The New Challenges for Obstetricians . The Prevention of NCDs

1. The New ChallengesforObstetricians. ThePrevention of NCDs L. Cabero Roura Barcelona

2. Non communicable diseasesDisease that is not transmitted by another person, a vector, or the environment.

3. NCDs Diabetes Obesity Hypertension Isquemic CVD Ictus Rheumatic diseases Cancer Others

4. Global Causes of Death Injuries Communicable diseases, maternal and perinatal conditions, and nutritional deficiencies Noncommunicable diseases Source: WHO, World Health Report 2000—Health Systems: Improving Performance (Geneva: WHO, 2000).

5. NCDs : leeding cause of mortality

6. A vicious circle may ensue: poverty exposes people to behavioural risk factors for NCDs and, in turn, the resulting NCDs may become an important driver to the downward spiral that leads families towards poverty

7. Low economic growth NCDs MM Poverty Poor health

8. The scope Mortality and morbidity data reveal the growing and disproportionate impact of the epidemic in lower resource settings. Over 80% of cardiovascular and diabetes deaths, and almost 90% of deaths from chronic obstructive pulmonary disease, occur in low- and middle-income countries. More than two thirds of all cancer deaths occur in low- and middle-income countries

9. Trends in Death in Developing Areas NCDs Comm. Dis. Injuries 40 30 Deaths (millions) 20 10 0 1990 2000 2010 2020 Global Burden of Disease

10. Non Communicable Diseases (NCDs) Vulnerable Population Groups • Impact • Humanitarian • Social • Economic

11. Non Communicable Diseases (NCDs) PREVENTION Vulnerable Population Groups • Impact • Humanitarian • Social • Economic

12. Total deaths around the world: 58 million

13. Total deaths around the world: 58 million Deaths from noncommunicable diseases around the world: 35 million

14. Total deaths around the world: 58 million Deaths from noncommunicable diseases around the world: 35 million Deaths from noncommunicable diseases in developing countries: 28 million

15. Total deaths around the world: 58 million Deaths from noncommunicable diseases around the world: 35 million Deaths from noncommunicable diseases in developing countries: 28 million Deaths from noncommunicable diseases in developing countries which could have been prevented: an estimated 14 million

16. VITAL EVOLUTION MOTHER ENVIROMENTAL FACTOS GENETIC FACTORS FETUS NEWBORN ADULT

20. Many diseseases of maturity have their origins early in life

21. NUTRITION DIABETES ANEMIA MOTHER HYPERTENSION TOBACCO INFECTIONS DRUGS FETUS STRESS OBESITY NEWBORN ADULT

22. NUTRITION DIABETES ANEMIA MOTHER HYPERTENSION TOBACCO INFECTIONS DRUGS FETUS STRESS OBESITY MORTALITY SDR GROWTH NEUROLOGIC DEFICIENCIES NEWBORN IUGR PREMATURITY PPH POSTPARTUM INFECTIONS ADULT HYPERTENSION CARDIOVASCULAR DISEASES ARTERIOSCLEROSIS OBESITY WHO Definition Hb <9,5g/l

23. OVER UNDER NUTRITION DIABETES ANEMIA MOTHER HYPERTENSION TOBACCO INFECTIONS DRUGS FETUS STRESS OBESITY MORTALITY SDR NEUROLOGIC PROBLEMS NUTRITIONAL PROBLEMS IMMUNE COMPETENCES NEWBORN CONGENITAL DEFECTS IUGR PREMATURITY MACROSOMIA FETAL INFECTIONS HYPERTENSION CARDIOVASCULAR DISEASES ARTERIOSCLEROSIS DIABETES OBESITY ADULT

24. Epidemiological studies show importance of development: Smaller babies have higher adult risk of: • Hypertension • Altered plasma lipids • Raised plasma fibrinogen and CRP • Impaired glucose tolerance, type 2 diabetes and central obesity • Endothelial dysfunction

25. Greater Mismatch; Inadequate response to environment; Greater risk of disease Too poor Too rich Quality of developmental environment

