María Eugenia Bonilla-Chacín
Noncommunicable diseases (NCDs) such as heart disease, stroke, cancer, and diabetes represent a large share of the burden of disease of Latin America and the Caribbean (LAC). They account for three of every four deaths and for two of every three disability-adjusted life years (DALYs) lost in the region. The burden of disease from NCDs in LAC is slightly lower than it is in higher-income Organisation for Economic Co-operation and Development (OECD) countries, but this difference is quickly narrowing (figure 1.1). The impact of these condi-tions on health will likely continue to increase as the population ages and as it increasingly becomes exposed to health risk factors such as an unhealthy diet, a sedentary lifestyle, tobacco use, and alcohol abuse.
c H A p t e r 1
Figure 1.1 Age-standardized Death rates (estimates for 2004 and 2008) and DAlYs lost (estimates for 2004), latin America and the caribbean and oecD
Source: Estimates based on WHO 2004 and 2008 data from the Global Burden of Disease. http://www.who.int/healthinfo/global_burden_disease / estimates_country/en/index.html.
Note: Regional estimates are population weighted. DALY = disability-adjusted life year; LAC = Latin America and the Caribbean;
NCD = noncommunicable disease; OECD = Organisation for Economic Co-operation and Development.
Communicable diseases and maternal, perinatal, and nutritional conditions NCDs
Injuries 100
2030 4050 6070 8090 100
LAC OECD
Percent
Death rates
100 2030 4050 6070 8090 100
LAC Low- and middle-income
countries
OECD Worldwide
Percent
DALYs
2004 2008 2004 2008
28 Noncommunicable Diseases in Latin America and the Caribbean
Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0 Figure 1.2 Age-standardized DAlYs from ncDs, communicable Diseases, and injuries, selected latin American and caribbean countries, estimates for 2004
Source: Estimates based on WHO 2004 and 2008 data from the Global Burden of Disease. http://www.who .int/healthinfo/global_burden_disease/estimates_country/en/index.html.
Note: DALY = disability-adjusted life year; NCD = noncommunicable disease.
0 20 40 60 80 100
Chile Costa Rica Uruguay Argentina Peru Dominican Republic Honduras Guyana Guatemala Bolivia Haiti
DALYs (percent) Communicable diseases, and maternal, perinatal, and nutritional conditions NCDs
Unintentional injuries
Intentional injuries
Some of the region’s countries face a double burden of disease, with both communicable and noncommunicable diseases causing many deaths and much disability. Thanks to advances in the control of infectious diseases and improvements in maternal and child health, the burden of disease due to communicable diseases and to maternal and child conditions has decreased significantly in the region. But in some countries, particularly Bolivia, Guatemala, Guyana, Haiti, and Honduras, communicable diseases are still responsible for much death and disability; in some cases, these conditions may account for one-quarter or more of healthy years of life lost. In contrast, in Argentina, Chile, Costa Rica, Cuba, and Uruguay, communicable diseases account for less than 15 percent of DALYs lost (figure 1.2). Injuries also pose a significant burden in the region, and some countries face a triple burden of disease, given the large share of deaths and disability due to injuries.
Cardiovascular diseases (CVDs) and cancer are the leading causes of death in the region (figure 1.3); in a few countries, diabetes also accounts for an important share of death and disability. In many countries, deaths due to CVDs (heart disease and stroke) are twice as high as those due to malignant neoplasms, which is the second cause of death in the region.1 In 2008,
Noncommunicable Diseases in Latin America and the Caribbean 29
Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0 Figure 1.3 percentage of Age-standardized Deaths, by Disease Groups, latin America and
the caribbean, 2008 Percent
Source: Estimates based on WHO 2008 data on the Global Burden of Disease. http://www.who.int/healthinfo/global _burden_disease/estimates_country/en/index.html.
diabetes was the second cause of death after CVDs in Mexico and Trinidad and Tobago. In most Caribbean countries and in Nicaragua, Paraguay, and República Bolivariana de Venezuela, diabetes was the third leading cause of death. The main causes of DALYs lost in the region as a whole in 2004 were neuropsychiatric disorders,2 but those conditions are outside the scope of this report. In 2010 the main cause of DALYs lost in the region was ischemic heart disease (IHME and World Bank 2013).
