The New Challenges for Obstetricians.

The Prevention of NCDs

L. Cabero Roura

Barcelona

Non communicable diseasesDisease that is not transmitted by another person, a vector, or the

environment.

NCDs• Diabetes

• Obesity

• Hypertension

• Isquemic CVD

• Ictus

• Rheumatic diseases

• Cancer

• Others

Global Causes of Death

Noncommunicable diseases

Communicable diseases,

maternal and perinatal

conditions, and nutritional

deficiencies

Injuries

Source: WHO, World Health Report 2000—Health Systems: Improving Performance (Geneva: WHO, 2000).

NCDs : leeding cause of mortality

• A vicious circle may ensue: poverty exposes people to behavioural risk factors for NCDs and, in turn, the resulting NCDs may become an important driver to the downward spiral that leads families towards poverty

Low economic growth

Poverty

Poor health

NCDsMM

The scope• Mortality and morbidity data reveal

the growing and disproportionate impact of the epidemic in lower resource settings.

• Over 80% of cardiovascular and diabetes deaths, and almost 90% of deaths from chronic obstructive pulmonary disease, occur in low- and middle-income countries.

• More than two thirds of all cancer deaths occur in low- and middle-income countries

Trends in Death in Developing Areas

0

10

20

30

40

1990 2000 2010 2020

Dea

ths

(mil

lion

s)

NCDs Comm. Dis. Injuries

Global Burden of Disease

Vulnerable Population Groups

Impact-Humanitarian-Social-Economic

Non Communicable Diseases (NCDs)

Vulnerable Population Groups

Impact-Humanitarian-Social-Economic

Non Communicable Diseases (NCDs)

Total deaths around the world:58 million

Total deaths around the world:58 million

Deaths from noncommunicable diseases around the world:35 million

Total deaths around the world:58 million

Deaths from noncommunicable diseases around the world:35 million

Deaths from noncommunicable diseases in developing countries:28 million

Total deaths around the world:58 million

Deaths from noncommunicable diseases around the world:35 million

Deaths from noncommunicable diseases in developing countries:28 million

Deaths from noncommunicable diseases in developing countries which could have been prevented: an estimated14 million

