by WHO and Harvard to derive best estimates of the disease burden for SA for the year 2000 from multiple sources of information.

• In 2003 the Initial Burden of Disease Estimates for SA, 2000 was published.

• In 2005: Estimates of Provincial Mortality, for 2000.

Cause Estimated numberof deaths

Percentage% of total deaths

HIV/AIDSHIV/AIDSIschaemic heart diseaseStrokeTuberculosisInterpersonal violenceLower respiratory infectionsHypertensive diseaseDiarrhoeal diseasesRoad traffic accidentsDiabetes mellitusChronic obstructive pulmonary diseaseLow birth weightAsthmaTrachea/bronchi/lung cancerNephritis/nephrosisSepticaemiaOesophageal cancerProtein-energy malnutritionSuicideCirrhosis of liver

132 99034 402 33 86628 90727 563 22 91016 64816 00615 99313 54612 76811 5977 0066 8856 7606 2345 5795 4995 4615 442

25.56.66.55.55.34.43.23.13.12.62.52.21.31.31.31.21.11.11.01.0

Leading 20 causes of death, South Africa, 2000

Male deaths by age, 2000

0

5

10

15

20

25

30

35

40

45

0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+

Age group

Deat

hs ('

000)

Other infectious/mat/peri/nutrition HIV/AIDS Non-communicable Injuries

Female deaths by age, 2000

0

5

10

15

20

25

30

35

40

45

0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+

Age group

Deat

hs ('

000)

Other infectious/mat/peri/nutrition HIV/AIDS Non-communicable Injuries

SA NBD: Age distribution of deathsby cause group, 2000

Burden of disease estimates (DALYs)South Africa 2000

Estimated DALYs for persons in 2000- Revised

0 1000 2000 3000 4000 5000 6000

HIV/AIDS

Inf / para excl HIV/AIDS

Neuropsychiatric conditionsIntentional injuries

Unintentional injuriesPerinatal Conditions

Cardiovascular disease

Respiratory diseaseMalignant neoplasms

Respiratory infectionsNutritional deficiencies

Diseases of digestive system

Sense OrgansCongenital abnormalities

Diabetes mellitusMusculo-skeletal diseases

Genito-urinary diseases

Maternal conditionsEndocrine and metabolic

Oral Conditions

DALYs ('000)

YLL

YLD

SA NBD: DALYs by broad cause group, 2000

Male DALYs, 2000 N = 7 851 457

Non-communicable

33.1%

Injuries20.1%

HIV/AIDS23.1%

Other communicable/mat/

peri/nutrition23.7%

Female DALYs, 2000N = 6 930 763

HIV/AIDS30.9%

Non-communicable

37.8%

Injuries7.8%

Other communicable

/mat/peri/nutrition 3.5%

Low-and-middle-income countries High-income countries

1 Perinatal conditions 6.4% Iscaheamic heart disease 8.3%2 Lower respiratory infections 6.0% Stroke 6.3%3 Ischaemic heart disease 5.2% Unipolar depressive disorders 5.6%4 HIV/AIDS 5.1% Alzheimer’s and other dementias 5.0%

6 Diarrhoeal disease 4.2% Hearing loss, adult onset 3.6%7 Unipolar depressive disorders 3.1% Chronic obstructive pulm. disease 3.5%8 Malaria 2.9% Diabetes mellitus 2.8%9 Tuberculosis 2.6% Alcohol use disorders 2.8%

5 Stroke 4.5% Trachea, bronchis, lung cancers 3.6%

Cause % of total DALYs

Cause % of total DALYs

10 Chronic obstructive pulm. disease 2.4% Osteoarthritis 2.5%

Leading 10 causes of burden of disease (DALYs) by income group, 2001

Source: Lopez, Mathers, Ezzati, Jamison, Murray, Lancet 2006; 367: 1747–57

SA and Afro-E estimates at age 15-59 yrs, 2001

South Africa* Deaths(%) Afro-E Deaths(%)

HIV/AIDS 38.0 HIV/AIDS

Violence 9.7 Tuberculosis 4.8

* MRC Burden of Disease Research Unit for year 2000

Lower respiratory infections

War

Road traffic accidents

Diarrhoeal diseases

Violence

Cerebrovascular disease

Ischaemic heart disease

Hypertensive disease 1.7 Maternal haemorrhage 1.3

55.6

Tuberculosis 8.3 3.3

Road traffic accidents 4.5 3.2

Cerebrovascular disease 3.7 2.3

Lower respiratory infections 3.1 2.0

Ischaeamic heart disease 3.1 1.8

Suicide 1.8 1.6

Diabetes mellitus 1.8 1.6

SA Comparative Risk Assessment (SA CRA)

• Next step was to estimate the relative contribution of 17 selected risk factors to the burden of disease in South Africa in 2000.

