CHRONIC DISEASE

• Chronic diseases are diseases of long duration and generally slow progression. • Chronic diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are by far the leading cause of mortality in the world, representing 60% of all deaths. • Although chronic diseases are among the most common and costly health problems, they are also among the most preventable.

- World Health Organization 4/27/2020 Environmental health issues – Chronic diseases 2

CAUSES OF DEATH, 2005

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HOW DID CHRONIC DISEASES EMERGE?

1. Demographic Transition

• Transition from developing to developed countries • Birth rate and death rate decline (almost all industrialized countries) • Higher life expectancy 4/27/2020 Environmental health issues – Chronic diseases 4

2. EPIDEMIOLOGICAL TRANSITION

A shift from infectious disease to chronic disease through: (1) Nutritional improvements (2) Industrial pollution problems emerge (3) Growth of cities (4) Improved hygiene and sanitation (5) Medical advancements and disease prevention (6) Higher Life Expectancy due to med. + sanitation improvements 4/27/2020 Environmental health issues – Chronic diseases 5

3. NUTRITIONAL TRANSITION

Urbanization, economic growth, technological changes for work, leisure, & food processing, mass media growth Pattern 3 Receding Famine Pattern 4 Degenerative Disease Pattern 5 Behavioral Change • starchy, low variety, low fat,high fiber • labor-intensive work/leisure • increased fat, sugar, processed foods • shift in technology of work and leisure • reduced fat, increased fruit, veg,CHO,fiber • replace sedentarianism with purposeful changes in recreation, other activity MCH deficiencies, weaning disease, stunting obesity emerges, bone density problems reduced body fatness, improved bone health Slow mortality decline accelerated life expectancy, shift to increased DR-NCD, increased disability period

Source: Popkin, Barry M. ( 2002) Public Health Nutrition 5:93-103.

4/27/2020 extended health aging, diseases reduced DR-NCD 6

IMPACT OF THE EPIDEMIOLOGICAL, NUTRITIONAL, AND DEMOGRAPHIC TRANSITION ON CHRONIC DISEASE Demographic Transition Epidemiologic Transition Nutrition Transition

High

___________________________________________________________________________________________________________________________________________

fertility/mortality High prevalence infectious disease High prevalence undernutrition Reduced mortality, changing age structure Receding pestilence, poor environmental conditions Receding famine Reduced fertility, aging Focus on family planning, infectious disease control Chronic diseases predominate Focus on famine alleviation/prevention Diet-related noncommmucable diseases predominate Focus on healthy aging spatial redistribution

Source: Popkin, Barry M. ( 2002) Public Health Nutrition 5:93-103.

Focus on medical intervention, policy initiatives, behavioral change 4/27/2020 Environmental health issues – Chronic diseases 7

HEART DISEASE

• Heart disease is an umbrella term used to describe a variety of diseases that affect the heart Coronary Heart Disease • Cardiomyopathy • Cardiovascular Disease • Ischaemic heart failure • Heart failure • Hypertensive heart disease • Inflammatory heart disease • Valvular heart disease 4/27/2020 Environmental health issues – Chronic diseases 8

2009 ESTIMATED US CANCER DEATHS*

Lung & bronchus Prostate Colon & rectum Pancreas Leukemia Liver & intrahepatic bile duct 30% 9% 9% 6% 4% 4% Esophagus Urinary bladder 4% 3% Non-Hodgkin 3% lymphoma Kidney & renal pelvis 3% All other sites 25%

Men 292,540 ONS = Other nervous system.

Source: American Cancer Society, 2009.

Women 269,800

26% 15% 9% Lung & bronchus Breast Colon & rectum 6% 5% 4% 3% 3% 2% Pancreas Ovary Non-Hodgkin lymphoma Leukemia Uterine corpus Liver & intrahepatic bile duct 2% Brain/ONS 25% All other sites 4/27/2020 Environmental health issues – Chronic diseases 9

The Impact of Chronic Disease Today

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(1) Impacts Daily Activities

Each year, arthritis results in estimated medical care costs of nearly $81 billion, and estimated total costs (medical care and lost productivity) of $128 billion. - CDC 11

(2) It is Extremely Costly

Some stats…. • The medical care costs of people with chronic diseases account for more than 75% of the nation’s $2 trillion medical care costs.

• The direct and indirect costs of diabetes is $174 billion a year. • The estimated direct and indirect costs associated with smoking exceed $193 billion annually.

- The Centers for Disease Control 4/27/2020 Environmental health issues – Chronic diseases 12

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(3) Chronic Disease are Preventable

Basic Preventative Steps:    Healthy diet Exercise Quit Smoking • Prevention Programs: Example: CDC Community Initiative: $450 million •

States and Environmental Change

Initiative: $120 million •

National Prevention and Media

Initiative: $40 million 4/27/2020 Environmental health issues – Chronic diseases 14

A Main Contributor to Chronic Disease Today:

OBESITY

The Facts:  2000: obesity-related health care costs totaled an estimated $117 billion.