MOTHERMOTHER

FETUSFETUS

NEWBORNNEWBORN

ADULTADULT

VITAL EVOLUTION

ENVIROMENTALFACTOS

GENETIC FACTORS

Many diseseases of maturityhave their origins early in life

MOTHERMOTHER

FETUSFETUS

NEWBORNNEWBORN

ADULTADULT

NUTRITION

NUTRITION

ANEMIAANEMIA

TOBACCO

TOBACCO

DIABETESDIABETES

HYPERTENSION

HYPERTENSION

INFECTIONSINFECTIONS

STRESSSTRESS OBESITYOBESITY

DRUGSDRUGS

MOTHERMOTHER

FETUSFETUS

NEWBORNNEWBORN

ADULTADULT

NUTRITION

NUTRITION

ANEMIAANEMIA

TOBACCO

TOBACCO

DIABETESDIABETES

HYPERTENSION

HYPERTENSION

INFECTIONSINFECTIONS

STRESSSTRESS OBESITYOBESITY

DRUGSDRUGS

IUGRPREMATURITY

PPHPOSTPARTUM INFECTIONS

IUGRPREMATURITY

PPHPOSTPARTUM INFECTIONS

MORTALITYSDR

GROWTHNEUROLOGIC DEFICIENCIES

MORTALITYSDR

GROWTHNEUROLOGIC DEFICIENCIES

WHO DefinitionHb <9,5g/l

WHO DefinitionHb <9,5g/l

HYPERTENSIONCARDIOVASCULA

R DISEASESARTERIOSCLERO

SISOBESITY

HYPERTENSIONCARDIOVASCULA

R DISEASESARTERIOSCLERO

SISOBESITY

MOTHERMOTHER

FETUSFETUS

NEWBORNNEWBORN

ADULTADULT

NUTRITION

NUTRITION

ANEMIAANEMIA

TOBACCO

TOBACCO

DIABETESDIABETES

HYPERTENSION

HYPERTENSION

INFECTIONSINFECTIONS

STRESSSTRESS OBESITYOBESITY

DRUGSDRUGS

CONGENITAL DEFECTS

IUGRPREMATURITYMACROSOMIA

FETAL INFECTIONS

CONGENITAL DEFECTS

IUGRPREMATURITYMACROSOMIA

FETAL INFECTIONS

HYPERTENSIONCARDIOVASCULA

R DISEASESARTERIOSCLERO

SISDIABETESOBESITY

HYPERTENSIONCARDIOVASCULA

R DISEASESARTERIOSCLERO

SISDIABETESOBESITY

MORTALITYSDR

NEUROLOGIC PROBLEMS

NUTRITIONAL PROBLEMS

IMMUNE COMPETENCES

MORTALITYSDR

NEUROLOGIC PROBLEMS

NUTRITIONAL PROBLEMS

IMMUNE COMPETENCES

OVERUNDEROVER

UNDER

Epidemiological studies show importance of development:

Smaller babies have higher adult risk of:

• Hypertension

• Altered plasma lipids

• Raised plasma fibrinogen and CRP

• Impaired glucose tolerance, type 2 diabetes and central obesity

• Endothelial dysfunction

Greater Mismatch; Inadequate response to environment; Greater risk of disease

Quality of developmental environment

Too poor Too rich

Greater Mismatch; Inadequate response to environment; Greater risk of disease

Quality of developmental environment

Too poor Too rich

Socioeconomic development

Even poorer rural

economiesMigrants to cities consume high fat, high GI diet, less physical activity

