Non-communicable Diseases In sub-Saharan Africa Research Articles

Determinants of Raised Blood Pressure in Urban Uganda: A Community-Based Case-Control Study.

Rapid urbanization is changing the epidemiology of non-communicable diseases in sub-Saharan Africa. We aimed to identify the determinants of raised blood pressure in urban Uganda to highlight targets for preventive interventions. Case-control. Three community-based sites in Kampala, the capital of Uganda. Participants were eligible to enroll if they were aged ≥18 years and not pregnant. 450 cases with raised blood pressure were frequency matched by sex and age to 412 controls. Unconditional logistic regression was used to evaluate the association of socio-demographic, lifestyle, anthropometric, and laboratory variables with the outcome of raised blood pressure. Cases currently treated with antihypertensive medication and cases not treated with antihypertensive medication were analyzed separately. Significantly increased odds of raised blood pressure were associated with overweight body mass index (BMI) (25 kg/m2 ≤ BMI < 30 kg/m2), obese BMI (BMI ≥ 30 kg/m2) and hemoglobin A1c ≥ 6.5%. Significantly decreased odds of raised blood pressure were associated with moderate-to-vigorous work-related physical activity of >4 hours/week. No significant associations were found between raised blood pressure and marital status, education level, car or flush toilet ownership, dietary habits, alcohol consumption, smoking habits, moderate-to-vigorous leisure-related physical activity > 4 hours/week, waist-to-hip ratio, or total cholesterol levels. Targeted interventions are needed to address the key modifiable risk factors for raised blood pressure identified in this study, namely elevated BMI and regular physical activity, in order to reduce the burden of cardiovascular disease in urban Uganda.

Disease burden and the role of pharmacogenomics in African populations.

The burden of communicable and non-communicable diseases in Sub-Saharan Africa poses a challenge in achieving quality healthcare. Although therapeutic drugs have generally improved health, their efficacy differs from individual to individual. Variability in treatment response is mainly because of genetic variants that affect the pharmacokinetics and pharmacodynamics of drugs. The intersection of disease burden and therapeutic intervention is reviewed, and the status of pharmacogenomics knowledge in African populations is explored. The most commonly studied variants with pharmacogenomics relevance are discussed, especially in genes coding for enzymes that affect the response to drugs used for HIV, malaria, sickle cell disease and cardiovascular diseases. The genetically diverse African population is likely to benefit from a pharmacogenomics-based healthcare approach, especially with respect to reduction of drug side effects, and separation of responders and non-responders leading to optimized drug choices and doses for each patient.

Stroke Investigative Research and Education Network: Public Outreach and Engagement.

Stroke is becoming a leading cause of disability and death, and a major public health concern in Sub-Saharan Africa (SSA). The Stroke Investigative Research and Education Network (SIREN) seeks to comprehensively characterize the genomic, sociocultural, economic, and behavioral risk factors for stroke and to build effective teams for research to address and decrease the burden of stroke and other non-communicable diseases in SSA. One of the first steps to address this goal was to effectively engage the communities that suffer high burdens of disease in SSA. This paper describes the process of SIREN project's community engagement activities in Ghana and Nigeria. The aims of community engagement (CE) within SIREN are to: i) elucidate information about knowledge, attitudes, beliefs, and practices (KABP) about stroke and its risk factors from individuals of African ancestry in SSA; ii) educate the community about stroke and ways to decrease disabilities and deaths from stroke; and iii) recruit 3000 control research subjects to participate in a case-control stroke study. CE focused on three-pronged activities-constitution and interaction with Community Advisory Board (CABs), Focus Group Discussions (n=27) and community education and outreach programs (n=88). FGDs and outreach programs indicate that knowledge of stroke, as well as risk factors and follow-up evidence-based care is limited and often late. Almost all indicated that genetic testing could help health provider’s better treat stroke and help scientists better understand the causes of stroke. Over 7000 individuals have received education on cardiovascular risk factors and about 5,000 have been screened for cardiovascular risk factors during the outreaches. The CE core within SIREN is a first of its kind public outreach engagement initiative to evaluate and address perceptions about stroke and genomics by patients, caregivers, and local leaders in SSA and has implications as a model for assessment in other high stroke risk populations.

