May 2012 Number 176 www.worldbank.org/enbreve A regular series of notes highlighting recent lessons emerging from the operational and analytical program of the World Bank‘s Latin America and Caribbean Region (LAC). Promoting Healthy Living in Latin America and the Caribbean by María Eugenia Bonilla Chacín 71403 variations across countries, some face a heavy double burden of disease as communicable diseases, maternal, perinatal, and nutritional conditions remain important causes of death and disability. In addition, injuries, particularly intentional, add to the burden (Figure 1). Figure 1: Main Causes of Death in Latin America and the Caribbean (2008) age-standardized Non-Communicable diseases generate an important health and economic burden in Latin America and the Caribbean. There is therefore an urgent need to promote healthy living and aging to prevent some of these diseases. This can be achieved through population-wide multi-sectoral interventions aimed at improving nutrition, promoting physical activity, and reducing tobacco use and alcohol abuse, along with targeted medical interventions. Source: WHO 2011a Even though NCDs represent a larger share of the burden of disease in higher income members of the Organization 1. An Increasing Threat for Economic Cooperation and Development (OECD) than in the Latin America and the Caribbean (LAC) region, Non-communicable diseases (NCDs), such as cardiovascular age standardized death rates due to these diseases are diseases, cancer, diabetes mellitus and chronic respiratory much higher in the region (Figure 2). For instance, the diseases generate a heavy burden in the Latin America LAC region has some of the highest diabetes death rates and the Caribbean region. Cardiovascular diseases (CVDs) in the world (WHO 2011a). However, the region has to cause nearly a third of all deaths, while malignant and confront these diseases with fewer resources. other neoplasms cause one in six. Although there are large 1 Figure 2: NCDs Death Rates per 100,000 (2008) the cost attributable to cardiovascular diseases to health age-standardized systems in Latin America and the Caribbean, except Cuba, was about US$10 billion and the total productivity cost was around US$19 billion (Table 1). This health and economic burden caused by NCDs is growing partly due to an aging population. The share of the population older than 60 years grew 5.4 times between 1950 and 2005 and is expected to almost quadruple between 2005 and 2050 (Cotlear 2011). However, the prevalence of NCDs in the region is not only due to population aging, but also to exposure to health risk factors. Source: Estimates based on WHO 2011a 2. Modifiable Risk Factors NCDs represent an increasing economic and development threat to households, health systems, and economies in Because they share common risk factors that can be the region. These conditions require continuous contact partially addressed through public policy changes, many with the health system for long periods of time and, NCDs are preventable. Cardiovascular diseases, cancers, if not controlled, can result in costly hospitalizations. chronic respiratory conditions, and diabetes share a They also generate large productivity losses due to number of intermediate risk factors, including high blood worker absenteeism, disability, and premature deaths. pressure, high blood glucose, abnormal blood lipids, and In addition, out-of-pocket payments for services and overweight or obesity (WHO 2005). These intermediate medicines can impoverish households with members factors are the result of common modifiable risk factors with these conditions (World Bank 2011). In 2010, such as unhealthy diets, physical inactivity, tobacco use, according to a study by the World Economic Forum and and the harmful use of alcohol (which is also a risk factor the Harvard School of Public Health (Bloom et al 2011), for road traffic accidents and violence). Table 1: Costs attributable to CVD in 2010 in the Americas (US$ billions) Total Costs Total costs Per capita (without Productivity (including Per capita The Americas Region total costs productivity costs productivity total costs (adults only) costs) costs) AMR-A (USA, Canada and Cuba) 165.9 108.2 274.0 736 1,206 AMR-B (all other countries in the 8.8 17.2 26.0 52 108 region) AMR-D (Bolivia, Ecuador, Guatemala, 0.9 2.1 3.1 36 91 Haiti, Nicaragua and Peru) Source: Bloom et al 2011 Table 2: Daily Calorie Intake per Adult Equivalent in Central American Countries (in percentage) Calories Guatemala 2006 Honduras 2004 Nicaragua 2005 Panama 2008 0 - 1,165 12.2 28.8 29.5 27.6 1,165 - 2,755 49.2 54.5 57.1 55.7 2,755 - 4,132 26.7 15.4 11.1 11.4 4,133 - 5,510 8.1 1.2 1.9 3.0 5,510 & over 3.8 0.1 0.4 2.4 Source: Bonilla-Chacín ME, Vázquez M (in preparation) 2 Despite the shortage of information on dietary patterns The WHO ranks Belize, Ecuador, Guatemala, Mexico, across time, data from countries where some information Nicaragua, and Paraguay as the countries in the region is available suggest that a large percentage of households with the highest alcohol-related health risk. These have unhealthy high calorie diets (Table 2). These energy countries have the highest consumption of alcohol per dense diets combined with sedentary lifestyles are likely drinker and the largest percentage of drinkers reporting responsible for the large percentage of overweight and binge drinking. In Ecuador, the average drinker obese adults (Figure 3). In most countries, this percentage consumed a staggering 29.9 liters of pure alcohol in is higher among women than men. In several countries, 2005, followed by Mexico with 27 liters and Nicaragua these high rates of overweight and obesity coexist with with 20 liters (WHO 2011e). high rates of chronic malnutrition. Three of the four countries in the world with the highest percentage of overweight mothers and malnourished children are 3. Policy Options and the World Bank Guatemala with 13 percent of households, Bolivia with 11 percent, and Nicaragua with 10 percent (Garrett et al The burden of NCDs is increasing and consequently the 2003). Often these conditions are related; for instance, pressure on regional health systems is growing. In this low birth weight and child malnutrition have been context, treatment alone will not be fiscally sustainable associated with increases in the rates of hypertension, as the cost of treating NCDs in