Unhealthy childhood

body comp., metabolism & cardiovascular

function

Mismatch between induced

phenotype & post-natal

environment

Healthy childhood

body comp., metabolism & cardiovascular

function

Match between induced

phenotype & post-natal

environmentMother’s body composition

& nutrition

Epigenetic modification of gene expression

Fetal and Infant growth & developmental adaptations

The Future

HE

AL

TH

DIS

EA

SE

Premature death and morbidity

Obesity Insulin resistance

Gestationaldiabetes

Enriched postnatal environmentdue to nutritional transition

Large babies

Stunting

low birth weight

Very poor postnatal environment

Women malnourishedLow pregnancy weight gain

Maternalmorbidity

Suboptimal fetal development

The Recurring Nightmare:Cycles of Disease with a Poor Start to Life

Modified from Gluckman and Hanson 2005

Large babies

Fat mothers

MOTHERMOTHER

FETUSFETUS

NEWBORNNEWBORN

ADULTADULT

NUTRITION

NUTRITION

ANEMIAANEMIA

TOBACCO

TOBACCO

DIABETESDIABETES

HYPERTENSION

HYPERTENSION

INFECTIONSINFECTIONS

STRESSSTRESS OBESITYOBESITY

DRUGSDRUGS

FETAL DEFECTSFETAL GROWTH ANOMALIES

FETAL-NEONATAL DEATHNEONATAL MORBIDITY

PREMATURITY/SDROBESITY

INFANT AND ADULT DIABETES

CARDIOVASCULAR DISEASESSCHIZOPHRENIA

FETAL DEFECTSFETAL GROWTH ANOMALIES

FETAL-NEONATAL DEATHNEONATAL MORBIDITY

PREMATURITY/SDROBESITY

INFANT AND ADULT DIABETES

CARDIOVASCULAR DISEASESSCHIZOPHRENIA

MOTHERMOTHER

FETUSFETUS

NEWBORNNEWBORN

ADULTADULT

NUTRITION

NUTRITION

ANEMIAANEMIA

TOBACCO

TOBACCO

DIABETESDIABETES

HYPERTENSION

HYPERTENSION

INFECTIONSINFECTIONS

STRESSSTRESS OBESITYOBESITY

DRUGSDRUGS

PREECLAMPSIAIUGR

MATERNAL DEATHFETAL-NEONATAL DEATHNEONATAL MORBIDITY

PREMATURITY/SDRADULT HYPERTENSION

CARDIOVASCULAR DISEASES

PREECLAMPSIAIUGR

MATERNAL DEATHFETAL-NEONATAL DEATHNEONATAL MORBIDITY

PREMATURITY/SDRADULT HYPERTENSION

CARDIOVASCULAR DISEASES

MOTHERMOTHER

FETUSFETUS

NEWBORNNEWBORN

ADULTADULT

NUTRITION

NUTRITION

ANEMIAANEMIA

TOBACCO

TOBACCO

DIABETESDIABETES

HYPERTENSION

HYPERTENSION

INFECTIONSINFECTIONS

STRESSSTRESS OBESITYOBESITY

DRUGSDRUGS

FETAL DEFECTSFETAL GROWTH ANOMALIES

MATERNAL DEATHFETAL-NEONATAL DEATHNEONATAL MORBIDITY

PREMATURITY/SDRADULT DIABETES

ADOLESCENT/ADULT OBESITY

CARDIOVASCULAR DISEASESHYPERTENSION

FETAL DEFECTSFETAL GROWTH ANOMALIES

MATERNAL DEATHFETAL-NEONATAL DEATHNEONATAL MORBIDITY

PREMATURITY/SDRADULT DIABETES

ADOLESCENT/ADULT OBESITY

CARDIOVASCULAR DISEASESHYPERTENSION

MOTHERMOTHER

FETUSFETUS

NEWBORNNEWBORN

ADULTADULT

NUTRITION

NUTRITION

ANEMIAANEMIA

TOBACCO

TOBACCO

DIABETESDIABETES

HYPERTENSION

HYPERTENSION

INFECTIONSINFECTIONS

STRESSSTRESS OBESITYOBESITY

DRUGSDRUGS

Strong IMPACT

MOTHERMOTHER

FETUSFETUS

NEWBORNNEWBORN

ADULTADULT

NON COMUNICABLE DISEASESNON COMUNICABLE DISEASES

VITAL CICLE

MOTHERMOTHER

FETUSFETUS

NEWBORNNEWBORN

ADULTADULT

NON COMUNICABLE DISEASESNON COMUNICABLE DISEASES

VITAL CICLE

Good news

• Effective interventions are available, and abundant evidence now demonstrates their clear and measurable impact in a range of resource settings.

Behavior Change Successes

• Reducing malnutrition (micronutrient initiatives)

• Reducing maternal obesity

• Diagnose and treat the diabetes during pregnancy

• Preventing anemia (iron supplements)

• Preventing malaria (insecticide-treated bednets)

• Helping children survive (breastfeeding)

• Improving maternal health (safe motherhood movement, emergency obstetric care)

• Making family planning a norm (worldwide efforts)

• Combating HIV/AIDS (Uganda program)

Sumary

• A well-constructed alliance between the

NCD and maternal and women’s health

fields has the potential to strengthen

both.

It is time to overcome the words and make the facts¡¡¡

Castells Humans

Key messages• • The majority of noncommunicable diseases can

be averted through interventions and policies that reduce major risk factors.

• • Many preventive measures are cost-effective, including for low-income countries.

• • Some preventive actions can have a quick impact on the burden of disease at the population level.

• • Interventions that combine a range of evidence-based approaches have better results.

• • Comprehensive prevention strategies must emphasize the need for sustained interventions over time.

Many things we need can wait, the child cannot. Now is the time his bones are being formed, his blood is being made, his mind is being developed. To him we cannot say tomorrow.

His name is today.

Gabrielle Mistral, Su Nombre es Hoy