Non-communicable diseases in sub-Saharan Africa: understanding the drivers of the epidemic to inform intervention strategies

Sub-Saharan Africa is experiencing a rapidly increasing epidemic of non-communicable diseases (NCDs), while it continues to face longstanding challenges from infectious diseases. This double burden of disease could have a devastating impact on a continent that already has significant resource constraints, emphasizing the urgent need for appropriate interventions in the region. However, it is crucial to have a careful understanding of the local drivers of NCDs. This should not only include study of the traditional lifestyle risk factors, but also an examination of emerging risk factors (such as the influence of insults early in life or interactions with infection), which may be of particular importance in Africa.

The role of family in non-communicable disease prevention in Sub-Saharan Africa.

Non-communicable diseases (NCDs), including cardiovascular disease risk factors such as diabetes (DM) and hypertension (HTN), are becoming an increasing burden in Sub-Saharan Africa (SSA); by 2030, NCDs are expected to eclipse communicable diseases as the leading causes of death. DM and HTN require daily management to prevent stroke, myocardial infarction, or other complications including kidney failure. In SSA, the concept of family is critical for DM and HTN management behaviors such as adhering to medications and possessing the ability to purchase related goods. Many management behaviors also serve as primary prevention for DM and HTN. For example, including family in primary and secondary prevention strategies for NCDs in SSA may enhance existing interventions by exposing the whole family to positive NCD management methods and reinforcing better NCD outcomes for family members with NCDs. Furthermore, family inclusion may encourage preventive behaviors and, as a result, increase primary prevention of NCDs among other family members.

Tackling Noncommunicable Diseases in Africa: Caveat Lector.

Noncommunicable disease (NCD), principally cardiovascular diseases, cancer, chronic lung disease, and diabetes, constitutes the major cause of death worldwide. Evidence of a continuing increase in the global burden of these diseases has generated recent urgent calls for global action to tackle and reduce related death and disability. Because the majority of NCD deaths occur in low- and middle-income countries, increased attention has been focused on this group of countries. However, in sub-Saharan Africa, where all countries are members of the low- and middle-income grouping, NCDs are not the leading causes of death or potential life years lost. Thus, strategies to tackle NCDs in sub-Saharan Africa are best conceived and executed in alignment with existing strategies for the prevention, treatment, and control of the actual leading causes of death in this region. This commentary addresses caveats to be considered as strategies are developed to tackle NCDs in sub-Saharan Africa as part of the global effort to prevent, treat, and control NCDs.

The Global Epidemiologic Transition: Noncommunicable Diseases and Emerging Health Risk of Allergic Disease in Sub-Saharan Africa.

Globally, there has been a shift in the causes of illness and death from infectious diseases to noncommunicable diseases. This changing pattern has been attributed to the effects of an (ongoing) epidemiologic transition. Although researchers have applied epidemiologic transition theory to questions of global health, there have been relatively few studies exploring its relevance especially in the context of emerging allergic disorders in sub-Saharan Africa (SSA). In this article, we address the growing burden of noncommunicable diseases in sub-Saharan Africa through the lens of epidemiologic transition theory. After a brief review of the literature on the evolution of the epidemiologic transition with a particular emphasis on sub-Saharan Africa, we discuss existing frameworks designed to help inform our understanding of changing health trends in the developing world. We subsequently propose a framework that privileges "place" as a key construct informing our understanding. In so doing, we use the example of allergic disease, one of the fastest growing chronic conditions in most parts of the world.

Stroke Investigative Research and Education Network: Community Engagement and Outreach Within Phenomics Core.

Stroke is the leading cause of neurological hospital admissions in sub-Saharan Africa (SSA) and the second leading cause of death globally. The Stroke Investigative Research and Education Network seeks to comprehensively characterize the genomic, sociocultural, economic, and behavioral risk factors for stroke and to build effective teams for research to address and decrease the burden of stroke and other noncommunicable diseases in SSA. One of the first steps to address this goal is to effectively engage the communities that suffer the high burden of disease. The purpose of this article is to describe plans to elucidate information about knowledge, attitudes, beliefs, and practices about stroke and genomics from patients, caregivers, and local leaders, to recruit participation in research activities and dissemination of ongoing results, as well as to facilitate research uptake and impact within the broader communities of scientists, health professionals, policy makers, and others. We describe the (a) study sites and their communities; (b) plans for community advisory boards, focus groups, and surveys; (c) methods for data management in REDCap database; (d) analyses of qualitative data; (e) evaluation of community and public engagement across multiple sites and research teams in SSA and the United States; (f) use of RE-AIM for presentation of evaluation data; and (g) community indicators of success. This is the first of its kind public outreach engagement initiative to evaluate stroke and genomics in SSA, and has implications as a model for assessment in other high-stroke risk populations.