• Risk factors were selected based on the following criteria:

– likely to be among the leading causes of burden of disease and injury;

– published evidence of causality; – potentially modifiable; and – availability of reliable data.

SOUTH AFRICAN COMPARATIVE RISK ASSESSMENTChildhood and maternal undernutrition1. Underweight 2. Iron deficiency 3. Vitamin A deficiency

Other nutrition-related risk factors and physical inactivity 4. High blood pressure 5. High cholesterol6. High BMI (overweight and obesity) 7. Low fruit and vegetable intake8. Diabetes 9. Physical inactivity

Sexual and reproductive health 10. Unsafe sex

Addictive substances11. Tobacco 12. Alcohol

Environmental risks 13. Unsafe water, sanitation and hygiene 14. Indoor smoke from solid fuels15. Lead exposure16. Urban air pollution

Other selected risks to health17. Interpersonal violence (includes child sexual abuse, intimate partner and community violence)

Key pathways for diet, physical activity, and obesity on nutrition-related chronic diseases

Adapted from Kim S, Popkin BM. 2006. Commentary: Understanding the epidemiology of overweight and obesity – a real global public health concern. Int J Epidemiology 35(1): 60-67. Note: Direction of effects are not presented.

Overweight/obesity

Hypertension

Dyslipidemia

Insulin resistance

Coronary Heart Dis

Stroke

Gallbladder disease

Osteoporosis

Osteoarthritis

Cancers

Type II Diabetes

Intermediary conditions

Chronic diseases

Trans fat

Fiber

Fruit/vegetables

Whole grains

Sugar

Alcohol

Calories

Saturated fat

Fetal/infant development

A. Possible fetal/infant factors

B. Dietary factors

C. Physical activity

Risk Factor Prevalencecriteria

South Africa 2000

Population affected

High blood pressure

Cut-off 140/90mmHg 34% males36% females(SA DHS 1998)

2.6 million men3.3 million women(30+ years)

High cholesterol Proportion ≥ 5 mmol/l Males 45%Females 50%

3.4 million men4.5 million women (30+ years)

Excess body weight(High BMI)

Proportion overweight/obese(BMI ≥25 kg/m2)

38% of males 68% of females(SA DHS 1998)

2.9 million men6.2 million women (30+ years)

Low fruit and vegetable intake

Proportion consuming less than 5 per day 80%

Males 80%Females 80%

6.1 million men7.3 million women (30+ years)

Diabetes Proportion diabetics with plasma glucose concentration of >11.1 mmol/l

Males 5%Females 6%

0.4 million men0.6 million women(30+ years)

Physical inactivity Doing no or very little physical activity

Males 43%Females 49%(WHS 2003)

6 million men7.6 million women(15+ years)

Smoking tobacco No smoking Males 44%Females 11%(SA DHS 1998)

6 million men1.1 million women(15+ years)

Mortality (deaths) Mortality (deaths)

Rank Risk factor% total deaths Rank Disease or injury

%Total deaths

1 Unsafe sex/STIs 26.3 1 HIV/AIDS 25.5

2 High blood pressure 9.0 2 Ischaemic heart disease 6.63 Tobacco 8.5 3 Stroke 6.5

4 Alcohol harm 7.1 4 Tuberculosis 5.5

5 High BMI 7.0 5 Interpersonal violence 5.3

6 Interpersonal violence 6.7 6 Lower respiratory infections 4.47 High cholesterol 4.6 7 Hypertensive disease 3.2

8 Diabetes 4.3 8 Diarrhoeal diseases 3.1

9 Physical inactivity 3.3 9 Road traffic accidents 3.1

10 Low fruit and vegetable intake 3.2 10 Diabetes mellitus 2.6

11 Unsafe water, san & hygiene 2.6 11 COPD 2.5

12 Child and maternal underweight 2.3 12 Low birth weight 2.2

13 Urban air pollution 0.9 13 Asthma 1.3

14 Vitamin A deficiency 0.6 14 Trachea/bronchi/lung cancer 1.3

15 Indoor smoke 0.5 15 Nephritis/nephrosis 1.3

16 Iron deficiency anaemia 0.4 16 Septicaemia 1.2

17 Lead exposure 0.3 17 Oesophageal cancer 1.1

South Africa, 2000

Attributable DALYs (% of 16.2 million)