 1987-2001: diseases associated with obesity account for 27% of the increases in medical costs.

 Medical expenditures for obese workers are between 29%–117% greater than those with normal weight.

 1979–1981 to 1997–1999: annual hospital costs related to obesity among children and adolescents increased, rising from $35 million to $127 million.

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The Health Consequences of Obesity

 Coronary heart disease  Type 2 diabetes     Cancer (endometrial, breast, and colon) Hypertension (high blood pressure) Dyslipidemia (high total cholesterol or high levels of triglycerides) Stroke   Liver and gallbladder disease Sleep apnea and respiratory problems  Osteoarthritis (degeneration of cartilage and underlying bone within a joint) http://medmovie.com/mmdatabase/mediaplayer.aspx?Message=VG9wa WNpZD05MjM7Q2xpZW50SUQ9NjU7VmVybmFjdWxhcklEPTE %3D-41OT%2BnKlNEA%3D 4/27/2020 Environmental health issues – Chronic diseases 16

Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2008 (*BMI



30, or about 30 lbs. overweight for 5’4” person) 1990 1999 2008 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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Chronic diseases are associated with Environmental Health

Based on WHO studies



WHO report "Preventing disease through healthy environments" (2006)

 

Environmental factors = 80% diseases

◦ infectious + chronic

Worse in developing countries but almost equal for non-communicable diseases

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 ◦ ◦ ◦

Environmental factors

◦ pollution of air, water, soil UV and ionizing radiations occupational risks availability of safewater and sanitation facilities 

Not included

◦ alcohol ◦ tobacco ◦ natural biological agents 4/27/2020 Environmental health issues – Chronic diseases 20

Units

 ◦ ◦

Disease burden

◦ deaths incidence DALY = Disability Adjusted Life Years   combines burden due to death and disability sometimes more helpful than the number of deaths to understand a burden 4/27/2020 Environmental health issues – Chronic diseases 21

Link disease/environment

 ◦ ◦

Asthma

◦ indoor: dampness, dust outdoor: air pollution workplace: chemical irritants 

Chronic Obstructive Pulmonary Disease (COPD)

◦ air pollution ◦ workplace: dusts and chemicals 4/27/2020 Environmental health issues – Chronic diseases 22

Link disease/environment



Cancers

◦ physical carcinogens: UV, ionizing radiations ◦ chemical carcinogens: asbestos, aflatoxin (food), arsenic 

Cardiovascular diseases

◦ ◦ ◦ air pollution risks on workplace exposure to chemicals (lead) 4/27/2020 Environmental health issues – Chronic diseases 23

Link disease/environment



Musculoskeletal diseases (osteoarthritis, rheumatoid arthritis)

◦ ergonomic stressors at work ◦ occupational risks (vibration, lifting heavy weights) ◦ occupational conditions 4/27/2020 Environmental health issues – Chronic diseases 24

Situation in the US

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Global estimates of burden of disease caused by the environment and occupational risks



Country groupings for the global assessment

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Country groupings for the global assessment

  ◦ ◦ ◦ ◦ ◦

Subregions:

◦ AFR = Africa AMR = Americas EMR = Eastern Mediterranean EUR = Europe SEAR = South-East Asia ◦ ◦ ◦ ◦ WPR = Western Pacific

Mortality:

◦ A = Very low child, very low adult mortality B = Low child, low adult mortality C = Low child, high adult mortality D = High child, high adult mortality E = High child, very high adult mortality 4/27/2020 Environmental health issues – Chronic diseases 27

Lots of data

     

Water, sanitation and hygiene Indoor air pollution Urban air pollution Lead Climate change Occupational:

◦ carcinogens ◦ airborne particulates ◦ ergonomic stressors ◦ noise 4/27/2020 Environmental health issues – Chronic diseases 28

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Chronic Diseases are not associated with Environmental Health

Elizabeth Garrard

Major Factors in Chronic Disease

    

Genetics Diet Exercise

◦ Built Environment

Medical Improvements Health Education

◦ Choices such as smoking and alcohol consumption ◦ Socioeconomic Status 4/27/2020 Environmental health issues – Chronic diseases 31

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   Significant changes in diet habits, physical activity levels, and tobacco consumption worldwide are a result of industrialization, urbanization, economic development and food market globalization. –WHO 2009   Five out of the 10 leading global disease burden risk factors identified by World Health Report 2002 - high blood pressure, high cholesterol, obesity, physical inactivity and insufficient consumption of fruits and vegetables - are strongly related to diet and physical activity. Together with alcohol and tobacco use, these preventable risks play a key role in the development of chronic diseases, which frequently involve overlapping risk factors and chronic conditions. – WHO 2009 The leading causes of death in 2000 were tobacco (435 000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (400 000 deaths; 16.6%), and alcohol consumption (85 000 deaths; 3.5%) (Ali et al 2004).