NCD death rates in the region are significantly higher than they are in high-income OECD countries. The age-standardized NCD death rate in LAC is 23 percent higher than that in OECD countries (figure 1.4). The gap is wide for most conditions, particularly for diabetes. The diabetes-related death rate in LAC is more than twice that in OECD countries.
Although more research is needed to understand the determinants of higher death rates from these diseases in the region, the following consider-ations may partially explain this: (a) persons in LAC are more exposed to certain health risk factors than are people in wealthier countries, particularly
30 Noncommunicable Diseases in Latin America and the Caribbean
Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0 Figure 1.4 Age-standardized mortality rates from specific ncDs, latin American and caribbean and oecD countries, 2008
Source: Estimates based on WHO 2004 and 2008 data on the Global Burden of Disease. http://www.who.int /healthinfo/global_burden_disease/estimates_country/en/index.html.
0 100 200 300 400 500 600
LAC OECD
Rate (per 100,000 population)
Other NCD Diabetes mellitus
Neuropsychiatric conditions Cardiovascular diseases Chronic respiratory diseases Cancers
in terms of an unhealthy diet; (b) many of those with chronic conditions in the region are unaware that they have them and, thus, do not control them (table 1.1), leading to complications and premature death; and (c) persons in the region may have lower access to quality health services.
Some Caribbean countries present the highest NCD death rates in the region.
For example, diabetes mortality rates in this subregion rank among the highest in the world, and CVD death rates are the highest in the region. As seen in figure 1.5, several Caribbean countries have estimates for diabetes death rates higher than 60 per 100,000 population in 2008; a few have rates higher than 80 per 100,000. A few countries in Mesoamerica, including Belize, Honduras, and Mexico, also had high diabetes death rates. Five out of the six LAC countries with CVD death rates higher than 300 per 100,000 are in the Caribbean, includ-ing the Dominican Republic, Guyana, Haiti, Suriname, and Trinidad and Tobago (figure 1.6). The only non-Caribbean country with such high estimates of diabe-tes death radiabe-tes is Honduras.
Noncommunicable Diseases in Latin America and the Caribbean 31
Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0
Age-adjusted NCD death rates are not only higher in LAC countries than in high-income countries, they also occur at younger ages. In low- and middle-income countries, almost one-third of deaths occur among adults aged 15–59 years, whereas in OECD countries, most deaths occur among those 60 years old and older. Table 1.2 shows that the percentage of deaths among persons younger than 60 years old in LAC nearly doubles those seen in OECD countries. The implications are significant: since NCD-related deaths and disability in low- and middle-income countries occur at younger ages, in the region these diseases tend to affect people in their most productive years, leading to significant productivity losses, as detailed in Chapter 3.
table 1.1 prevalence (%) of Adults 20 Years and older with existing and newly Diagnosed Diabetes mellitus and Hypertension, selected central American cities, 2003–06
Belize
City San José
San Salvador
Guatemala
City Tegucigalpa Managua
Diabetes mellitus
Previously known 7.6 6.3 5.4 4.3 2.5 5.3
Newly diagnosed 5.3 2.5 2.2 2.9 2.9 4.5
Hypertensiona
Stage 2 2.9 2.3 0.7 1.2 2.7 2.8
Stage 1 9.6 7.7 3 5.1 8.3 7.5
Prehypertension 22.8 26.7 17.5 26.6 25.1 33.2
Previously known 18.8 15.3 16.4 11.2 11.8 18.6
Source: PAHO 2010.
a. Hypertension stage 1 corresponds to systolic blood pressure between 140 and 159 and stage 2, ≥160.
Figure 1.5 Age-standardized mortality rates from Diabetes, selected latin American and caribbean countries and regional Average, 2008
Source: Estimates based on WHO 2008 data on the Global Burden of Disease. http://www.who.int/ healthinfo /global_burden_disease/estimates_country/en/index.html.
Note: LAC = Latin America and the Caribbean.
