Richard Smith: What I learnt about non-communicable disease in one afternoon

Richard SmithMost of my work is concerned with non-communicable disease (NCD) in low and middle income countries, so I’ve got to know a fair bit about the subject. But yesterday I spent an afternoon at Imperial College listening to a series of short presentations on NCD in low middle income countries (LMIC), and I learnt a lot. I thought that you might be interested in what I learnt, and I’ve found it best to summarise my learning in a series of short statements (some of which I’ve Tweeted).

40-50% of deaths from NCD occur in people under 60 in LMIC. In Sweden it’s 10%.

Age specific mortality declined globally at all ages between 1970 and 2010. The biggest decline (70%) occurred in those under 5. The smallest decline was in young men.

Most of Asia and Latin America saw big declines in mortality.

The World Health Assembly target of a 25% reduction in deaths under 70 from NCD by 2025 is probably achievable—in that 20% of countries (all high income) have already achieved it.

BMI and blood glucose have increased in all countries. It might be that these increases will mean that the World Health Assembly target will not be reached. We simply don’t know.

Blood pressure has fallen in high income countries but increased in LMIC, increasing global inequalities.

If you want to avoid asthma have lots of older siblings, live on a farm, and sleep with a dog and a cat.

Lung size increases dramatically in countries that have a GNP per capita over $10 000, and small lung size means higher mortality.

Once a country has a GDP per capita above $10 000 then about 85% of deaths are from NCD

England spends over £200 per head on mental health and just over £100 per head each on cancer and circulation problems. These are the top three with respiratory problems coming next at about £80.

Health expenditure per head is $27 in low income countries, $71 in low middle income countries, $382 in upper middle income countries, and $4879 in high income countries. The proportion that is state funding is 65% in high income countries and 39%  in low income countries. Out of pocket health expenditure (the most inefficient of health expenditure) is 14% in high income countries and 48% in low income countries.

Hypertension is managed so badly across the world because of physician inertia, poor information on drugs, resistant hypertension, drug costs, drug side effects, and guideline confusion (all saying different things).

There is no evidence whatsoever for treating diabetics with blood pressures of 130/80 mmHg,  but this is what all the guidelines say.

South Asians have a 40% higher burden of heart attack wherever they live.

There are no trials of which drugs are best for treating hypertension in South Asians, which is a scandal.

The dogma of cancer until recently was that cancer was the result of carcinogens. Now we know that’s wrong. There is a 10 fold variation in global rates of breast cancer, but there are no carcinogens for breast cancer. The variation is explained by different reproduction patterns (hard to fix) and lifestyle.

As countries get richer cervical cancer declines and breast cancers increases. Similarly stomach cancer declines and colon cancer increases.

Prostate cancer is one of the commonest cancers in high income countries but is rare in low income countries. (Is this because of the diagnosis of early and non-fatal cases of prostate cancer?)

Pacific islanders who 50 years ago had diets high in fish, low in meat, and high in fibre had the world’s lowest rate of colon cancer. Now after their diets have changed they have one of the highest, illustrating powerfully the effect of diet.

Obesity now accounts for 20% of global cancer, about the same as tobacco.

About 20% of breast cancer in Britain is attributable to alcohol compared with 1% in China, where women drink very little alcohol.

Increasingly HbA1c rather than glucose tolerance tests is being used to diagnose diabetes.

Almost every ethnic group has a higher rate of diabetes than Europeans.

There is tremendous hype about the possibilities of m-health, but the Txt2stop study published in the Lancet is almost the only example of an RCT showing benefit. Smokers who received regular text messages were more likely than controls to stop.

Spirometry is not useful for diagnosing asthma. We still depend on symptoms

Adherence with corticosteroid inhalers in patients with asthma is a major problem not only because of absence of immediate benefit but also probably because bronchodilators do give immediate benefit

There needs to be a cluster randomised trial in LMIC of developing an algorithm for detecting cases and then prescribing a single inhaler that combines a bronchodilator and a steroid at low dose (which gives most of the benefit but far fewer side effects)

Disbursements of the Global Fund for AIDS, TB, and malaria saw a 25% drop in  2011.

In 2011, 3.5 million people were being treated with antiretrovirals. 2.5 million will still be alive in 2020.

Adherence of antiretrovirals drops to 70% in four years. In some countries it drops much lower. This is likely to be a bigger problem with treating hypertension and diabetes because unlike with antiretrovirals there is no immediate benefit for the patient.

Competing interest: RS is an adjunct (unpaid) professor in the Imperial College Institute for Global Health Innovation.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

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