Improving Global Health

![Graphic][1] Improving the quality of pathology and laboratory medicine is not solely a local mission. Rather, it is a global one that ASCP has been vigorously engaged in for more than a decade, and it is a charge that we continue to serve as a global leader. Over the past year we've launched a major initiative in conjunction with the White House and the Clinton Global Initiative that involves a large portion of our membership to provide rapid cancer diagnostics coupled with in-country care and treatment. This initiative was launched in response to the massive escalation of non-communicable diseases in Sub-Saharan Africa. We rolled out the technology in Botswana last year and are currently installing these leapfrog systems in Rwanda. Our plan is to roll out … [1]: /embed/inline-graphic-1.gif

Placing a Health Equity Lens on Non-communicable Diseases in sub-Saharan Africa.

Deaths from non-communicable diseases are increasing worldwide. Low and middle-income countries, particularly those in sub-Saharan Africa (SSA), are projected to see the most rapid increase over the next two decades. While non-communicable diseases such as diabetes and cardiovascular disease increasingly contribute to mortality in SSA, communicable diseases such as malaria and HIV/AIDS remain major causes of death in this region, leading to a double burden of disease. In this paper, we use World Health Organization data and life table techniques to: (1) delineate the magnitude and toll of the double burden of disease in four SSA countries: Ghana, Gabon, Botswana, and Kenya, and (2) scrutinize assumptions linking changes in disease patterns to economic development and modernization. Our findings suggest that non-communicable and communicable diseases warrant equal research attention and financial commitment in pursuit of health equity.

Out-of-pocket expenditure on chronic non-communicable diseases in sub-Saharan Africa: the case of rural Malawi.

In Sub-Saharan Africa (SSA) the disease burden of chronic non-communicable diseases (CNCDs) is rising considerably. Given weaknesses in existing financial arrangements across SSA, expenditure on CNCDs is often borne directly by patients through out-of-pocket (OOP) payments. This study explored patterns and determinants of OOP expenditure on CNCDs in Malawi. We used data from the first round of a longitudinal household health survey conducted in 2012 on a sample of 1199 households in three rural districts in Malawi. We used a two-part model to analyze determinants of OOP expenditure on CNCDs. 475 respondents reported at least one CNCD. More than 60% of the 298 individuals who reported seeking care incurred OOP expenditure. The amount of OOP expenditure on CNCDs comprised 22% of their monthly per capita household expenditure. The poorer the household, the higher proportion of their monthly per capita household expenditure was spent on CNCDs. Higher severity of disease was significantly associated with an increased likelihood of incurring OOP expenditure. Use of formal care was negatively associated with the possibility of incurring OOP expenditure. The following factors were positively associated with the amount of OOP expenditure: being female, Alomwe and household head, longer duration of disease, CNCDs targeted through active screening programs, higher socio-economic status, household head being literate, using formal care, and fewer household members living with a CNCD within a household. Our study showed that, in spite of a context where care for CNCDs should in principle be available free of charge at point of use, OOP payments impose a considerable financial burden on rural households, especially among the poorest. This suggests the existence of important gaps in financial protection in the current coverage policy.

Planning and developing services for diabetic retinopathy in Sub-Saharan Africa.

Over the past few decades diabetes has emerged as an important non-communicable disease in Sub-Saharan Africa (SSA). Sight loss from Diabetic Retinopathy (DR) can be prevented with screening and early treatment. The objective of this paper is to outline the required actions and considerations in the planning and development of DR screening services. A multiple-case study approach was used to analyse five DR screening services in Botswana, Ghana, Tanzania and Zambia. Cases included: two regional screening programmes, two hospital-based screening services and one nationwide screening service. Data was collected using qualitative methodologies including: document analysis, in-depth interviews and observation. The World Health Organization (WHO) Health Systems Framework was adopted as the conceptual framework for analysis. Planning for a sustainable and integrated DR screening programme demanded a health systems approach. Collaboration with representatives from a variety of ministerial departments and professional bodies was required. Evolution of DR screening services may occur in a variety of ways including: increasing geographical coverage, integration into the general healthcare system, and stepwise progression from a passive, opportunistic service to one that systematically and proactively seeks to prevent DR. Lessons learned from the implementation of cervical cancer prevention programmes in resource-poor settings may assist the development of DR programmes in similar settings. To promote good planning of DR screening services and ensure limited resources are used effectively, there is a need to learn from screening programmes in other medical specialities and a need to share experiences between newly-developing DR programmes in resource-poor countries. The WHO Health Systems Framework presents an invaluable tool to ensure a systematic approach to planning DR screening services.

