(September 2011) In 2008, 36 million people died from noncommunicable diseases (NCDs). Deaths related to these chronic diseases are increasing, especially in low- and middle-income countries. Over half of deaths are associated with behaviors that begin or are reinforced during adolescence, including tobacco and alcohol use, poor eating habits, and lack of exercise. Global trends indicate that NCD-related behaviors are on the rise among young people, and that they establish patterns of behavior that persist throughout life and are often hard to change.
Despite the contribution of adolescent health to reducing NCDs globally, the September 2011 High-Level Meeting of the UN General Assembly in New York did not address these issues. What is known about adolescent contributions to NCDs? What are effective strategies to address them?
In a PRB Discuss Online, Dr. Robert Blum, William H. Gates Sr. professor, and chair, Department of Population, Family, and Reproductive Health at Johns Hopkins Bloomberg School of Public Health, and director, Johns Hopkins Urban Health Institute, answered questions from participants about how chronic diseases affect youth and what we can do to prevent them.
Sept. 27, 2011 NOON (EDT)
Transcript of Questions and Answers
Dr. Anima Sharma: Dear Dr. Blum, the youths of modern times, especially in the developing countries like India are surrounded by the multitude of problems at psychological, environmental, personal and professional fronts. People often complaint that the lives have become very complex these days and it does have, no doubt, but according to me many such situation which lead to severe and chronic types of sufferings could be avoided if we could teach the youths about the ways to adjust with their environ (at home and at work place). Many times the slight adjustments may change their lives entirely but we need Mentors and Trainers who could teach them the right skills of personal and professional management.
I am an Anthropologist and have been lucky enough to get a chance to study urban, rural and ethnic societies in India. I found that types of problems faced by these three types of societies are different but we can't say that it is better in any because the even the ethnic societies are no more as simpe as those used to be, say 50 years back. Hence, my summation is that while thinking about the youths in the context of the chronic diseases we should also think about the ethnic populations, their health problems and the prevailing healthcare system/ facilities in their areas. Thanks.
Robert W. Blum: Dr. Sharma raises some interesting and important points. First, we know that in every country of the world where there are data, ethnic minorities are disadvantaged when compared with the majority population. The evidence is clear that they have less good health status and more chronic conditions compared with majority peers. As it relates to NCDs there are things that young people can do including avoidance of harmful behaviors such as eating high-fat foods or smoking tobacco, but there are also community-level strategies that improve outcomes. As Dr. Sharma sugests, we need to ask ourselves: Why are those who are ethnic minorities least likely to enjoy positive health?
Henry Tagoe: It is evidently clear that countries in the Global South are facing the strain of the double burden of disease because they are straggling with the challenges of infectious diseases and due to demographic, nutritional and epidemiological transitions chronic non-communicable diseases are now a major challenge not forgetting limited health system. One major issue is the lack of national representative data for research especially the levels of the major modifiable risk factor such alcohol, smoking obesity more at child and youth level to inform policy to effect behavioral change. This is one on the major areas that countries in the developing world should focus on since such behavior at early ages will be carried on to adulthood and the implication to chronic disease. Can data be made available to researchers in this area if available?
Robert W. Blum: This is an excellent question. For youth there are some data sources. First, in a recent paper in the Lancet, Gore and her colleagues report disability adjusted life year data for low- and middle-income as well as high-income countries as they relate to adolescents and youth. The Global Tobacco Survey of the World Health Organization is another data source as is the adolescent module of the MICS (which is a UNICEF global survey). A third source of data that relates to certain NCDs among adolescents and youth are the DHS national surveys those these relate mostly to sexual and reproductive health. The issue of dual burden of disease is an increasingly pressing issue for many LMI countries.
Meskerem Bekele, Ethiopia: Yes, you are right! The problem is ours also. As you mention religious institution is one way to protect youth from this chronic disease. As a journalist I was produced programs about this issue. And many of the person's told me that they are out of this addiction because of their religion. But as a journalist can we mention this situation?
Robert W. Blum: Much of what we know about the protective effects of religion comes from research primarily done in the United States and what we see there relates less to religion per se than to religiosity. Religiosity can be viewed as having two primary dimensions: private (prayer for example) and public (going to church, mosque, synagogue, etc.) For youth it appears that public religiosity has a more powerful impact on behavior than private behaviors. We see in other communities around the world that certain religious prohibitions have an impact only if they are reinforced by the climate and culture of the family and community. So for example, a religious prohibition against smoking or drinking has more of an impact when one lives in a community where such substances are either expensive or difficult to obtain as a consequence of that prohibition.
Tyjen Tsai: Do you think that behavior change communication strategies like using peer educators to help educate about chronic diseases (or a specific one, like tobacco use, for example) would work with youth? And if so, what kind of BCC would be most effective?
Robert W. Blum: There is an extensive body of literature on the use of peer educators. While peer education can be effective, it often is not. What seems to differentiate effective from ineffective peer education is the extent of adult involvement, supervision, and mentorship of the mentors. Where there is a lot, the effectiveness increases. Additionally, what we also know is that the people who are the greatest beneficiaries of peer interventions are the peer educators themselves. This suggests that as a strategy, recruiting those most likely to engage in a health-compromising behavior, as an educator may have beneficial impact.
Now, turning to your question and going beyond peer education, effective behavior change strategies for youth are grounded in both a developmental understanding of young people and an explicit theory of change (for example Bandura's Social Learning Theory). We see numerous examples of effective behavioral interventions around the world but in truth we see many more that don't work (at great cost). One reason is that we often fail to evaluate our interventions, and even when we do, we tend to stick to them when they should be abandoned (witness prograns like "Scared Straight," DARE, abstinence-only interventions.)
