What can WHO do to
control the epidemic of
diabetes?
Gojka Roglic
World Health Organization, Geneva, Switzerland
Chronic Diseases and Health Promotion – www.who.int/chp/en
The World Health Organization
•
United Nations specialized
agency for health
•
Governed by 192 Member
States
•
Headquarters in Geneva
•
Six regional offices
•
Numerous country offices
Support to member states to enhance the health of their populations
Chronic Diseases and Health Promotion – www.who.int/chp/en
The World Health Organization
•
First World Health Assembly 1948
•
Priorities for the organization:
•
Malaria
•
Tuberculosis
•
Venereal diseases
•
Maternal and child health
•
Sanitary engineering
Nutrition
Support to member states to enhance the health of their populations
•
Chronic Diseases and Health Promotion – www.who.int/chp/en
Examples of WHO activities
• Successful:
Smallpox eradication 1977
Campaigns against yaws,
endemic syphilis, leprosy,
trachoma, malaria in Europe
Control of cholera pandemic
Chronic Diseases and Health Promotion – www.who.int/chp/en
Examples of WHO activities
• Moderately successful, ongoing:
Polio eradication (since 1988)
Expanded programme on Immunization (since 1974)
"3 by 5" initiative (antiretroviral therapy for 3 million
people in low and middle-income countries by end of
2005)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Examples of WHO activities
• Unsuccessful:
Safe Motherhood Initiative
(aim in 1987: reduce maternal morbidity & mortality by 50% by the
year 2000)
Chronic Diseases and Health Promotion – www.who.int/chp/en
The comparative advantages of
WHO are:
-
Neutral status
Nearly universal membership
Impartiality
Strong convening power
Normative and technical roles
Chronic Diseases and Health Promotion – www.who.int/chp/en
Three sources of funding
Assessed Contributions
and Miscellaneous Income
(Regular budget )
Negotiated core
voluntary
contributions
Project-type
voluntary contributions
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO
Programme
budget
Assessed contributions to Regular
Budget - 10 member states pay 77 %
77 %
10 major
contributors
103
Member
States at
<1 % less than
0.01%
22 %
81 Member
States
Chronic Diseases and Health Promotion – www.who.int/chp/en
Top 10 Country contributions to WHO's
Regular Budget 2008-09 in %
1- USA 22 %
2- Japan 16.6%
3- Germany 8.57%
4- UK + Northern Ireland
6.64%
5- France 6.30%
6- Italy 5.07%
7- Canada 2,97%
8- Spain 2,96%
9- China 2.66%
10- Mexico 2.25%
Following countries: Republic of Korea 2.17% Netherlands 1.87%
Australia 1.78% / Brazil 0.87%
Switzerland 1.21%
Chronic Diseases and Health Promotion – www.who.int/chp/en
Source of voluntary contributions 20062007
77 %
10 major
contributors
103
Member
States at
<1 % less than
0.01%
22 %
81 Member
States
Chronic Diseases and Health Promotion – www.who.int/chp/en
Without action the imbalance between voluntary
contributions and regular budget will continue to increase
6,000
US$ (millions)
5,000
Voluntary Contributions
Regular Budget
4,000
3,000
2,000
83%
72%
1,000
28%
17%
0
1994- 1996- 1998- 2000- 2002- 2004- 2006- 2008- 2010- 2012- 20141995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic,
noncommunicable diseases
(NCDs)?