31.5%

8.5%

7.0%

4.0%

2.9%

2.7%

2.6%

2.4%

1.6%

1.4%

1.1%

1.1%

1.1%

0.7%

0.4%

0.4%

0.3%

Unsafe sex/STIs

Interpersonal violence

Alcohol harm

Tobacco

High BMI

Childhood and Maternal underweight

Unsafe water sanitation and hygiene

High blood pressure

Diabetes

High cholesterol

Low fruit and vegetable intake

Physical inactivity

Iron deficiency anaemia

Vitamin A deficiency

Indoor smoke

Lead exposure

Urban air pollution

South Africa, 2000

• Top three risk factors have strong social determinants. There is an urgent need to build social cohesion and the rights-based vision embedded in the South African Constitution. A sense of humanity(ubuntu) and a culture of respecting human rights and valuing life need to be fostered.

• The reduction of poverty is not an automatic consequence of development, particularly in the context of current globalisationtrends. It is essential to ensure that development is sustainable so as to avoid harmful health effects such as pollution, and so ensure that the environment can provide for future generations.

• In terms of chronic diseases there is a need to promote healthy lifestyles, diagnose chronic diseases at an early stage, and implement cost-effective management of risk factors and disease. (The WHO refers to a healthy lifestyle in terms of no tobacco use, good nutrition and increased physical activity).

• So - what does it mean for the public service?

• The public service employs a cross-section of South Africans. Sector specific studies show public service is affected by HIV – and is unlikely to be exempt from the other burdens.

• Chronic diseases and mental health problems could possibly be higher in public service.

• Public service has an important contribution towards interventions.

Ecological model for interventions

Biological Behavioural Societal Structural

Up-streamDown-stream

Physical inactivity, tobacco use, and diet-related risk factors to chronic diseases of lifestyleIndividual Balance dietary intake and energy expenditure to achieve and

maintain a healthy weight.• Maintain daily physical activity.• Limit excessive caloric intake from any source.• Limit consumption of sugar and sugar-based beverages.

Eat a healthy diet• Eat 5 fruit and vegetable portions a day.• Reduce intake of salt.• Reduce intake of saturated and trans-fat content.

Avoid tobacco use.Reduce alcohol intake. Regularly check weight, blood pressure, blood sugar and

cholesterol.

Physical inactivity, tobacco use, and diet-related risk factors to chronic diseases of lifestylePopulation/Community

• Consistent messages on television, radio, and the print media –must be locally relevant.

• Promote workplace, health care provider, and community healthy lifestyle programmes.

• Develop school programmes that integrate nutrition, physical activity, tobacco and alcohol use into core curricula and/or lifestyles programmes, and healthy nutrition into school food/snack services.

• Improve primary care diagnosis and management of risk factors for chronic diseases including hypertension, raised blood sugar,raised cholesterol levels and excess bodyweight. Promote secondary prevention such as exercise after cardiovascular events or diagnosis of diabetes.

• Implement smoking cessation programmes in primary care clinics. Target pregnant women – particularly coloured women who have amongst the highest female smoking prevalence in the world.

Physical inactivity, tobacco use, and diet-related risk factors to chronic diseases of lifestyleMacrolevel/National

• Policy makers can influence consumption patterns through subsidies, taxes, regulations and policies, as well as concertedactions - to ensure wide availability and affordability of healthy foods including fruit and vegetables; limit the salt content of manufactured foods and staples such as bread, reduce the saturated fat content of food; limit the promotion of unhealthy food to children. Food labeling has and important role to play. There is a need to further tighten, enforce and monitor the impact of tobacco regulation South African tobacco legislation.

• Design the environment to promote health: Modify town, road, building and environmental designs to promote physical activity through safe walking, cycling, and use of stairs, and improve access to public transportation.

• Allocate funds for interventions and research.

www.who.int/chp

The global goal

A 2% annual reduction in chronic disease death rates worldwide, per year, over the next 10 years.The scientific knowledge to achieve this goal already exists.

Reality: 80% of premature heart disease, stroke and type 2 diabetes is preventable, 40% of cancer is preventable

Reality: inexpensive and cost-effective interventions exist

Reality: these people are the rare exceptions

Reality: death is inevitable but it does not need to be slow, painful or premature

Dying slowly, painfully and prematurely

Burden of Disease Research Unit

www.mrc.ac.za/bod/bod.htm

www.sahealthinf.org