26. Socioeconomic development Even poorer rural economies Migrants to cities consume high fat, high GI diet, less physical activity Greater Mismatch; Inadequate response to environment; Greater risk of disease Too poor Too rich Quality of developmental environment

27. The Future Match between induced phenotype & post-natal environment Healthy childhood body comp., metabolism & cardiovascular function HEALTH Mother’s body composition & nutrition Fetal and Infant growth & developmental adaptations Epigenetic modification of gene expression Unhealthy childhood body comp., metabolism & cardiovascular function Mismatch between induced phenotype & post-natal environment DISEASE

28. low birth weight The Recurring Nightmare: Cycles of Disease with a Poor Start to Life Gestational diabetes Large babies Women malnourished Low pregnancy weight gain Suboptimal fetal development Enriched postnatal environment due to nutritional transition Very poor postnatal environment Obesity Insulin resistance Stunting Premature death and morbidity Maternal morbidity Fat mothers Large babies Modified from Gluckman and Hanson 2005

29. NUTRITION DIABETES ANEMIA MOTHER HYPERTENSION TOBACCO INFECTIONS DRUGS FETUS STRESS OBESITY NEWBORN FETAL DEFECTS FETAL GROWTH ANOMALIES FETAL-NEONATAL DEATH NEONATAL MORBIDITY PREMATURITY/SDR OBESITY INFANT AND ADULT DIABETES CARDIOVASCULAR DISEASES SCHIZOPHRENIA ADULT

31. NUTRITION DIABETES ANEMIA MOTHER HYPERTENSION TOBACCO INFECTIONS DRUGS FETUS STRESS OBESITY NEWBORN PREECLAMPSIA IUGR MATERNAL DEATH FETAL-NEONATAL DEATH NEONATAL MORBIDITY PREMATURITY/SDR ADULT HYPERTENSION CARDIOVASCULAR DISEASES ADULT

32. NUTRITION DIABETES ANEMIA MOTHER HYPERTENSION TOBACCO INFECTIONS DRUGS FETUS STRESS OBESITY NEWBORN FETAL DEFECTS FETAL GROWTH ANOMALIES MATERNAL DEATH FETAL-NEONATAL DEATH NEONATAL MORBIDITY PREMATURITY/SDR ADULT DIABETES ADOLESCENT/ADULT OBESITY CARDIOVASCULAR DISEASES HYPERTENSION ADULT

35. NUTRITION DIABETES ANEMIA MOTHER HYPERTENSION TOBACCO NON COMUNICABLE DISEASES INFECTIONS DRUGS FETUS STRESS OBESITY NEWBORN ADULT Strong IMPACT

36. NON COMUNICABLE DISEASES MOTHER FETUS VITAL CICLE NEWBORN ADULT

37. NON COMUNICABLE DISEASES MOTHER FETUS VITAL CICLE NEWBORN ADULT

41. Good news Effective interventions are available, and abundant evidence now demonstrates their clear and measurable impact in a range of resource settings.

42. Behavior Change Successes Reducing malnutrition (micronutrient initiatives) Reducing maternal obesity Diagnose and treat the diabetes during pregnancy Preventing anemia (iron supplements) Preventing malaria (insecticide-treated bednets) Helping children survive (breastfeeding) Improving maternal health (safe motherhood movement, emergency obstetric care) Making family planning a norm (worldwide efforts) Combating HIV/AIDS (Uganda program)

43. Sumary • A well-constructed alliance between the NCD and maternal and women’s health fields has the potential to strengthen both. It is time to overcome the words and make the facts¡¡¡

44. Castells Humans

46. Key messages • The majority of noncommunicable diseases can be averted through interventions and policies that reduce major risk factors. • Many preventive measures are cost-effective, including for low-income countries. • Some preventive actions can have a quick impact on the burden of disease at the population level. • Interventions that combine a range of evidence-based approaches have better results. • Comprehensive prevention strategies must emphasize the need for sustained interventions over time.

48. Many things we need can wait, the child cannot. Now is the time his bones are being formed, his blood is being made, his mind is being developed. To him we cannot say tomorrow. His name is today. Gabrielle Mistral, Su Nombre es Hoy