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Reduce disease and improve quality of life: a rational approach to NCD control

The issue of non-communicable diseases (NCDs) is gaining more and more attention as the rates of NCDs rise throughout the world. Much discussion is ongoing in terms of how to address this global disease epidemic. In addition to being a major public health issue, the epidemic presents an opportunity which it would be tragic to miss.

There are two main approaches to addressing NCDs, neither of which is sufficient by itself. One is treatment: ensuring high quality of diagnosis and care for those affected. This is undoubtedly important. The other approach is prevention: trying to reduce the number of people who have an NCD, and the age at which people are affected. While this too is undoubtedly important, many may question how realistic it is to reduce disease rates in a population.

For all of those concerned about NCDs, two issues are vitally important. One is that a treatment-only approach will prove too costly and ineffective to make a significant impact in improving public health. The other is that it is indeed possible to reduce the rates of NCDs in the population as a whole, and that given this possibility, a prevention approach must play a significant role in any overall NCD strategy.

Consider the treatment approach from viewpoint of the individual patient, a health care system, or the nation overall. The assumption that all cases of disease are inevitable and thus the only approach is diagnosis and treatment places an unnecessarily large burden on everyone involved. NCDs are chronic; there is typically no cure, only lifelong treatment, as with diabetes and high blood pressure. Where there is a cure, as with many cancers, the cure is by no means guaranteed or always completely effective. Diabetes, stroke, heart disease, cancer, and respiratory illness all detract from the patient’s quality of life over the long term. The health care costs to the individual and to society are overwhelming. Treatment can push an already-overburdened health care system to the verge of collapse. And a nation can ill-afford to lose a significant portion of its workforce just as they enter their most productive years.

Prevention of NCDs is thus vitally important. It reduces the burden on everyone involved, in terms of suffering, economic costs, and burden on the health system. Evidence is abundant that a change in lifestyle will reduce rates of NCDs. The key elements are physical activity, healthy diet, and avoidance of tobacco and alcohol. Daily moderate exercise (e.g. walking 30 minutes a day or more) has been shown to lead to substantial reductions in type 2 diabetes, dementia, depression, ischaemic heart disease, cerebrovascular disease, breast cancer, and colon cancer. Even small reduction in weight and half an hour of walking each day reduced diabetes by over 50% in overweight subjects with mild Impaired Glucose Tolerance (IGT). Diet accounts for up to 20% of all cancers in developing countries, ranking second after tobacco as a preventable cause of cancer. At least 1/3rd of cancer cases annually could be prevented. The risk of cardiovascular disease is 1.5 times higher in people who do not achieve the minimum recommendations for daily physical activity; physical inactivity is estimated to cause two million deaths worldwide annually.

The World Health Organization and others make clear that the approach to NCD prevention must focus not on individuals but on the physical environment. This includes attractive, safe, and convenient options for purposive physical activity. What this means is good conditions for walking and cycling to necessary destinations such as schools, workplaces, and shops. It also includes policies to reduce the availability and attractiveness of high-calorie, low-nutrition foods such as soft drinks, fast food, and junk food, while increasing the availability and affordability of healthy foods, particularly fresh fruits and vegetables, whole grains, and legumes (dal, beans). It also includes measures to reduce the availability and attractiveness of tobacco and alcohol, for instance by banning all forms of promotion and advertising, reducing the venues where they can be consumed, and improving labelling of products.

How much of this is practical for a country like Bangladesh facing a dual epidemic of communicable and non-communicable disease? It is not only practical but absolutely essential. Already Bangladesh has passed a comprehensive tobacco control law that eliminated virtually all tobacco advertising, mandated many public places as smoke-free, and greatly if not sufficiently improved the labelling of cigarette packs. Alcohol is not a major contributor to NCDs in Bangladesh. Little has been done yet in terms of food, but the potential is great in terms of efforts to preserve existing bazaars and mobile vendors of fruits and vegetables, and to limit promotion of unhealthy foods and their availability in different institutions, as well as to mandate a tax scheme to reward producers and distributors of fresh fruits and vegetables and penalize those dealing in disease-causing foods and beverages.

We have also made much progress in Bangladesh in terms of purposive physical activity, though far more remains to be done. As is typical in low-income countries, too much money is spent on infrastructure for the car (despite very low rates of car ownership) and far too little on non-motorized transports, despite their being the dominant mode. Since most trips in cities are made on foot already, there is vast potential to improve the walking environment and thus make walking safer and more attractive. WBB has carried out an important study on walkability in Dhaka which provides concrete recommendations on ways to improve the situation. Initiatives have recently begun to promote cycling in Dhaka. And ongoing efforts to protect parks and public spaces from encroachment have helped ensure that people have access to possibilities for active outdoor recreation.

The right of patients to affordable, quality care absolutely must be ensured. Ensuring that right will be easier if there are fewer people seeking such care due to an overall decrease in NCDs. People would also benefit from remaining healthy rather than being forced to seek care. Fortunately, the changes needed to create an environment that makes the healthy choices the easy choices are within reach and would have the additional benefit of reducing other critical problems such as traffic congestion, pollution, and high spending by individuals and the nation on transport. Support to local farmers to provide fresh produce to local schools and other institutions would help address poverty reduction goals. Preservation and expansion of public places including parks and playing fields would make our cities more liveable. The opportunities are too important to let slip by. With all the current concern about NCDs, we absolutely must face up to the challenge in the most sensible, rational way possible: by creating better environments that allow our citizens to enjoy healthier, better lives free of disease.