Developing countries face double burden of disease



Sarah Jane Marshall




Following 18 months of multi-stakeholder consultations, and two days of tense negotiations at the 57th World Health Assembly in May, the Global strategy on diet, physical activity and health was finally — and unanimously — adopted by WHO Member States. The adoption of the nonbinding strategy opens the way for policy-makers to develop new initiatives to tackle the global rise in chronic noncommunicable diseases (NCDs) such as cardiovascular diseases, a rise that has been particularly marked in the developing world.

"Noncommunicable diseases are imposing a growing burden upon low- and middle-income countries, which have limited resources and are still struggling to meet the challenges of existing problems with infectious diseases," said Dr Catherine Le Galès-Camus, Assistant-Director General at WHO's department of Noncommunicable Diseases and Mental Health.

WHO estimates that non-communicable diseases — including cardiovascular diseases, diabetes, cancers and obesity-related conditions — now account for 59% of the 56.5 million deaths which occur globally every year and almost half (45.9%) of the global burden of disease.

Traditionally associated with developed countries, some 80% of all cardiovascular disease-related deaths now occur in low- and middle-income countries. An estimated 171 million people were affected by diabetes in 2000, two-thirds of which live in developing countries. By the year 2030, WHO predicts that there will be 284 million people with diabetes living in developing countries. Worst affected countries are China where there were 20.8 million cases in 2000 and India where in 2000, there were 31.7 million cases of diabetes.

Obesity, commonly associated with industrialized nations — in the US about 30% of adults are obese — is becoming a major problem in some developing nations too. According to data from the WHO Global NCD InfoBase Online, in Egypt between 1991 and 1994, 56% of men and 45% of women in Cairo's urban region were obese. In South Africa, 30% of women were obese in 1998, rising to 46% for women aged between 55 and 64 years. More than one billion adults worldwide are currently overweight, of which 300 million are clinically obese.

The majority of cardiovascular diseases can be attributed to major risk factors such as high cholesterol, high blood pressure, low fruit and vegetable intake, inactive lifestyle and tobacco use. Worldwide people are consuming more foods that are nutritionally poor but energy-dense — high in sugar and/or saturated fats — or excessively salty.

"In developing countries, the change in nutritional intake combined with increasingly sedentary lifestyles resulting from food market globalization and increasing urbanization, has led to the emergence of chronic diseases as a major new health threat," said Amalia Waxman, Project Manager for the Global strategy on diet, physical activity and health. "In Viet Nam for example, the shift from bicycles to motorbikes as the most popular form of transport has led to a dramatic fall in levels of physical activity contributing, together with dietary changes and tobacco consumption, to a rise in noncommunicable disease risk factors whilst the country is still trying to bring malnutrition under control."

Taking a preventative approach, the strategy recommends that people limit their intake of foods high in saturated fats and trans fatty acids, salt, and sugars, and increase their consumption of fruit and vegetables as well as boosting levels of physical activity. The 22-page document also includes recommendations on fiscal policies, monitoring and surveillance systems, health claims and nutrition labelling, marketing and advertising and school policies.

Described by WHO Director-General, Dr LEE Jong-wook, as "a landmark achievement in global public health policy," the strategy has taken two years to develop and has involved extensive consultations with all concerned stakeholders, including WHO Member States, other UN agencies, civil society and nongovernmental organizations, and the private sector.

A draft of the strategy was first published in December 2003. Initial objections, largely voiced by the US, centred on the sole citation of the Joint WHO-Food and Agriculture Organization (FAO) report (TRS 916), which recommended specific limits on the consumption of sugar, salt, saturated fats, and trans fatty acids, for the development of food-based national dietary guidelines. Of particular concern to lobbyists for the sugar industry, was TRS 916's recommendation that free sugars not exceed 10% of total daily calorie intake. Although, the reference to TRS 916 was removed, it is widely understood that the WHO-FAO report will remain a key referral document for policy-makers and recommendations to limit sugars, salt and fats remain in the strategy.

Barry Popkin, Professor of Nutrition at the University of North Carolina in the US, believes that addressing the problem "requires macroeconomic shifts that affect the structure behind a population's diet such as removing many subsidies and encouraging other shifts such as cheaper fruit and vegetables."

According to Carlos Monteiro, Professor in Public Health and Nutrition at Brazil's University of Sao Paolo, some lessons may be learnt from countries like Brazil — the only country to see a decline in obesity among women. The Brazilian Government has been working on a number of initiatives as part of a comprehensive approach for addressing poor dietary and activity patterns which have led to obesity and nutrition-related noncommunicable diseases. These include new nutrition labelling and claims regulations, legislation to promote healthy diets in schools, strengthening the capacity of school teachers and health workers for nutrition promotion and innovative community-based initiatives such as the promotion of healthy cooking among professional chefs in Rio de Janeiro.

"The adoption of the strategy was a crucial first step," said Waxman, "but its success will depend on its implementation at the country level. WHO is currently developing an implementation plan which will emphasize that governments must take a multi-sectoral approach — involving consumer groups, NGOs, the private sector and all stakeholders. You can't produce a strategy on food without involving the food industry."

World Health Organization Genebra - Genebra - Switzerland