English

Essential hypertension is one of the most prevalent non-communicable diseases in sub-Saharan Africa and elsewhere in people of sub-Saharan origin. This study investigated the role of nitric oxide (NO) and glucose 6-phosphate dehydrogenase (G6PD) activity in aetiology of essential hypertension. An analytical cross-sectional design was applied to 89 essential hypertensive participants and 89 healthy normotensive participants, making a total of 178. Blood was collected for G6PD activity and serum levels of nitric oxide, glucose, creatinine, urea and electrolytes. Analysis of variance was employed to establish whether there was a difference in mean levels of NO between those that were G6PD deficient and those who were not. Lower NO levels were observed in those who were G6PD deficient though the difference was not statistically significant. A logistic regression was used to investigate the association of age, sex, NO levels, and G6PD deficiency with essential hypertension as the dependant variable. It was established that with an increase in NO levels there was less likelihood of developing hypertension (odd ratio (OR)=0.99), whereas individuals with impaired G6PD activity were 2.9 times more likely to develop hypertension than those with normal activity (OR=2.9). Our conclusion was that NO is important in prevention of hypertension through its vasodilator effect on arterioles. &nbsp; Key words: Hypertension, nitric oxide (NO), glucose 6-phosphate dehydrogenase (G6PD), reactive oxygen species.&nbsp;

Readiness of the primary care system for non-communicable diseases in sub-Saharan Africa.

Readiness of the primary care system for non-communicable diseases in sub-Saharan Africa.

Mobile health for non-communicable diseases in Sub-Saharan Africa: a systematic review of the literature and strategic framework for research.

BackgroundMobile health (mHealth) approaches for non-communicable disease (NCD) care seem particularly applicable to sub-Saharan Africa given the penetration of mobile phones in the region. The evidence to support its implementation has not been critically reviewed.MethodsWe systematically searched PubMed, Embase, Web of Science, Cochrane Central Register of Clinical Trials, a number of other databases, and grey literature for studies reported between 1992 and 2012 published in English or with an English abstract available. We extracted data using a standard form in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsOur search yielded 475 citations of which eleven were reviewed in full after applying exclusion criteria. Five of those studies met the inclusion criteria of using a mobile phone for non-communicable disease care in sub-Saharan Africa. Most studies lacked comparator arms, clinical endpoints, or were of short duration. mHealth for NCDs in sub-Saharan Africa appears feasible for follow-up and retention of patients, can support peer support networks, and uses a variety of mHealth modalities. Whether mHealth is associated with any adverse effect has not been systematically studied. Only a small number of mHealth strategies for NCDs have been studied in sub-Saharan Africa.ConclusionsThere is insufficient evidence to support the effectiveness of mHealth for NCD care in sub-Saharan Africa. We present a framework for cataloging evidence on mHealth strategies that incorporates health system challenges and stages of NCD care. This framework can guide approaches to fill evidence gaps in this area. Systematic review registration: PROSPERO CRD42014007527.

Urbanization and International Trade and Investment Policies as Determinants of Noncommunicable Diseases in Sub-Saharan Africa

There are three dominant globalization pathways affecting noncommunicable diseases in Sub-Saharan Africa (SSA): urbanization, trade liberalization, and investment liberalization. Urbanization carries potential health benefits due to improved access to an increased variety of food imports, although for the growing number of urban poor, this has often meant increased reliance on cheap, highly processed food commodities. Reduced barriers to trade have eased the importation of such commodities, while investment liberalization has increased corporate consolidation over global and domestic food chains. Higher profit margins on processed foods have promoted the creation of ‘obesogenic’ environments, which through progressively integrated global food systems have been increasingly ‘exported’ to developing nations. This article explores globalization processes, the food environment, and dietary health outcomes in SSA through the use of trend analyses and structural equation modelling. The findings are considered in the context of global barriers and facilitators for healthy public policy.

