Oxford Vision 2020

1. Oxford Vision 2020 An introduction to a non-communicable disease control consortium www.oxfordvision2020.org

2. “Chronic diseases are the largest cause of death in the world. In 2002, the leading chronic diseases – cardiovascular disease, cancer, chronic respiratory disease, and diabetes – caused 29 million deaths worldwide.” Derek Yach (Yach, Hawkes et al. 2004)

3. Purpose of Oxford Vision 2020 Oxford Vision 2020 is a consortium of a broad range of disparate people and organizations to act together to prevent the global health risks of tobacco, physical inactivity and poor diet andblunt the impact of the diseases they cause

4. The issues • A chronic disease pandemic, growing rapidly in developing countries • Insufficient public health focus or funding • Complex set of interrelated factors • Risk factors and diseases can be reduced • Needs innovative solutions • Requires multiple stakeholder involvement • Needs a catalyst for global action • Already lots of evidence for effective interventions

5. (Yach, Hawkes et al. 2004)

7. The biggest killers of the poor Source: WHO, 2002

8. Tobacco High BMI High BMI Physical inactivity (Yach, Hawkes et al. 2004)

9. Some key facts • If unchecked, 400 million people world-wide will be suffering from diabetes by 2020 • In developing countries CVD causes four times as many deaths in mothers than childbirth & HIV/AIDS combined • Over the last 20 years, physical activity in adolescents in the US has decreased by 13% and the number of obese children aged 6 to 11 has doubled • 40-year-old male and female non-smokers can expect to lose about six and eight years of their life respectively because of obesity

10. But… • Smokers who quit cut their risk of heart disease & stroke by half within two years • In much of the developed world, the death toll from heart disease & stroke has tumbled by 60% since 1960 • Diet exercise, and anti-smoking campaigns or tobacco taxes, have not yet occurred in most developing countries • Community intervention projects can successfully cut levels of obesity and cardiovascular disease

11. 3 risk factors lead to 4 diseases 50% of global mortality

12. Myths related to health development • We must deal with AIDS/TB/malaria first One must deal with both and develop the health system accordingly. There is co-morbidity and some of the infectious diseases become chronic, e.g., AIDS • Economic growth will automatically improve all health conditions Economic growth may actually exacerbate chronic conditions • Chronic conditions are individual failure and your own responsibility Governments, industry and others play an important role

13. Myths continued • Chronic conditions are issues for the rich and old in the developed world, and a natural consequence of their lifestyle Low socio-economic status leads to cumulative exposure and decreased access to quality medical care. One high risk group are 30-40 yrs old in developing nations • Treatment of chronic conditions will only benefit people with the specific diseases Chronic conditions control benefits societies economically and, thus, us all • The health care system can deal with chronic conditions Healthcare systems mainly deal with acute diseases, not chronic

14. History of Oxford Vision 2020 • Founded at the Oxford University in December 2003 • Supports the World Health Organization’s strategy to combat chronic diseases, presented in May 2004 to the World Health Assembly

15. Participants • 8 treasury and public health departments from the USA, China, Canada, South Africa, Brazil and the UK • 16 corporations from the pharmaceutical, health care, food and media industries • 16 world leading universities focusing on medicine and public health as well as economics, geography and development • 12 leading non-governmental and inter-governmental organisations

16. Five working groups • Building evidence • Document the causes, incidence and impact of the illnesses and co-morbidities and identify gaps in current research • Learning from the tobacco experience • Draw lessons from the fight against tobacco consumption for tackling other risk factors • Communications • Examine how communications might be used to achieve the objectives • Community demonstration projects • Develop an approach for instigating projects • Grand Challenges • Identify how the Grand Challenges approach may be taken forward in the area of chronic diseases

17. Evidence-base working group • We need evidence of the problem, of the size of the problem, and of the reasons for the problem • We need evidence that the problem could be solved, and the evidence of how this might be done • We need evidence of the cost of the solution and the cost of failure to find a solution.