Chronic Diseases and Health Promotion – www.who.int/chp/en
Adult mortality
Chronic Diseases and Health Promotion – www.who.int/chp/en
Noncommunicable diseases
2005
2006-2015 (cumulative)
Total
deaths
(millions)
NCD deaths
(millions)
NCD
deaths
(millions)
Trend: Death from
infectious disease
Trend: Death from
NCD
Africa
10.8
2.5
28
+6%
+27%
Americas
6.2
4.8
53
-8%
+17%
4.3
2.2
25
-10%
+25%
Europe
9.8
8.5
88
+7%
+4%
South-East Asia
14.7
8.0
89
-16%
+21%
Western Pacific
12.4
9.7
105
+1
+20%
Total
58.2
35.7
388
-3%
+17%
Geographical regions
(WHO classification)
Eastern Mediterranean
WHO projects that over the next 10 years, the largest increase in
deaths from cardiovascular disease, cancer, respiratory disease and
diabetes will occur in Sub-Saharan Africa (+27%)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Importance of Chronic Diseases
•
57 Million Total Deaths
•
35 Million due to Chronic Disease
•
16 Million Deaths less than 70 yrs
Chronic Diseases and Health Promotion – www.who.int/chp/en
Expenditure within WHO HQ
ONLY US$ 0.50 SPENT ON LEADING CHRONIC
DISEASES PER DEATH COMPARED WITH $7.50
FOR LEADING COMMUNICABLE DISEASES
Chronic Diseases and Health Promotion – www.who.int/chp/en
Funding for Noncommunicable Chronic
Diseases at WHO
Total WHO expenditure on NCDs
Global NCD disease burden
Other
NCDs
DM
Injuries
CVD
CD
In 2002, 3.5% of total budget of
US$ 43.6 million on NCDs
Source: WHO long-term strategy for prevention and control of leading chronic diseases
© World Health Organization [2004]
Department of Chronic Diseases and Health Promotion
World Health
Organization
Donor aid for the health sector
Increased health support by donors mostly directed towards HIV/AIDS,
not NCDs
Official Overseas
Development Aid to the
health sector in 2002
allocated to
NCDs
(including mental health)
Source: WHO long-term strategy for prevention and control of leading chronic diseases
© World Health Organization [2004]
Department of Chronic Diseases and Health Promotion
World Health
Organization
World Bank and Regional Development Banks
World Bank loans for chronic diseases
of their $4.2 billion total to
health, population and nutrition
between 1997 and 2002
Source: WHO long-term strategy for prevention and control of leading chronic diseases
© World Health Organization [2004]
Department of Chronic Diseases and Health Promotion
World Health
Organization
Nevertheless…..
WHO is the largest source of funding for chronic diseases
WHO provides tenfold more funds than all bilateral agencies
combined
1998
2002
US$ 16 million
US$ 43.6 million
US$ 383,000
US$ 13.2 million
Mental disorders
US$ 7.1 million
US$ 13.3 million
Other chronic disease activities
US$ 9.4 million
US$ 14.3 million
WHO expenditure for chronic disease
Overall
Tobacco
33 %
mental health
30 %
tobacco
37 %
unspecified chronic disease components
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic,
noncommunicable diseases?
1998 – Tobacco Free Initiative to coordinate a
global response to the Tobacco epidemic
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic,
noncommunicable diseases?
2000 World Health Assembly adopts the Global
Strategy for the Prevention and Control of
Noncommunicable diseases
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic,
noncommunicable diseases?
2003 – World Health Assembly adopts the
Framework Convention on Tobacco Control –
first treaty negotiated under the auspices of WHO (in
force since 2005)
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic,
noncommunicable diseases?
2004 – World Health Assembly adopts the Global
Strategy on Diet, Physical activity and Health
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic,
noncommunicable diseases?
2005 – First WHO report on chronic,
noncommunicable diseases
Chronic Diseases and Health Promotion – www.who.int/chp/en
2008: Action Plan for the Global Strategy
• February – Informal
consultations with Member
States, International Partners
and the business community
• April – Final draft of Action Plan
available online
• May – adoption by the World
Health Assembly
Chronic Diseases and Health Promotion – www.who.int/chp/en
Scope of the Action Plan
• The major noncommunicable diseases:
• Cardiovascular disease
• Cancer
• Respiratory disease
• Diabetes
• The main causes are 4 shared preventable risk factors:
• Tobacco use
• Unhealthy diet
• Physical inactivity
• Harmful use of alcohol
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about diabetes?
Chronic Diseases and Health Promotion – www.who.int/chp/en
Noncommunicable Diseases and
Mental Health Cluster
Cardiovascular diseases: 1 person
Cancer: 2 persons
Asthma and COPD: 2 persons
Diabetes: 1 person
Chronic Diseases and Health Promotion – www.who.int/chp/en
The beginnings of the WHO Diabetes
Programme in the 1980s…….
Dr Hilary King
Chronic Diseases and Health Promotion – www.who.int/chp/en
The WHO Diabetes Programme
at its strongest (early 2000s) …..