Burden of non-communicable diseases in sub-Saharan Africa in 1990 and 2010: Global Burden of Diseases, Injuries, and Risk Factors Study 2010

BackgroundSince 1990, health priorities in sub-Saharan Africa (SSAF) have been set primarily by epidemics of infectious diseases. For future global health efforts, it is important to understand the growing burden of non-communicable diseases (NCDs). MethodsFor ten major causes of NCDs, the burden of 357 diseases and sequelae was estimated. Cause-specific death rates were estimated by an ensemble method using vital registration and verbal autopsy data. The number of patients was estimated with DisMod III by mathematical modelling of epidemiological measures of each sequela. Disability weights were estimated by an open-access web-based survey, in addition to population-based surveys in Bangladesh, Indonesia, Peru, and the USA. FindingsIn 2010, more than 2·06 million deaths due to NCDs occurred in SSAF, a 46% (95% CI 41–59) increase from 1990. The risk in terms of age-standardised death rate has declined by about 12% (95% CI 8–14) from 1990 to 2010, with a negligible decline in central SSAF. The total burden of NCDs in terms of disability-adjusted life-years (DALYs) showed a similar pattern, with an increase of 45% (95% CI 41–52) in DALYs and a decrease of 9% (7–12) in standardised DALYs per capita. The fraction of burden of cancers remained at 8% in 2010, while cardiovascular and respiratory diseases decreased slightly from 16% and 12% in 1990 to 15% and 10% in 2010, respectively. Mental and behavioural disorders, musculoskeletal diseases, and diabetes and endocrine diseases increased by 3%, 2%, and 1% in 2010, respectively (from 12%, 9%, and 11% in 1990). In southern SSAF, the proportion of DALYs due to infectious diseases increased by 17% between 1990 and 2010, while the proportion of DALYs due to NCDs and injuries declined by about 20% and 15%, respectively. The decline in the burden of NCDs may be due to the pressure of competing infectious disease risks over this period. InterpretationAn increasing burden of NCDs in Africa shows a growing health iceberg hidden under epidemics of infectious diseases. The NCDs with an increasing burden of disease in SSAF are mental and behavioural conditions and musculoskeletal diseases. FundingBill & Melinda Gates Foundation.

The general population cohort in rural south-western Uganda: a platform for communicable and non-communicable disease studies

The General Population Cohort (GPC) was set up in 1989 to examine trends in HIV prevalence and incidence, and their determinants in rural south-western Uganda. Recently, the research questions have included the epidemiology and genetics of communicable and non-communicable diseases (NCDs) to address the limited data on the burden and risk factors for NCDs in sub-Saharan Africa. The cohort comprises all residents (52% aged ≥13years, men and women in equal proportions) within one-half of a rural sub-county, residing in scattered houses, and largely farmers of three major ethnic groups. Data collected through annual surveys include; mapping for spatial analysis and participant location; census for individual socio-demographic and household socioeconomic status assessment; and a medical survey for health, lifestyle and biophysical and blood measurements to ascertain disease outcomes and risk factors for selected participants. This cohort offers a rich platform to investigate the interplay between communicable diseases and NCDs. There is robust infrastructure for data management, sample processing and storage, and diverse expertise in epidemiology, social and basic sciences. For any data access enquiries you may contact the director, MRC/UVRI, Uganda Research Unit on AIDS by email to mrc@mrcuganda.org or the corresponding author.

Tackling Heart Disease at the Global Level

This article reflects on the United Nations' recent statement on the prevention and control of noncommunicable disease, the disproportionate burden of these diseases in low- to middle-income countries (with a particular focus on noncommunicable forms of heart disease), and the practical difficulties of tackling such a historically underresourced and complex health problem. ### Perceptions Are Everything Like many of us, I have spent more than a decade of my research career trying to persuade the lay public and, indeed, many health care workers and administrators, that cardiovascular disease (CVD) and its major component heart disease is a major burden to rival that of the common forms of cancer. The American Heart Association's “Go Red for Women” campaign is indicative of our collective fight to address common misperceptions about the risk of heart disease in women and its often fatal consequences.1 Even when presenting compelling evidence of the disproportionate number of men and women who lose their life prematurely (many suddenly and with little warning2) to acute myocardial infarction and chronic heart failure relative to the common malignancies,3 the response is underwhelming. Is this so surprising, given the entrenched branding of cancer sufferers as predominantly young “survivors” in a heroic battle to overcome a life-long disease? The broad misperception of heart disease, of course, is often limited to male-dominated “heart attacks” that leave the “victim” deceased (and therefore unable to tell their battle to survive) or the idea of an instant “cure” thanks to modern-day technology—the external and implantable cardiac defibrillator being the most recognizable of these. There is no “right or wrong” in our efforts to highlight serious public health issues and educate the public and health administrators alike to the enormity of the problem. The terminal malignancy that killed my own father at an early age deserves equal attention to …

NCDs--what's in an acronym?