0 20 40 60 80 100 120
Antigua and Barbuda Belize Dominican Republic Grenada Guyana Haiti Honduras Mexico St. Kitts and Nevis St. Lucia Trinidad and Tobago LAC average
Rate (per 100,000 population)
32 Noncommunicable Diseases in Latin America and the Caribbean
Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0 Rheumatic heart St. Vincent and the Grenadines Trinidad and Tobago
Figure 1.6 Age-standardized Death rates from specific cardiovascular Diseases, selected latin American and caribbean countries and regional, oecD, and Worldwide Averages, 2008
Source: Estimates based on WHO Global Burden of Disease data for 2008. http://www.who.int/healthinfo /global_burden_disease/estimates_country/en/index.html.
Note: CVD = cardiovascular disease.
table 1.2 percentage of Deaths from All causes, communicable Diseases, noncommunicable Diseases, and injuries, by Age Group, latin America and the caribbean, lower- and middle-income countries, oecD, and Worldwide, 2008
Latin America and the Caribbean (age group)
Low- and middle-income countries
(age group) OECD (age group) Worldwide (age group) 0–14 15–59 60 and + 0–14 15–59 60 and + 0–14 15–59 60 and + 0–14 15–59 60 and +
All causes 8.7 29.7 61.6 20.8 27.8 51.4 1.7 15.9 82.4 16.9 27.6 55.5
Communicable
diseases 34.7 24.4 40.9 54.4 24.4 21.2 11.9 11.9 76.1 52.0 26.8 21.2
Noncommunicable
diseases 3.0 23.6 73.4 2.9 24.4 72.7 0.7 13.4 85.9 2.3 23.0 74.7
Injuries 7.2 75.2 17.6 12.5 63.7 23.8 3.2 55.1 41.7 12.2 63.2 24.6
Source: Estimates based on WHO Global Burden of Disease Data for 2008.
Note: OECD = Organisation for Economic Co-operation and Development.
Noncommunicable Diseases in Latin America and the Caribbean 33
Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0 Figure 1.7 prevalence of ncDs, by rural and Urban Areas, sex, Age, and educational subgroups and income levels
0
Total RuralUrban FemaleMale 14 and younger
15–3031–4041–5051–6061–70
71 and olderNo education
Primary school and belowSecondary, middle, and vocational school University and above
Poorest
Q2 Q3 Q4 Wealthiest 10
20 30 40 50 60 70 80 90
Percent
a. Brazil, 2008
figure continues next page
Who is most Affected?
NCDs affect everyone in the region: men and women, rich and poor, rural and urban residents, and people with different educational levels. Figure 1.7 shows the distribution of people who reported a chronic condition, by several demo-graphic and socioeconomic factors, in five countries in the region. While these numbers are not comparable because different countries use different survey instruments (see appendix A), they do provide an overall view of the burden that these conditions pose for each country. For the countries shown in figure 1.7, roughly 10 percent or more of the population at different consumption quintiles report having a chronic condition; in Brazil, more than 20 percent report an NCD in every income quintile. Similar results were found in Jamaica, where persons at different socioeconomic levels reported having asthma (4.34 percent), diabetes (4.8 percent), and hypertension (9.97 per-cent) (Shao, Carpio, and de Gent 2010). In addition, an important percentage of rural and urban residents reported having a chronic condition; differences between the two areas are small in all countries with available data. Similarly, a large share of people at different levels of education reported a chronic con-dition; the pattern varies by country, but, in general, people without any for-mal education are more likely to report a chronic condition. Data limitations
34 Noncommunicable Diseases in Latin America and the Caribbean
Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0 b. Chile, 2009
0 10 20 30 40 50 60
Percent
Total RuralUrban Female Male 14 and younger
15–3031–4041–5051–6061–70
71 and olderNo education
Primary school and belowSecondary, middle, and vocational schoolUniversity and above Poorest
Q2 Q3 Q4 Wealthiest
figure continues next page c. Colombia, 2008
0 5 10 15 20 25 30 35 40 45 50
Percent
Total RuralUrban FemaleMale 14 and younger
15–3031–4041–5051–60 61–70
71 and olderNo education
Primary school and belowSecondary, middle, and vocational schoolUniversity and above
Poorest
Q2 Q3 Q4 Wealthiest Figure 1.7 prevalence of ncDs, by rural and Urban Areas, sex, Age, and educational subgroups and
income levels (continued)
Noncommunicable Diseases in Latin America and the Caribbean 35
Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0 Figure 1.7 prevalence of ncDs, by rural and Urban Areas, sex, Age, and educational subgroups and income levels (continued)
Sources: Estimates from Brazil, Pesquisa Nacional Por Amostra de Domicilios (PNAD 2008); Chile, Encuesta de Caracterización Socioeconómica Nacional (CASEN 2009); Colombia, Encuesta de Calidad de Vida, 2008; Nicaragua, Encuesta de Hogares sobre Medición de Nivel de Vida (EMNV 2009); Peru, Encuesta Nacional de Hogares 2008.