Chronic Diseases and Health Promotion – www.who.int/chp/en
The core functions of WHO
•
•
•
•
•
•
•
Providing leadership and engaging in partnerships
where joint action is needed
Shaping the research agenda, stimulating the
generation and translation of knowledge
Setting norms and standards
Articulating ethical and evidence-based policy options
Providing technical support
Monitoring the health situation and assessing health
trends
High-level advocacy and awareness raising on
matters critical to health
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function: Partnership
where joint action is needed
International Diabetes Federation (IDF)
•A natural ally and partner to WHO
•In official relations since 1957
Chronic Diseases and Health Promotion – www.who.int/chp/en
Partnership where joint action is
needed
IDF
WHO
• Works with governments
• Strong public health voice
• WHO offices in almost every
country
• Global reference centre for
health statistics
• Has prestige among
governments/health ministries
• Works through member
associations
• Strong lay and professional
advocacy voice
• Network of member
associations
• Well-developed secretariat to
respond to calls for
information
• Has prestige among NGOs
and private sector
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO-IDF Collaboration
• Norms and standards
• Capacity building (Cambridge Seminar)
• Global estimates
• Management of diabetes in crises and humanitarian
settings
• Awareness raising
• Access to essential medicines/equipment
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function : Awarenessraising and advocacy
• Rationale for investing in
chronic diseases that
share the same risk
factors
• Evidence for dispelling
myths on chronic
diseases
Chronic Diseases and Health Promotion – www.who.int/chp/en
Joint WHO-IDF project, supported by
the World Diabetes Foundation
Chronic Diseases and Health Promotion – www.who.int/chp/en
Main aim of Diabetes Action
Now…..
• To achieve a major increase in the awareness
of the impact of diabetes in low and middle
income countries
Chronic Diseases and Health Promotion – www.who.int/chp/en
Chronic noncommunicable diseases
effectively excluded from Millennium
Development Goals
Chronic diseases excluded from UNICEF Action Plan for
"A World Fit for Children" and from WHO/UNICEF high
level consultation
Chronic diseases excluded from UNFPA initiatives, and
from WHO/UNFPA high-level consultations
Chronic Diseases and Health Promotion – www.who.int/chp/en
Diabetes is an obstacle to
achieving the Millennium
Development Goals……
• Diabetes is likely to be responsible
for 15% of all new tuberculosis
cases in India
(AIDS accounts for 3-4%)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Diabetes Action Now – Diabetes
Awareness in Chennai (Murugesan et
al, 2007)
Do not know what diabetes is
Policy
makers
(n=20)
35%
General
public
(n=3681)
60%
Think diabetes is preventable
61%
by meditation
Correctly identify healthy body 15%
size
6.3%
Correctly identify healthy body 0%
shape
25%
Chronic Diseases and Health Promotion – www.who.int/chp/en
25%
Analysis of articles on diabetes
in India (2005)
Online newspapers:




The Hindu – 39 articles
The Hindustan Times – 21 articles
The Indian Express – 2 articles
The Times of India – 17 articles
WHO/IDF key messages in newspaper
articles (India, 2005)




Diabetes is a life threatening illness: 10%
Diabetes is a common condition and its
frequency is increasing dramatically: 40%
A full and healthy life is possible with diabetes:
30%, but only a clear statement in a few articles
In many cases, diabetes can be prevented: 40%
Raising awareness….
Chronic Diseases and Health Promotion – www.who.int/chp/en
Chronic Diseases and Health Promotion – www.who.int/chp/en
UN Resolution on Diabetes…..
Chronic Diseases and Health Promotion – www.who.int/chp/en
Percentage of countries with specific action
plan for diabetes control (WHO, 2007)
WHO Region
2000
2006
AFR
17
25
AMR
46
63
EMR
EUR
46
53
69
67
SEAR
50
67
WPR
NA
NA
TOTAL
41
56
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function: Setting norms
and standards
• What is diabetes?
Definition, Diagnosis and Classification of
Diabetes Mellitus
WHO report 1965
WHO report 1980
WHO report 1985
WHO report 1999
Chronic Diseases and Health Promotion – www.who.int/chp/en
Norms and standards
• Definition and
Diagnosis of Diabetes
Mellitus and
Intermediate
Hyperglycaemia
WHO/IDF consultation report 2006
Chronic Diseases and Health Promotion – www.who.int/chp/en
Norms and standards
Definition,Diagnosis and
Classification of Diabetes Mellitus,
2009
• HbA1c for diagnosis
• "Pre-diabetes"
• Refinement of etiological classification
Chronic Diseases and Health Promotion – www.who.int/chp/en
Norms and standards
The metabolic syndrome: useful
concept or clinical tool?
2009
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function: Monitoring the
health situation
Surveillance of chronic, noncommunicable
diseases
• STEPS – stepwise methodology for monitoring
risk factor prevalence in countries
• Global InfoBase – data warehouse that collects, stores
and displays information on chronic diseases and risk
factors by country (country profiles, comparison of
countries)
http://www.who.int/ncd_surveillance/infobase
Chronic Diseases and Health Promotion – www.who.int/chp/en
Monitoring the health situation
• Is diabetes a public health problem?
