Chronic diseases in India: Burden and implications

Sailesh Mohan, Srinath Reddy, 30 Jan 2014

India currently faces the dual burden of communicable diseases and chronic non-communicable diseases (NCDs) such as cardiovascular disease (CVD), diabetes, cancer and chronic obstructive pulmonary disease (COPD). Success in controlling communicable diseases to some extent as well as increased longevity and changes in people’s lifestyles driven by health transitions and economic progress are contributing to the increase in NCDs. Increasing burden of NCDs has had not only obvious health implications but also economic and developmental consequences. In this paper we outline the major reasons for the increase in NCDs, the current and future risk factor and disease burdens, the responses so far and suggest key public health actions that can contribute to addressing and controlling NCDs effectively.

Why are NCDs increasing in India?

The latter half of the 20th century had brought in substantial progress in societal development, health, nutritional as well as life expectancy. Consequently, deaths from communicable diseases have decreased while those from NCDs have risen. This has been attributed to multiple health transitions such as demographic (population ageing), epidemiological (change from communicable to non-communicable diseases) and nutritional (high caloric consumption and low physical activity levels) transitions. As a result, NCDs currently account for 53% of the total deaths and 44% of disability adjusted life years (DALYs) lost. Projections indicate a further increase to 67% of total deaths by 2030. CVD is the major contributor to this burden, attributable to 52% of NCD associated deaths and 29% of total deaths. (Figure 1)1,2

Figure 1: Causes of deaths in India

Source: Adapted from reference 1 and 2

What are the major risk factors?

Chief NCD risk factors are shown in Figure 2 and their contribution to the disease burden summarised below.

Figure 2: Deaths (%) from Leading Risks in India

Source: Adapted from reference 1

 

Tobacco use

In India, tobacco is widely used in many forms (bidis, cigarettes and smokeless forms) and the country is the second largest producer and the third largest global consumer. There are about 275 million tobacco users (Figure 3) and it is a leading preventable cause of premature, NCD-associated death and disability. Of concern, tobacco use is increasing among youth, women and the poor. Almost a million deaths occur due to tobacco use, with most of these deaths occurring among the poor and in the economically productive age group of 30-69 years. By 2030 nearly 1.5 million deaths will occur annually from tobacco use. However, it not only entails health implications but also significant economic costs with the conservative cost of treating three major tobacco-related NCDs (cancer, heart disease and COPD) in 2002-2003 estimated to be INR 308.3 billion, which far exceeds the revenue added by tobacco taxes to the public exchequer.3,4

Figure 3: High tobacco use in India

Source: Adapted from reference 4

Diet, physical activity and alcohol use

Even though discernable changes in the per capita calorie consumption over past few decades in India has not been reported, there have been noteworthy increases in edible oil and fat consumption both in rural as well as urban areas. Oil intake had increased from 18 grams per person daily in 1990-1992 to 27 grams per person daily in 2003-2005, while fat intake increased from 41 grams to 52 grams per person daily during the same period. Aggregate consumption data also indicate an increasing trend in edible oil consumption, which has grown from 9.7 million tonnes in 2000-2001 to 14.3 million tonnes in 2007-2008, with a high proportion of unhealthy oils high in saturated and trans-fats that are linked to NCDs, particularly CVD. 2

Conversely, fruits and vegetable consumption, which provides protection against NCDs, is inadequate, particularly among the poor. Similarly, physical activity, another protective factor is less than recommended levels, with 29% of the population being insufficiently active. Rapid and extensive urbanisation, increased mechanisation of work and adoption of sedentary lifestyles are attributable to reduced activity levels. 2

Dietary salt consumption, a key determinant of hypertension and associated CVD, is also very high with the average intake ranging between 9-12 grams/day, far exceeding the World Health Organization (WHO) recommended intake of ≤ 5 grams/day. 2

Alcohol consumption which results in not only adverse health outcomes but also social implications is increasing. It accounts for a significant proportion of neuropsychiatric disorders, fatal road traffic accidents and suicides. Use of alcohol is higher among the poor and less educated but disconcertingly is also increasing among youth.