People are consuming a more energy-dense, nutrient-poor diet and are less physically active. These are no longer only diseases of the developed world: some 80% of all CVD deaths world-wide took place in developing, low and middle-income countries, while these countries also accounted for 86% of the global CVD disease burden. – WHO 2009  

Genetics

◦ ◦ High Blood Pressure – High Cholesterol – Predisposed Also a result of more energy-dense, nutrient-poor diet

Nutrition

◦ High Salt intake increases blood pressure ◦ Insufficient consumption of fruits and vegetables – 2.7 million deaths  Many fruits and vegetables have protective effects that may be mediated with antioxidants, micronutrients such as flavonoids, carotenoids, vitamin C, and folic acid, as well as dietary fiber. – WHO 2009 ◦ Dall et al estimate that permanent 100-kcal reductions in daily intake would eliminate approximately 71.2 million cases of overweight/obesity and save $58 billion annually.   Long-term sodium intake reductions of 400 mg/d in those with uncontrolled hypertension would eliminate about 1.5 million cases, saving $2.3 billion annually. Decreasing 5 g/d of saturated fat intake in those with elevated cholesterol would eliminate 3. 9 million cases, saving $2.0 billion annually.



Exercise

◦ ◦

Brownson et al 2004 "DECLINING RATES OF PHYSICAL ACTIVITY IN THE UNITED STATES: What Are the Contributors?."

Regular physical activity reduces the risk of premature death and disability from a variety of conditions including coronary heart disease, diabetes, colon cancer, osteoarthritis, and osteoporosis (51). In the United States, estimates of the annual cost in lives lost have ranged from 200,000 to 300,000 (17, 26–28, 32), and medical costs due to inactivity and its consequences are estimated at $76 billion in 2000 dollars (33).

◦ ◦ ◦ relatively stable or slightly increasing levels of leisure-time physical activity, declining work-related activity, declining transportation activity, declining activity in the home, and increasing sedentary activity.

overall trend of declining total physical activity.

Built Environment  suburbs 4/27/2020 Environmental health issues – Chronic diseases 38

  

Medical Improvements

◦ ◦ ◦

Socioeconomic Status

◦ A comparison of Americans and Europeans on 6 Chronic Diseases by Avendano et al, found that eighteen percent of Americans reported heart disease, compared with 12% of English and 11% of Europeans. ◦ At all wealth levels, Americans were less healthy than were Europeans, but differences were more marked among the poor.

Health Education Todd Jackson 2009 - “Profiles of Chronic Illness Knowledge in a Community Sample of American Adults”

Awareness of symptoms, risks, and consequences of chronic illnesses can facilitate prevention, early detection, and treatment Consistent with past work (e.g., Beier & Ackerman, 2003; Klug et al., 2005; McCafferty et al., 2003; Persell et al., 2004; Reeves et al., 2002), respondents with the least accurate level of illness knowledge were more likely to be young adult, unmarried, and lower on a subjective measure of SES than their counterparts in medium- and high-knowledge groups.

◦ ◦ ◦ \The low-knowledge group also reported lower education, occupation, and income levels than the high-knowledge group, a pattern that is consistent with data suggesting low SES groups have limited health literacy, less access to preventative medical information, and a reduced capacity to view messages about health and illness as information rather than “noise” higher SES groups may have greater direct access to medical information and are said to interact in information rich environments wherein social networks and media indirectly contribute to knowledge and risk-reduction Sociodemographic experiences corresponded not only to illness knowledge level but also to relations between illness knowledge and other measures of interest.

       References (APA) Avendano, M., Mackenbach, J., Glymour, M., & Banks, J. (2009). Health Disadvantage in US and Adults Aged 50 to 74 years: A Comparison of the Health of Rich and Poor Americans With That of Europeans. American Journal of Public Health, 99(3), 540-548. doi:10.2105/AJPH.2008.139469.

Brownson, R., Boehmer, T., & Luke, D. (2005). DECLINING RATES OF PHYSICAL ACTIVITY IN THE UNITED STATES: What Are the Contributors?. Annual Review of Public Health, 26(1), 421-443. doi:10.1146/annurev.publhealth.26.021304.144437.

Dall, T., Fulgoni, I., Zhang, Y., Reimers, K., Packard, P., & Astwood, J. (2009). Potential Health Benefits and Medical Cost Savings From Calorie, Sodium, and Saturated Fat Reductions in the American Diet. American Journal of Health Promotion, 23(6), 412-422. Retrieved from Academic Search Premier database.

Jackson, T. (2009). Profiles of Chronic Illness Knowledge in a Community Sample of American Adults. Journal of Genetic Psychology, 170(3), 197-212. Retrieved from Academic Search Premier database.

Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004). Actual Causes of Death in the United States, 2000. JAMA, 291(10), 1238-1245.

WHO 2009. “Chronic Diseases” Website . © Copyright World Health Organization (WHO), 2009. All Rights Reserved. Accessed Nov 10, 2009.

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