Where did all the other non-communicable diseases go?

Serious consideration is needed about which non-communicable diseases to discuss at this month’s United Nations meeting if people in low income countries are to benefit.1 The diseases selected are more problematic in high income than in low income countries. Stroke, heart disease, diabetes, and chronic obstructive lung disease primarily affect older adults while low income countries remain largely populated by youth. According to World Health Organization data,2 upper middle income countries stand to benefit most if comparing the burden of non-communicable diseases that would be addressed in the proposed agenda with the burden that would not be addressed using age adjusted mortality.

The risk factors targeted are also more prevalent in high and upper middle income countries. Tobacco, alcohol, and obesity are to some extent luxuries that are not yet affordable to the poorest people in the world (table). Targeting risk factors where they are less prevalent will be less efficient.

Prevalence by income of risk factors targeted in proposed non-communicable disease programme.* Values are mean percentages of population unless stated otherwise

Country GDP (n=193)	Mean annual alcohol consumption (L) (n=188)	Obesity (n=163)	Tobacco use (n=152)	Raised blood glucose (n=101)	Physically inactive (n=122)	Hypertension(n=133)
High	9.2	24.4	20.9	6.3	43.6	41.0
Upper Middle	8.4	25.8	21.9	10.2	42.6	42.3
Lower middle	5.2	20.2	19.1	23.4	34.9	38.0
Low	3.7	5.0	12.4	3.3	18.0	38.0
	P<0.0001	P<0.0001	P=0.0003	P=0.0007	P<0.0001	P=0.006

*Based on World Health Organization data.1

GDP=gross domestic product.

The table raises additional interesting questions that won’t be addressed. For example, given that some risk factors for hypertension (such as obesity and physical inactivity) are comparatively low in low income countries, why are hypertension rates fairly similar? Furthermore, the targeted risk factors apply to these conditions in higher income countries. Risk factors for the same conditions are likely to be different in low income countries and won’t be considered in this “one size fits all” approach. Substantial evidence suggests that early deprivation and environmental exposures affect adult health,3 but these will not be explored in the proposed programme.

Invitations for the meeting had not been extended to selected delegates in August.4 The meeting has reportedly gone “wobbly” partly because countries in Africa don’t want to be diverted from today’s immediate health burden to address health problems they may have tomorrow. Indeed, the programme’s narrow proposed focus may have negative consequences for the people it aims to help.