Stopping the rising tide of chronic diseases
Chronic diseases used to be considered "disease of the rich," but not anymore. Developing countries are facing a tsunami of deaths and illness due to cancer, heart disease, stroke and diabetes.
Prevention of chronic diseases should start early in life.
Patricia Pizarro speaks with a tone of pained frustration.
"I had no idea I might be hurting him," she says of her son Fernando. Pizarro had taken her 12-year-old son to the doctor for a rash on his arm. She left on the verge of tears, not because of the minor allergy that was causing his skin problem but because of the doctor's overall diagnosis: Fernando is obese and has high blood pressure, and if nothing is done about it he could soon become diabetic. Even more frightening: "The doctor told me he could have a heart attack if we're not careful!"
Fernando's typical day goes something like this: In the morning, he gets up and eats a sandwich. He goes to school, where he eats sweets at recess and just about anything but vegetables at lunch. At most a couple of hours per week are set aside for sports. When he gets home, he watches television or plays on the computer (it's easier than going out to ride his bicycle, Fernando says, and there's no risk that someone will steal his bike). While watching TV or sitting at the computer, he snacks on cookies, potato chips, candy, a sandwich, and soda. His social life consists mostly of "chatting" with online friends. When his parents get home, Fernando eats again, then goes to bed at around 10:00 p.m.
That daily routine is not unusual for children living in Santiago, Chile, or in any other Latin American city for that matter. With "modernization," people throughout the region are changing their habits and customs, with serious implications for their health. Experts say that if current trends continue, the region's health systems will face a tidal wave of patients suffering from diabetes, hypertension, cancer and heart problems. In fact, the tidal wave has already started: in the last 15 years, the Americas have seen an explosion of chronic noncommunicable diseases, or NCDs.
Chronic diseases used to be considered "diseases of the rich": poorer people and poorer countries suffered from infectious maladies like malaria, tuberculosis, and AIDS, while those who were better off had higher rates of heart disease, diabetes, and stroke.
Today that picture has changed. NCDs are now the leading killers worldwide, causing twice as many deaths as infectious diseases, complications of childbirth, and malnutrition combined. Eight out of ten chronic disease deaths are in low- to middle-income countries, and in all countries, poor people bear the heaviest burden of these diseases (see box to the right).
In the Americas region, chronic diseases have been the leading cause of death in Canada and the United States for decades. But today they are the leading killers in Latin America and the Caribbean as well, accounting for two out of every three deaths in the region, according to Pan American Health Organization (PAHO) data for 2002.
Striking as these figures are, they probably understate the problem because of underreporting, says James Hospedales, chief of PAHO's Chronic Diseases Unit. What is certain is that the trend is upward.
"We've seen a lot of progress in other areas-continuing declines in deaths from infectious diseases, for example, and childbirth and malnutrition," he says. "But with chronic diseases, we see the opposite. They're increasing at a fast rate as the population ages and as the underlying risk factors become more widespread. Given current trends, we expect deaths from chronic diseases to increase 17 percent in just the next eight years."
In addition to illness and deaths, Hospedales notes that chronic diseases take a toll on economies and workforce productivity. The current estimated cost of diabetes in Latin America and the Caribbean is $85 billion per year. "Some Caribbean countries are losing five to eight percent of their GDP just due to diabetes and hypertension," he says.
The good news is that much of the burden of chronic diseases is preventable. According to the World Health Organization (WHO), 80 percent or more of heart disease, stroke and type 2 diabetes, along with 40 percent of cancers, could be prevented by eliminating a handful of risk factors.
"Lifestyle issues are key," says Hospedales, adding a familiar list of dos and don'ts: "People need to eat healthier foods, less fat and salt, more fruits and vegetables; they need to be more active physically; and they need to stop or never start smoking. You have to educate people and do more health promotion."
But there's more, he says. "We can't put the blame entirely on the individual. We also have to make the right choices easier, and for that you need action at the population level-government, the private sector and civil society acting together to address the social and political determinants of the epidemic."
It's easy to blame the rise of fast food for the decline of healthy living in the Americas, but the problem is much more complex. As part of a long-term "nutrition transition," countries around the world have moved from traditional diets high in grains and vegetables toward diets higher in fat, sugar, and calories. This trend has accelerated in recent decades as consumption of processed and fast foods has grown, as a result of women's growing participation in the workforce but also due to urbanization, the rise of the supermarket, and marketing and retail trends, says Enrique Jacoby, PAHO regional advisor on healthy eating and healthy living.
In the United States, Jacoby notes, prices for fruits and vegetables more than doubled from 1985 to 2000, while fats only rose 35 percent and soft drinks, 20 percent. Similar trends can be seen in Latin America and the Caribbean.
"In urban areas, processed foods cost less today than fresh fruits and vegetables, and prices of fruits and vegetables are increasing faster than processed foods," says Jacoby. "So it costs people more to eat healthy but less to consume more calories."
Equally important are changing trends in work, transportation, and leisure. Modern jobs require less physical exertion, and as more people own cars, fewer rely on public transit and walking. Meanwhile, urban growth and development are squeezing out parks and recreational spaces in cities around the world, while personal safety concerns mean both children and adults are spending more and more time indoors. A WHO study in 2002 found that 30-60 percent of people in Latin America and the Caribbean do not get the recommended amount of exercise: 30 minutes of moderate physical activity five times a week for adults and an hour daily for children and adolescents.
The result of these trends is alarming and increasing rates of overweight and obesity, among the top risk factors for chronic disease. According to PAHO data for 2002, 50-60 percent of adults in Latin America and the Caribbean are overweight or obese, along with 7-12 percent of children under 5.