general is much higher cardiovascular diseases and diabetes (WHO 2003). than that of communicable diseases (World Bank 2011). Thus the urgent need to promote healthy living in Figure 3: Percentage of Adults Older than 20 Years the region through population-wide multi-sectoral Overweight or Obese (2008) interventions to improve nutrition, promote physical (Body Mass Index> 25 – age standardized) activity, and reduce tobacco use and alcohol abuse. The role of the health sector is central to ensuring that multi- sectoral interventions to promote healthy lifestyles are designed and implemented along with targeted health care services. Also crucial is surveillance of NCDs and their risk factors. This function needs to be strengthened to improve information on the prevalence of NCDs and their risk factors and to respond adequately to the epidemic. Governments in Latin America and the Caribbean are implementing multi-sectoral interventions to reduce the prevalence of NCDs risk factors. Some of these interventions fall within the list of interventions that WHO considers “Best Buys� (WHO 2011f ). Source: WHO 2011b To improve diets and increase physical activity, governments can promote public awareness about Around 27.4 percent of adult men and 14.4 percent healthy diets and physical activity through mass and of adult women in the region smoke tobacco. In the other media. An example of this type of policy to Southern Cone countries, Cuba, and Venezuela between promote physical activity in the region is that of Agita a third and two-fifths of adult men and between a Sao Paulo in Brazil (Matsudo et al 2002). To reduce salt quarter and a third of adult women currently smoke. content of food and trans fats, a promising experience in Smoking prevalence is also quite high among youth. the region is that of the Argentinean program “Less Salt, Data from the WHO Global Youth Tobacco surveys show More Life� (Menos Sal, Más Vida) and the government’s that Chile has the fourth largest prevalence of youth agreement with the industry to reduce sodium and trans tobacco smoking among women in the world. Among fats in processed foods. male youth, Ecuador and Nicaragua are among the fifteen countries with highest tobacco prevalence with An example to evaluate of community-based 31 and 30 percent respectively (WHO 2010, WHO 2011b, interventions to promote healthy diets and physical WHO 2011c, WHO 2011d). activity is that of Mexico where measures have been taken to ban the sale of junk food and mandate physical activity classes in schools. Another example of 3 community-based interventions aimed at promoting access to retail alcohol. Some countries in the region do physical activity is that of Academia da Cidade in different not impose taxes while others impose very low levels Brazilian cities1. Finally, the city of Bogota is an example (WHO 2011e). to evaluate as a city with a built an environment that promotes physical activity with its public transportation The World Bank supports many of these efforts through system, TransMilenio bus rapid transit, bike paths, and different knowledge, convening and financial services. recreational bike routes (Sarmiento n.d.). For example, the Bank has developed knowledge activities in Jamaica, the Eastern Caribbean and Central To reduce the prevalence of smoking, governments America. Through lending operations, Bank projects have can increase current tax levels and harmonize this supported overall prevention and control programs and price level with neighboring countries. In addition, the strengthening of surveillance systems in Argentina, governments can enforce legislation to ensure smoke- Uruguay, and Brazil. In addition, Bank projects support free environments, marketing bans of tobacco products the financing of health services, including, NCD and restrictive warning labels. The tobacco control prevention and control interventions at the clinical level program in Uruguay is an example to evaluate. in the Dominican Republic and Panama. Finally, the Bank is currently carrying out a regional study on multi- To reduce alcohol abuse, governments can impose sectoral approaches to promote healthy living and aging. excise taxes on alcohol and impose more restrictions on 1http://www.projectguia.org/en/project-acedemia_da_cidade.html Sources Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S. Feigl AB Gaziano T, Mowafi M, Pandya A, Prettner K, Rosenberg L, Seligman B, Stein AZ, Weinstein C 2011. The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum. Bonilla-Chacín ME, Vázquez M (in preparation) based on the analysis of the following household data bases: Guatemala Encuesta de Condiciones de Vida 2006, Honduras Encuesta de Condiciones de Vida 2004, Nicaragua Encuesta de Condiciones de Vida 2005 y Panamá Encuesta de Condiciones de Vida 2008. Cotlear D ed 2011. Population Aging: is Latin America Ready? The World Bank, Washington DC. Garret J, Ruel M 2003. Stunted Child-Overweight Mother Pairs: An Emerging Policy Concern�. FCND Discussion Paper 148. IFPRI : Washington DC. Matsudo V, Matsudo S, Andrade D, Araujo T, Andrade E, de Oliveira L, Braggion G 2002. Promotion of physical activity in a developing country: The Agita Sao Paulo experience. Public Health Nutrition 5(1A), 253-261. Sarmiento O, del Castillo AD n.d., Segura Durán E. Bogotá como ejemplo de ciudad que promueve la actividad física. (in preparation). WHO 2003. Diet, Nutrition and the Prevention of Chronic Diseases. Technical Report Series 916. WHO: Geneva. WHO 2005. Preventing Chronic Diseases: a vital investment. WHO: Geneva. WHO 2010. Gender, Women and the Tobacco Epidemic. WHO: Geneva. WHO 2011a. World Health Observatory Data Repository – Burden of Disease. WHO 2011b. World Health Observatory Data Repository – Risk Factors. WHO 2011c. World Health Observatory Data Repository – Tobacco Control. WHO 2011d. Report on the Global Tobacco Epidemic, 2011. WHO: Geneva. WHO 2011e. Global Status Report on Alcohol and Health, 2011. WHO: Geneva. WHO 2011f. Global Status Report on Noncommunicable Diseases 2011. WHO: Geneva. World Bank 2011. Chronic Emergency: Why NCDS Matter. Washington DC: The World Bank Disclaimer: The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Executive Directors of the International Bank for Reconstruction and Development / The World Bank or the governments they represent. 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