Cardiovascular disease

Currently, about 2.7 million die of CVD and this is projected to increase by 1.5 million by 2030. Estimates indicate that currently there are about 30 million coronary heart disease (CHD) patients, with 14 million residing in rural and 16 million in urban areas. The prevalence of CHD in those aged ≥ 20 years ranges from 6.6% - 12.7% in urban and 2.1% - 4.3% in rural India. During the past few decades, CHD prevalence has increased almost fourfold in rural areas and six fold in urban areas as a result of varied health transitions. Paralytic stroke prevalence is between 334 - 424 per 1,000,00 population in urban areas and between 244 - 262 per 1,000,00 population in rural areas. Notably, about 10-12% of all stroke deaths in India occur in those below 40 years, highlighting the huge impact on families, households and for the nation’s economy as it affects workforce productivity. 2,5

Diabetes mellitus

Type-2 diabetes mellitus has been rising rapidly, with the country until recently being often labeled as the ‘diabetes capital’ of the world. Most recent estimates of the International Diabetes Federation (IDF), report that there are about 65 million people with diabetes, with projected increase to 109 million by 2035.6 Moreover, diabetes is an important risk factor for CVD and CVD is the major cause of death and disability in persons with diabetes. Diabetes currently accounts for almost a million deaths annually.

Hypertension

Hypertension is the leading risk factor for CVD and accounts for nearly 10% of all deaths in India. There are currently 20-40% adults in urban areas and 12-17% in rural areas who suffer from it. The number of hypertensives in India is projected to nearly double from 118 million in 2000 to 213 million by 2025. Besides, nearly 40% adults have pre-hypertension, a precursor condition with high likelihood of converting into hypertension if left unaddressed. 1,5

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is more common among men as the major underlying cause is tobacco smoking but is also increasing among women due to the adverse impact of indoor air pollution as a result of solid fuels usage for cooking. The number of COPD patients is estimated to increase from 13 million in 1996 to 22 million by 2016 with many likely to require hospitalisation with consequent financial repercussions for both patients and the resource constrained healthcare system. 2

Cancer

Each year about 800,000 new cases of cancer and 550,000 deaths occur in India. The most common cancers in men are those of the oral cavity, oesophagus and lung while in women the main sites are the cervix, breast and ovaries. Early diagnosis and treatment are often delayed, with more than 75% of cancer patients presenting and seeking care when already in advanced stages of the disease.2 This vastly decreases the likelihood of positive treatment outcomes. Tobacco use is one of the leading risk factors, while alcohol use contributes to a substantial proportion of head, neck and stomach cancers.

Inadequate management and secondary prevention

Notwithstanding the availability of proven and effective prevention and treatment strategies for major NCDs like hypertension and diabetes, their management vis-a-vis detection and control rates are abysmally low. There is a huge gap between detection and adequate treatment: less than half of those who have hypertension or diabetes are actually detected, less than half of those detected receive appropriate treatment and less than half of those receiving treatment have their blood pressure or blood sugar treated to recommended targets (“The rule of halves”). In addition to poor control rates, of considerable concern is the fact that once hypertension-related CVD occurs, the use of proven, inexpensive evidence-based secondary prevention therapies is also very low in primary and secondary care, leading to a large and escalating burden of avoidable and premature mortality.2 A recent global study indicated that up to 80% individuals were not on proven and effective life-saving drug treatment after a stroke or heart attack in countries like India. This results in avoidable complications, increased healthcare costs, poor quality of life, premature disability and death.7

Economic impact of NCDs

NCDs and risk factors entail huge costs not only to individuals but also to the national economy. Most people suffering from NCDs incur out-of-pocket expenses to take care of healthcare costs. Medicines account for up to 45% of this expenditure. In 2004 the annual income loss among working adults due to NCDs was INR 251 billion. In 2010, the annual median direct cost per diabetic individual was reported to be USD 525, and the annual total cost of diabetes care in India was estimated to be USD 32 billion. During 2005-2015, the projected income loss due to CVD and diabetes alone is likely to be more than USD 237 billion. For obtaining NCD care, individuals and families often resort to distress financing and shell out vast amounts of catastrophic expenditures, which impoverish and ultimately drive people into poverty. Furthermore, families suffering from NCDs suffer income losses not only due to disease but also due to care giving and premature death.8,9,10