A stealthy foe
Though these trends have been building for some time, they have taken many countries by surprise. Governments throughout the PAHO region were until recently more focused on infectious diseases, maternal mortality, environmental problems, and malnutrition, rather than growing rates of overweight and obesity.
Chile is a case in point. Supplementary food programs aimed at the poor continued to operate well into the 1990s, despite the fact that hunger had virtually disappeared by then. Today, half of Chilean school children are overweight, while 17 percent are obese.
"I have to admit, we lacked vision and failed to take as a reference point what has happened in the United States," says Cecilia Castillo, former chief of nutrition in Chile's Ministry of Health and currently an advisor to the Organization of Consumers and Users (ODECU). "Now we're in a critical situation. We have an epidemic upon us."
Chile is not alone. Other Latin American and Caribbean countries have only recently begun to pay attention to chronic diseases and their risk factors, says Alberto Barceló, PAHO regional advisor on chronic diseases.
"There are countries with very good programs, such as Chile, Mexico, and Brazil. But in many countries, programs do not yet exist, and in others, the resources are very limited."
But all that is beginning to change. In 2006, ministers of health from throughout the region agreed to boost their efforts to fight the epidemic and signed on to a comprehensive PAHO Regional Strategy for the Prevention and Control of Chronic Diseases, Including Diet and Physical Activity.
In September 2007, at a special summit in Trinidad and Tobago, Caribbean heads of state vowed to put chronic diseases at the top of their health concerns and adopted a 14-point declaration, "Uniting to Stop the Epidemic of Chronic Diseases." Among the measures they promised were establishing national commissions, mandated nutritional labeling on foods, tougher controls on tobacco sales and advertising, more physical education in schools, and promotion of local agricultural products to mitigate the negative effects of globalization on the food supply (see also PAHO Today).
Experts point out that fighting chronic diseases cannot be seen as solely the responsibility of the health sector.
"We need strategies that cut across all sectors," says PAHO's Barceló, "not just health but also education, agriculture, development. We need to involve nongovernmental organizations, industry, scientific and academic institutions, advocacy groups, the media, and international organizations."
Examples of such efforts include "five-a-day" campaigns to encourage people to eat more fruits and vegetables, but also agricultural policies that provide incentives to increase production of healthy foods. Other examples include community-based initiatives such as "healthy schools" and "healthy municipalities" that work to create physical and social environments that encourage healthy living among both children and adults.
Stronger health systems
To be sure, the health sector has a special responsibility to deal with the growing epidemic of chronic diseases. According to evidence published in the medical journal The Lancet in December 2007 (free registration required), widespread use of low-cost drugs to treat people with or at high risk of cardiovascular disease could prevent at least 18 million deaths worldwide (the analysis included Argentina, Brazil, Colombia and Mexico). And in addition to the 40 percent of cancers that could be prevented through lifestyle changes, an additional 30 percent can be treated effectively, according to WHO.
To strengthen the health sector's response to NCDs, PAHO's regional strategy calls for strengthening health systems with a greater focus on health promotion and primary health care to boost prevention and improve disease management. This includes developing effective referral systems that can steer patients toward primary, secondary, and tertiary levels of care as needed.
Equally important is a strong, well-trained health workforce and a "'team approach" to chronic diseases, says Felix Rigoli, PAHO regional advisor on human resources development.
"We need training programs-including continuing education-to create expertise in different areas of prevention and management of chronic diseases," he says. "And we need those trained health professionals to partner with patients and other providers to provide truly multidisciplinary care."
But experts like Chilean nutritionist Cecilia Castillo emphasize that the health sector needs to move beyond its traditional approach to prevention of chronic diseases, which relies heavily on health education and health promotion.
"There's been a lot of education, but the educational methods are perhaps not very interesting when you contrast them with advertising," says Castillo. For example, she notes, it's hard to get children to eat vegetables when they are constantly bombarded with colorful and engaging ads selling unhealthy foods.
Guido Girardi, a physician and member of the Chilean senate, agrees. "The food industry and their advertisers take full advantage of that need embedded in our genes to seek foods that are rich in fat, sugar, and salt.… Today we know that kind of diet, created for an environment of scarcity and constant physical activity, is not a healthy alternative for your average citizen."
To counter these influences, Girardi is sponsoring legislation, now before the Chilean senate, that would restrict advertising and sales of unhealthy foods to children, require warning labels on unhealthy foods as well as labels identifying processed foods as having high, medium, or low fat, sugar, and salt content.
Others think even tougher measures are necessary to counter the growing tide of chronic diseases. These include prohibiting the sale of soft drinks and junk food in schools and imposing taxes on high-fat foods while providing tax breaks or subsidies for fruits, vegetables, and other healthier foods.
PAHO's Jacoby says price and availability of healthy alternatives are key. "We have to make healthy choices easier and less expensive. Research shows people will buy healthier foods if the healthier choice is also the cheaper choice."
Meanwhile, campaigns promoting healthier diets and increased physical activity are becoming more commonplace throughout Latin America and the Caribbean, including the PAHO-sponsored campaign "Let's Eat Well, Live Healthy, and Get Moving, America," whose spokesperson is the Hispanic television personality Mario Kreutzberger (alias "Don Francisco").
Campaigns like these are "progress," says Kathy Pramparo, head of epidemiology and prevention at the Inter-American Heart Foundation.
"But they'll only get good results if they are combined with credible opinion leaders and energetic public policies-and without pressure from the food industry," says Pramparo.
"Eating habits and lifestyles don't change overnight. You have to work on several fronts at once, using laws and regulations, saying 'no' to tobacco, requiring prevention in schools, regulating the food industry, and ensuring access to health for all."