Ryan: What effect has climate change had/may have on noncommunicable diseases?
Robert W. Blum: This is a complicated question. One element of climate change is the decline in air quality in many urban settings that has contributed to asthma. So too, exposure to environmental toxins has an impact on fetal health and development; and as our knowledge of epigenetics increases we are learning that these fetal changes have impact across the life span. So for example, Hoek et al. has shown that nutritional deprivation during the Dutch famine of 1944 was associated with an increase in psychiatric disorders among adolescents who were born 6 to 8 months after the worst of the famine. So too, we see the strong association between birth weight and diseases later in life including diabetes mellitus, hypertension, metabolic syndrom and cardiovascular disease (Barker Hypothesis).
Kate: As smoking prevention efforts have shown,it's very difficult to get people (and youth in particular) to act to prevent health consequences that may not appear for years. How can we make youth understand the risks of chronic disease?
Robert W. Blum: When you look at trends in smoking in many Western countries over the past 25 years we have seen extraordinary and positive changes. Today in the United States for example cigarette smoking is at an all-time low with approximately 20 percent of youth who smoke. Conversely, 80 percent of youth disapprove of smoking. So, while we have made a lot of progress we still have a long way to go. What we know is that health risk-reduction strategies work best when a number of elements line up. Specifically, we know that information alone is not sufficient for behavior change but when it is coordinated with minimum age of purchase laws that are enforced, taxation that makes tobacco purchase cost-prohibitive for youth, and smoking laws that prohibit indoor smoking; you then begin to create a culture where it is expensive, difficult, and increasingly socially unacceptable to smoke.
Eric Zuehlke: How can health systems that are already strapped for resources in developing countries balance the need to treat communicable diseases and at the same time address prevention strategies to combat non-communicable diseases?
Robert W. Blum: As we look across the globe we see a decline in infectious causes of morbidity and mortality in the adolescent years. That is not to say that infectious diseases are not important, but in most LMIC as well as high-income countries, today NCDs represent the primary causes of death in adolescents. Additionally as populations age in countries around the world increasingly it will be NCDs that will be the primary causes of morbidity. So for LMIC these issues are and will increasingly become important drains on national economies and resources. That is why the United Nations held a High-Level Meeting last week in New York to draw attention to these concerns.
Ryan: What are the differences in diseases and treatments between the developed and developing countries? Or between economic classes?
Robert W. Blum: We know that in every country of the world, those who are the poorest have also the worst health status and that includes both infectious diseases and NCDs. In sub-Saharan Africa, in some countries women are more than 100 times more likely to die in childbirth than in HIC. So too, in countries where abortion is illicit and clandestine the mortality rate is very high, while in countries where it is is legal and safe, mortality is below that of child birth. When we compare high- and low-income countries there is a big gap in access to a number of interventions that reduce morbidity and subsequent NCDs: the HPV vaccine for example.
maricela: What public policies would help with this population?
Robert W. Blum: Numerous public policies make a difference:
- Tobacco taxes-smoking among youth is very price-sensitive.
- Menu labeling—the evidence is that information impacts food selection and also content of prepared foods.
- Graduated licenses for new drivers—it is estimated to reduce vehicular deaths during the first year of driving by as much as 40 percent.
- Restrictions on advertising harmful products.
- Minimum age of purchase laws with strict enforcement.
Jeff Meer: How can advocates best make the case that children and youth represent great potential for creating positive change on chronic diseases (and not just a problem to be dealt with)? It seems to me that if there is inspiration to be drawn in the non communicable disease prevention and control field, it would be in working with kids. After all, their lifestyle choices, dietary habits, recreational choices and other modifiable risks are not yet set. Perhaps if we can view kids and youth as assets, and not so much as liabilities, we would be better off.
Robert W. Blum: I fully agree with you. We need to highlight what young people are doing around the globe to make a difference in their neighborhoods. We need to give prizes and recognitions (like the CNN Heroes awards) for youth interventions to shine a spotlight on outstanding work. We as adults need to help train young people so that they have the skills to be effective advocates. We need to engage young people with chronic conditions as part of the solution—as youth leaders.
Ryan: Regarding the recent health care reform, how far do you see it going in cutting down on noncommunicable diseases?
Robert W. Blum: I think that it will have some benefits since there are provisions for preventive services. When we look for example of what will be covered for women, for the first time oral contraception will be covered as will more widely available cancer screening. However, the primary focus of the legislation is on financing of medical services; and until there is a focus on health care delivery and until there is a significant commitment to take to scale interventions that we know work then we will be playing catch-up at a high cost to health and our economy.
Tyjen Tsai: Thanks for answering my other question. With the rise of diabetes, do you think that will go hand-in-hand with a rise in chronic depression as well?
Robert W. Blum: The rise in diabetes is a result of a dramatic increase in obesity...a trend we are seeing globally. We know that there is an association between obesity and depression; and so too, we know that there is a positive association between exercise and mental well-being.
Cat: Dr Blum, How important is getting NCDs onto the national health priority agendas in developing countries? If you take a country like China, where about 50 percent of their tax revenue comes from the tax on tobacco, smoking is a behavior the government doesn't want the public to stop doing. So my question also relates to how to navigate the political environment when working on NCDs is unsupported.
Robert W. Blum: The point that you make is a good one; however, I would point out that in countries like China where the population is aging the economic costs to the economy will only escalate with increasing NCDs. So it is with countries around the world (both rich and poor)...while there may be short-term benefits to ignoring the consequences of pollution or some of our decisions on pesticide use or cash crops, the real costs will be passed on to our children—and theirs.