Special features of NCDs in India

In comparison to developed countries, NCDs, particularly CVD, diabetes and associated deaths in India occur at younger ages with related adverse health, economic and societal consequences. This is mainly attributable to higher risk factor burden at younger ages, earlier disease onset (at least 10 years younger), premature mortality, and higher case fatality rate of CVD-related complications. Indians also have higher predisposition to develop CVD and diabetes at lower thresholds of overweight and obesity.1,2,11 Reports also indicate the reversal of the social gradient whereby the poor suffer increased exposure to risks such as tobacco use, hypertension and acquiring diseases such as CVD and diabetes, a situation similar to that observed in developed countries that already have undergone health transitions.12 Besides, compared to other countries India suffers a very high loss in potential productive years of life because of premature CVD deaths in those aged 35- 64 years: 9.2 million years were lost in 2000 and 17.9 million years are expected to be lost in 2030.13 These factors are further compounded by the poor lacking access to expensive medical care once disease occurs leading to widening disparities in care and social inequity.

Current efforts to address NCDs

The health system has not yet fully re-oriented to effectively address the rising burden of NCDs, as the focus is still largely on providing acute care and not in providing chronic care. Thus, there are considerable inadequacies in service delivery both at the primary and secondary care level. Heterogeneity of providers, wide variations in the quality, availability and accessibility of care, has led to disparities with the rich having access to most expensive evidence based care and the poor lacking access to basic primary care. Efficient referral systems within the public sector as well as between the public and private sectors are also weak. Required emphasis on early diagnosis and evidence based management approaches are also limited in both public and private sectors. Furthermore, in the absence of financial risk protection, most people with NCDs rely on out of pocket expenses to meet healthcare costs.

The government has initiated a national programme to address NCDs in addition to existing programmes that addresses cancer, tobacco, mental health and healthcare of the elderly. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), has hypertension and diabetes as one of the focus areas. It is being implemented in 100 districts and expected to cover the rest of the country within the 12th 5 year plan period. The NPCDCS aims at: a) assessment of risk factors, early diagnosis and appropriate disease management for high risk groups; and b) health promotion for the general population. Debates are ongoing on implementing universal health coverage strategies, health sector strengthening and reforms that can likely contribute to reducing NCDs.14

India is a signatory to the WHO Framework Convention on Tobacco Control (FCTC) and is implementing the Cigarettes and Other Tobacco Products Act, 2003 (COTPA), which obligates smoking bans in public and work places, advertisement bans, prohibition of sales to and by minors, regulating the contents of tobacco products and graphical health warnings on tobacco product packages.

The way forward to address NCDs

Following the landmark United Nations High Level Meeting on NCDs in 2011 which concluded that NCD prevention and control is high priority issue, many countries have now agreed to a goal of 25% reduction in NCDs by 2025 and to establish a global monitoring framework to measure progress toward this goal.15 The Ministry of Health and Family Welfare, Government of India is in the final stages of establishing a national monitoring framework that is in alignment with the global framework and developing an action plan to prevent and control NCDs.16 The aforementioned global goal and the framework is anticipated to provide an impetus to prioritise NCD control efforts in India to improve population health. A cohesive national action plan that incorporates effective public health interventions to minimise risk factor exposure in the whole population and to reduce the risk of disease related events in individuals at high risk is necessary. Despite many challenges that are likely to be encountered, there are also opportunities to initiate actions required for attaining the WHO-UN goal of 25% reduction NCD related mortality. This combination of the population approach and the high risk clinical approach is synergistically complementary, cost-effective, and sustainable; and provides the strategic basis for early, medium and long term impact on NCDs in India in alignment with the aforesaid WHO-UN mandate.