18. Evidence can be… • From Randomised Controlled Trials • Epidemiological • Consensus based • Wisdom (experience) based • Anecdotal

19. Risk factor area Examples of published Cochrane reviews Tobacco Community interventions for preventing smoking in young people Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours Workplace interventions for smoking cessation Obesity Advice on low-fat diets for obesity Interventions for preventing childhood obesity Diet Reduced or modified dietary fat for preventing cardiovascular disease Physical activity Exercise for preventing and treating osteoporosis in post menopausal women Exercise to improve self-esteem in children and young people

20. Smoking • Trials • None. These would be, in any case, unethical. But prospective studies amount to near-trial status and yield strong evidence. • Epidemiology • The epidemiology related to smoking has been studied over fifty years. There is no real remaining debate that cigarette smoking causes a huge burden of morbidity and mortality. • Evaluation of evidence • Good. The size of the epidemiological changes observed both for smoking illness and for its decline on smoking cessation amounts to incontrovertible evidence.

21. Doll, Peto et al BMJ, 2004

22. Twelve Lessons from Tobacco Control (examples) • Address the issue of individual responsibility versus collective/environmental action early and often • Evidence of harm is necessary but not sufficient to motivate policy change • Decisions to act need not wait for evidence of the effectiveness of interventions • The more comprehensive the package of measures considered, the greater the impact • Broad-based, vertical and horizontal coalitions, well networked, are key • Change in support for tobacco control took decades of dedicated effort by all – led by media-savvy and politically astute leaders

23. Physical activity

24. Physical inactivity • Trials • Randomised controlled trials show that a healthy lifestyle, including physical activity, reduce the risk of diabetes. Post myocardial infarction, there is an increasing body of evidence that mortality is reduced. • Epidemiology • There are some epidemiological data relating to the protective effect of physical activity. • . Evaluation of evidence • Strong evidence base for prevention of diabetes and diabetic complications.

25. Tuomilehto et al. 2001 New England Journal of Medicine. 344 (18): 1343 a reduction in weight of 5 percent or more, in total intake of fat to less than 30 percent of energy consumed, and in intake of saturated fat to less than 10 percent of energy consumed; an increase in fiber intake to at least 15 g per 1000 kcal; and moderate exercise for at least 30 minutes per day.

26. Obesity

27. Diet and obesity • Trials • Few randomised controlled trials and none with long-term outcome data. Some evidence of the role of changing dietary constituents, for example type of fat There is little evidence for the protective effect of vitamins. • Epidemiology • Good demographic evidence of differences in diet, associated with differences in morbidity and mortality.. Epidemiological data supports the role of obesity in chronic disease development. • Evaluation of evidence • The evidence of association of high energy, high fat, high sugar diets with obesity is good. The association of obesity with diabetes, CVD and some cancers is demonstrable in all epidemiological analyses.

28. Diabetes attributable to weight gain

29. Diet

30. =700 bananas per year

31. Community Actions to Prevent Chronic Diseases • Demonstration projects: • planning projects to design and test interventions supported by current epidemiologic and clinical evidence • exploratory studies to establish an evidence base for future interventions. • Croatia: • High rates of CVD and smoking-related cancers • Good Public Health Infrastructure • Ongoing partnerships (Europress Holdings, Andrija Stampar School of Public Health, Univ. of Zagreb)

32. Other issues

33. Value of human life • Life cannot be preserved indefinitely. • From cost effectiveness studies, value of prolonged health life is about $50,000 per life year. • Interventions which are cheaper than this are thought to be good value and interventions costing more than this are seen as expensive. • Moral and theological arguments can be applied to the individual, while, generally, economic arguments are applied to population approaches. • There is reluctance or abhorrence in applying specific economic arguments to specific cases.

34. Freedom of the individual • Smoking might cause an ‘inconvenience’ to others and thereby be cause for restraint. (Evidence that it is actually a cause of illness in others and has significant economic externalities has led to massive policy change). • An unhealthy diet might be ethically appropriate to indulge in by oneself, but inflicting such diet on one’s family, school children through school food programs, and especially one’s own children is unethical. • The economic costs incurred to health systems through inappropriate individual health behavior is a concern for governments.

35. Social responsibility • Social responsibility includes fair and ethical trade in food, tobacco, and other consumer products. • More of it is necessary to resist the exploitation of the developing world by western organizations marketing fast food and tobacco products. • Social responsibility should be part of the ethos of a company—maybe even a marketing tool. • Global governance for multinational action.

36. Commitments of Oxford Vision • Global communications strategy and web site • Influence major agendas • Knowledge and research resource • Community demonstration projects • Set up non-profit organisation • Include young people

37. www.oxfordvision2020.org