Global estimates and projections of diabetes prevalence
King et al, 2000
Wild et al, 2004
Chronic Diseases and Health Promotion – www.who.int/chp/en
Monitoring the health situation
• Is diabetes a public health problem?
• Number of deaths
attributable to diabetes
in the world in 2000
= 2.9 million
(routine health statistics estimate ~1
million deaths)
Roglic et al, 2005
Chronic Diseases and Health Promotion – www.who.int/chp/en
Update: Global Burden of Diseases,
Injuries, and Risk Factors Study 2005
Harvard Initiative for Global Health
Institute for Health Metrics and Evaluation, University of Washington
Johns Hopkins University
University of Queensland
WHO
•
•
•
•
Prevalence
Incidence
Mortality
Complications
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function: Articulating
evidence-based policy options
What can countries do
to prevent diabetes?
Global Strategy on
Diet, Physical
Activity and Health
2004
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO Global Strategy on Diet, Physical
Activity and Health (DPAS) - a public
health tool to support countries fight the
increasing burden of NCDs by




reducing major risk factors through public
health actions
Increasing awareness of importance of healthy
diet and physical activity
Developing, strengthening and implementing
policies and plans on healthy diet and physical
activity and engaging all sectors
Monitoring science and promoting research
DPAS




Implementation should be coordinated by governments
Based on multisectoral action involving the private
sector and civil society
Makes specific recommendations for governments, civil
society groups, international agencies and the private
sector
WHO has initiated dialogue with the food and nonalcoholic beverages industry on issues of food
labelling, salt content and marketing
DPAS implementation at country levels

Several countries have developed national diet & PA
strategy / plans /materials / platform, modelled after
DPAS, e.g.
Chile
New Zealand
Healthy Eating - Healthy Action
Oranga Kai - Oranga Pumau
CAN WE
Stategic
Framework and
PUT SWISS
Implementation
Plan
BALANCE
HERE ?
Spain
Diet, PA & tobacco guide
Percentage of countries implementing the
Global Strategy on Diet and Physical Activity
(WHO, 2007)
WHO Region
2006
AFR
8
AMR
26
EMR
EUR
0
45
SEAR
50
WPR
NA
TOTAL
26
Chronic Diseases and Health Promotion – www.who.int/chp/en
Articulating evidence-based policy
options
What is the evidence for
prevention of diabetes
and prevention of its
complications?
Prevention of
diabetes mellitus
(1994)
Update 2009
Chronic Diseases and Health Promotion – www.who.int/chp/en
Articulating evidence-based policy
options
To screen or not to
screen?
Screening for
Type 2
Diabetes
2003
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function: Stimulating and
supporting research
• 1975 Multinational Study of Vascular Disease in
Diabetes
• Follow-up
Chronic Diseases and Health Promotion – www.who.int/chp/en
Stimulating and supporting research
• 1991 DiaMond study of global incidence of
type 1 diabetes (coordinated by Helsinki
and Pittsburgh)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Stimulating and supporting research
• Health beliefs and awareness of diabetes in
Chennai (Murugesan et al, 2007)
• Health beliefs and awareness of diabetes in
Cameroon (ongoing)
• Cost of diabetes in Shanghai (China) and
Tanzania
Chronic Diseases and Health Promotion – www.who.int/chp/en
Stimulating and supporting research
In China, the DM/nonDM ratio of
• Direct Health Expenditure is 2.4
• Indirect Health Expenditure is 5.7
• Total Health Expenditure is 2.7
Chronic Diseases and Health Promotion – www.who.int/chp/en
Stimulating and supporting research
• Impact of the diabetes epidemic on TB
trends in India (Stevenson et al, 2007)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Stimulating and supporting research
Long-term follow-up of the Da Qing diabetes
prevention trial cohort (Lancet, May 2008)
Chronic Diseases and Health Promotion – www.who.int/chp/en
% with diabetes
Cumulative incidence of DM in Da
Qing Follow-up Study (Li et al, 2008)
100
90
80
70
60
50
40
30
20
10
0
Control group
Intervention group
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20
Follow-up (years)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Diabetes WHO Collaborating centres
Chronic Diseases and Health Promotion – www.who.int/chp/en
With a little help from our friends……
Chronic Diseases and Health Promotion – www.who.int/chp/en
[email protected]
Chronic Diseases and Health Promotion – www.who.int/chp/en