Note: NCD = noncommunicable disease, Q2 = second quintile, Q3 = third quintile, and Q4 = fourth quintile.
d. Nicaragua, 2009
0 10 20 30 40 50 60
Percent
Total RuralUrban FemaleMale 14 and younger
15–3031–4041–50 51–6061–70
71 and olderNo education
Primary school and belowSecondary, middle, and vocational schoolUniversity and above
Poorest
Q2 Q3 Q4 Wealthiest
e. Peru, 2009
0 10 20 30 40 50 60 70 80
Percent
Total RuralUrban FemaleMale 14 and younger
15–3031–4041–5051–60 61–70
71 and olderNo education
Primary school and belowSecondary, middle, and vocational schoolUniversity and above Poorest
Q2 Q3 Q4 Wealthiest
36 Noncommunicable Diseases in Latin America and the Caribbean
Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0
make it impossible to determine who is most affected or to make reliable country comparisons.3
Although data are not fully comparable across countries, information from Colombia, Chile, and Nicaragua seems to show the smallest socioeconomic gradient among people reporting a chronic condition, while Peru’s shows one with the highest. In fact, in analyzing the variables associated with reporting a chronic condition, income quintiles are not among the statistically significant variables in Colombia, but they are in Peru. The reasons behind this difference are unknown, but it is possible that screening services in Chile and Colombia are more accessible than those in Peru. As detailed in Chapter 3, income quin-tile is not significantly associated with health care utilization in Colombia, but it is in Peru.4
An important percentage of the working-age population in the five countries shown in figure 1.7 reported having an NCD. In Chile, Colombia, and Nicaragua about 15 percent of adults 41–50 years old have a chronic condition; in Peru, one-third do; and in Brazil, one-half do. Among those 51–60 years old, one-quarter of adults in the first three countries have a chronic condition; in Peru, one-half do, and in Brazil, more than 60 percent do.
Diabetes, hypertension, and asthma are the most frequently reported condi-tions. In Chile in 2009, for example, about 7 percent of persons reported having hypertension; 3 percent, diabetes; and 1 percent, asthma. In Brazil, 14 percent reported hypertension; 5 percent, asthma; and 3.6 percent, diabetes (Shao, Carpio, and de Gent 2010).5 Although there is little information on co-morbidities in household surveys, 2009 data from Brazil show that about 13 percent of the population reported having more than one chronic condition, about 41 percent of those reporting NCDs.6
Differences in ncD Death rates by sex
The differences in NCD rates by sex are significant regionwide. Although more women than men report having an NCD (figure 1.7), except in the Dominican Republic and Jamaica, the overall death rate due to NCDs across the region is higher in men than in women, with some variation seen across diseases. In most of the region’s countries, women have higher death rates due to diabetes and musculoskeletal disorders, but men have higher death rates for all other NCDs, particularly for neuropsychiatric disorders, respiratory diseases, and digestive diseases.
Sex differences also vary from country to country. Overall, diabetes affects more women than men in LAC, but there are exceptions (figure 1.8). In Argentina, for example, age-adjusted death rates due to diabetes are 60 percent higher among men than among women. In Uruguay, death rates are equal among men and women, and in Chile and Trinidad and Tobago, they are 40 percent higher among men (WHO 2008).