References

1.    Patel V, Chatterji S, Chisholm D, Ebrahim S, Gopalakrishna G, Mathers C, Mohan V, Prabhakaran D, Ravindran RD, Reddy KS. Chronic diseases and injuries in India. Lancet 2011; 377:413-28.
2.    Mohan S, Reddy KS, Prabhakaran D. Chronic non-communicable diseases in India. Reversing the tide. Public Health Foundation of India, 2011.Available at: http://www.phfi.org/images/what_we_do/PHFI_NCD_Report_Sep_2011.pdf
3.    Reddy KS, Gupta PC (eds). Report on tobacco control in India, 2004. Ministry of Health and Family Welfare, New Delhi, India.
4.    Global Adult Tobacco Survey, GATS India 2009-10. Ministry of Health and Family Welfare, New Delhi, India.
5.    Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005; 366:1744-49.
6.    IDF Diabetes Atlas, 6th edition, 2013. Available at: http://www.idf.org/diabetesatlas/
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8.    Mahal A, Karan A, Engelgau M. The economic implications non-communicable diseases for India. World Bank Discussion Paper, January 2010.
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Authors

Sailesh Mohan

PhD of Public Health Foundation of India, Senior Research Scientist

Dr Sailesh Mohan is currently a Senior Research Scientist and Associate Professor at the Public Health Foundation of India (PHFI). At PHFI, he is involved in research in non-communicable disease (NCD) prevention and control. Dr Mohan also serves as a Technical Expert to the World Health Organization, India on hypertension and NCD prevention and control.

Srinath Reddy

President, Public Health Foundation of India (PHFI); President, World Heart Federation

Srinath Reddy is presently President, Public Health Foundation of India (PHFI) and formerly headed the Department of Cardiology at All India Institute of Medical Sciences (AIIMS). He was appointed as the First Bernard Lown Visiting Professor of Cardiovascular Health at the Harvard School of Public Health in 2009. He is also an Adjunct Professor of the Rollins School of Public Health, Emory University and Honorary Professor of Medicine at the University of Sydney. PHFI is engaged in capacity building in Public Health in India through education, training, research, policy development, health communication and advocacy.

Having trained in cardiology and epidemiology, Mr Reddy has been involved in several major international and national research studies including the INTERSALT global study of blood pressure and electrolytes, INTERHEART global study on risk factors of myocardial infarction, national collaborative studies on epidemiology of coronary heart disease and community control of rheumatic heart disease. Widely regarded as a leader of preventive cardiology at national and international levels, Mr Reddy has been a researcher, teacher, policy enabler, advocate and activist who has worked to promote cardiovascular health, tobacco control, chronic disease prevention and healthy living across the lifespan. He edited the National Medical Journal of India for 10 years and is on editorial board of several international and national journals. He has more than 350 scientific publications in international and Indian peer reviewed-journals.

Mr Reddy has served on many WHO expert panels and is presently the President of the World Heart Federation (2013-14). He also chairs the Core Advisory Group on Health and Human Rights for the National Human Rights Commission of India and is a member of the National Science and Engineering Research Board of Government of India. He recently chaired the High Level Expert Group on Universal Health Coverage, set up by the Planning Commission of India and also serves as the President of the National Board of Examinations which deals with post-graduate medical education in India.

Prof. Reddy is a member of the Leadership Council of the Sustainable Development Solutions Network (ww.unsdsn.org), established to assist the United Nations in developing the post-2015 goals for sustainable development. He chairs the Thematic Group on Health in the SDSN.

His contributions to public health have been recognized through several awards and honours.  They include: WHO Director General’s Award for Outstanding Global Leadership in Tobacco Control (World Health Assembly, 2003), Padma Bhushan (Presidential Honour, India, 2005), Queen Elizabeth Medal (Royal Society for Health Promotion, UK, 2005), Luther Terry Medal for Leadership in Tobacco Control (American Cancer Society, 2009), Membership of the US National Academies (Institute of Medicine, 2005), Fellowship of the London School of Hygiene and Tropical Medicine (2009), Fellowship of the Faculty of Public Health, UK (2009), Cutter Lecture (Harvard, 2006), Koplan Lecture (CDC, 2008),  Gopalan Oration (2009), Ramalingaswami Oration (2010), Paul Dudley White Lecture (AHA, 2010), Sheth Lecture (Emory, 2012), Philip Poole Wilson Memorial Oration (AIIMS-UKIERI, 2012), Sir John Wilson Oration (IAPB,2012), Doctor of Science (Honoris Causa)  conferred by University of Aberdeen, Scotland (2011), Dr. NTR Medical University (2o11) and University of Lausanne, Switzerland (2012). 

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