This issue contains the first of a set of eight articles on the current state and future prospects for epidemiology in the different regions of the globe. WHO Western Pacific Region (WPR) leads the series, comprising countries as populous as China and as remote as Kiribati, which makes summarizing the burden of disease, epidemiological training, resources and research and predicting the future a real challenge. Perhaps surprisingly, WPR has the lowest agestandardized disability-adjusted life years (DALYs) rate of all WHO regions, and even in lowand middle-income countries of WPR, two-thirds of DALYs lost are attributable to non-communicable diseases (NCDs). In terms of risk factors the epidemiologic transition is well established—alcohol, tobacco and high blood pressure are the top three risk factors, contributing over 20% of DALYs lost. Published epidemiology output is highest per head of population for New Zealand and, inexplicably, Micronesia, although China heads the field in terms of absolute numbers of publications. The authors emphasize the importance of reorientation of epidemiology training and research towards NCDs—a theme that I expect will recur in subsequent articles. The editors are very grateful to Cesar Victora (President-elect, IEA), Ahmed Mandil (Treasurer-elect, IEA) and Neil Pearce (President, IEA) for guest editing this series. NCDs are a hot topic at present in the run-up to the United Nations High Level Meeting on NCDs in September 2011. The only previous one—for HIV/ AIDS—was a decade ago and is generally viewed as a triumph of global health action. There is a growing consensus about what needs to be done for NCDs— leadership, prevention, treatment, monitoring and accountability and international cooperation and funding, but an overwhelming agenda, splits by disease factionalism, and an adverse funding climate may limit what can be achieved. Epidemiologists can make an important contribution in preparing the evidence for the UN High Level Meeting as shown in this issue by Dalal et al. who take a look at what we know about NCDs in sub-Saharan Africa. Reviewing the available literature they found published community-based studies in only 13 out of 45 sub-Saharan countries amounting to 94 papers about heart disease, stroke, diabetes and cardiovascular risk factors. These studies confirmed the high prevalence of risk factors, particularly hypertension. In an accompanying commentary, Saidi Kapiga emphasizes the inter-relationships between infectious diseases and NCDs and argues for taking action and not just conducting more surveys. Peer reviewers commenting on a grant proposal I made to integrate NCD risk factor surveillance and treatment with AIDS services in sub-Saharan Africa said there was no convincing evidence that NCDs are of importance in this region. There is now. It remains to be seen whether ‘NCDs’ will become a household term in the same way as AIDS has been adopted despite few people knowing what the acronym stands for these days. NCDs are a mixed bag and as a descriptive term defining disease groups by exclusion is unsatisfactory. Moreover, with a third of all cancers in sub-Saharan Africa attributable to infectious causes, it makes aetiological nonsense to lump all cancers into the NCD group. ‘Chronic diseases’ is no better as a term. Many presentations of these ‘chronic’ diseases are actually very acute— myocardial infarction, diabetic ketosis, asthma attacks and many infectious diseases are ‘chronic’. As is becoming apparent in current dialogues, the inclusion or exclusion of specific diseases is causing friction— should mental health, epilepsy and arthritis be in or out? NCDs for the purposes of the UN High Level Meeting now include cardiovascular diseases, cancers, diabetes and chronic obstructive lung disease, because these diseases make a dominant contribution to burdens of disease and, to an extent, share risk factors. So, despite the problems, we persist with NCDs. Maybe we should just revert to ‘diseases’— they are all important, they all need a functioning health system, most are preventable and older people, in particular, often experience several of them at once. A recent publication of global prevalence and trends since 1980 in obesity, indexed by body mass index (BMI), provoked concerns about tsunamis of cardiovascular disease, despite remarkably low levels of obesity in India and China. But have we been using the wrong metric all this time? Abdullah et al. have used the Framingham cohort study which has updated measures of BMI every 2 years for almost 50 years. They find that the number of years lived with obesity is an independent, dose–response Published by Oxford University Press on behalf of the International Epidemiological Association