Noncommunicable Diseases in Latin America and the Caribbean 37
Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0
notes
1. Data for 2008 comes from WHO’s Global Repository. For more information, visit:
http://www.who.int/gho/mortality_burden_disease/global_burden_disease_death _estimates_sex_2008.xls.
2. See WHO Global Health Observatory Data Repository, DALYs, WHO Regions.
Data available at: http://apps.who.int/gho/data/node.main.923?lang=en.
3. Very few countries have information on the distribution of NCDs across socioeco-nomic conditions or even across educational levels or between urban and rural resi-dence in LAC. What little information is available (as it is for the countries shown in figure 1.7), is often self-reported and, thus, likely to be biased, since many people with an NCD are unaware that they have one. Those with better access to health services, such as better-educated urban dwellers and the wealthy, might be more likely to be aware of their condition. In three of the five surveys analyzed in the fig-ure, Colombia’s, Nicaragua’s, and Peru’s questions about chronic conditions included chronic communicable diseases such as HIV/AIDS and tuberculosis. Colombia’s survey did not give examples of chronic conditions, but Peru’s did, and included information on HIV/AIDS and tuberculosis (for a more detailed analysis of data limi-tations see the section on the labor market impact of NCDs in chapter 3 of this publication).
4. This analysis was not done for Chile or Nicaragua.
Figure 1.8 Age-standardized Death rates from Diabetes, by sex, selected latin American and caribbean countries, 2008
Source: WHO 2008 Global Burden of Disease Data.
0 20 40 60 80 100 120 140 160
Barbados Guatemala Nicaragua St. Vincent and the Grenadines Paraguay Grenada Honduras Haiti Antigua and Barbuda Dominica St. Lucia Belize St. Kitts and Nevis Mexico Guyana Trinidad and Tobago
Rate (per 100,000 population) Female Male
38 Noncommunicable Diseases in Latin America and the Caribbean
Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0 5. In addition to figures from Shao, Carpio, and de Gent 2010, these numbers come from
estimates from Chile’s CASEN 2009 and Brazil’s PNAD 2008 surveys.
6. Figures come from Brazil’s PNAD 2008 National Household Survey.
Bibliography
Departamento Administrativo Nacional de Estadística, Dirección de Metodología y Producción Estadística y Dirección de Metodología y Producción Estadística. 2008.
Encuesta Nacional de Calidad de Vida. Bogota, Colombia.
IHME (Institute for Health Metrics and Evaluation), and World Bank. 2013. The Global Burden of Disease: Generating Evidence, Guiding Policy—Latin America and Caribbean Regional Edition. Seattle, WA: IHME.
Instituto Brasileiro de Geografia e Estatística. 2008. Pesquisa Nacional Por Amostra de Domicilios (PNAD 2008).
Instituto Nacional de Estadística e Informática. 2008. Encuesta Nacional de Hogares sobre Condiciones de Vida en el Perú. Lima, Peru.
Instituto Nacional de Información de Desarrollo. 2009. Encuesta de Medición del Nivel de Vida 2009. Managua, Nicaragua.
Ministerio de Desarrollo Social. 2009. Encuesta de Caracterización Socioeconómica Nacional. Santiago, Chile.
Ministerio de Economía y Finanzas y el Instituto Nacional de Estadísticas y Censos de la Contraloría General de la República. 2008. Encuesta de Niveles de Vida ENV 2008.
Panama, Panamá.
PAHO (Pan American Health Organization). 2010. The Central American Diabetes Initiative (CAMDI). Survey of Diabetes, Hypertension, and Chronic Disease Risk Factors.
Belize, San José, San Salvador, Guatemala City, Managua, and Tegucigalpa. Washington, DC: PAHO.
Shao S., C. Carpio, and W. de Gent. 2010. The Burden of NCDs in Jamaica. Washington, DC: World Bank.
WHO (World Health Organization). 2008. The Global Burden of Disease: 2004 Update.
Geneva: WHO.
39 Promoting Healthy Living in Latin America and the Caribbean • http://dx.doi.org/10.1596/978-1-4648-0016-0