Chronic Diseases in Developing CountriesHealth and Economic Burdens

RACHEL NUGENT

Center for Global Development, Washington, DC, USA

Chronic diseases are increasing in global prevalence and seriously threaten developing nations’ability to improve the health of their populations. Although often associated with developed nations,the presence of chronic disease has become the dominant health burden in many developingcountries. Chronic diseases were responsible for 50% of the disease burden in 23 high-burdendeveloping countries in 2005 and will cost those countries $84 billion by 2015 if nothing is done toslow their growth. The rise of lifestyle-related chronic disease in poor countries is the result ofa complex constellation of social, economic, and behavioral factors. Variability in the prevalenceof chronic disease is found both at the country level and within countries as differences in riskfactors are observed. This upward trend is forecast to continue as epidemiologic profiles and agestructures of developing countries further shift. More research is needed to identify a full range ofprevention-focused, cost-effective interventions against chronic diseases in the developing world.

Key words: chronic diseases; obesity; developing country; poor; economics

Overview of Disease Burden

Chronic Diseases Comparedto Infectious Diseases

Chronic diseases are a serious threat to health andlongevity in developing countries. In all but the poorestcountries, the death and disability from chronic dis-eases now exceeds that from communicable diseases—comprising 49%, compared with about 40% for com-municable disease and 11% for injuries.1 The domi-nance of chronic disease in developing countries is notwell recognized among health experts and nonexpertsalike because these ailments are often less visible thancommunicable diseases, progress slowly, and are under-diagnosed. Further, the presence of chronic disease hasovertaken the communicable disease burden in part be-cause of success in reducing the latter—but tragically,also because poor countries are increasingly adoptingthe unhealthy lifestyles of the developed world.

This chapter is primarily about lifestyle-relatedchronic diseases—those that derive from personal deci-sions about diet, exercise, and tobacco consumption—driven largely by changing environments and risingincomes. The most prominent of these diseases arecoronary artery disease, ischemic stroke, diabetes, and

Address for correspondence: Rachel Nugent, Ph.D., 1776Massachusetts Ave., NW, Washington, DC 20036. Voice: 202-415-5617;fax: 202-416-5629.

rnugent@cgdev.org

some cancers. Overweight and obesity are commonprecursors caused by the some of the same risk factors.1

Thus, this chapter addresses a new and emerging as-pect of health in developing countries—one that posesa serious and growing burden on individuals, healthsystems, and economies of poor countries but is alsolargely preventable.

Trends Show Growing EffectTrends in chronic disease can be viewed in two ways:

through projections from WHO data in the Global Bur-

den of Disease and Risk Factors reporta and from individualand cross-country observational survey data obtainedfrom official country statistics and private researchers.Lacking adequate disease prevalence data, country sur-veys usually present data on specific risk factors. Bothmethods tell the same story but with different metricsand periods.

The WHO projects increases in deaths and illnessdue to chronic diseases in low- and middle-incomecountries up to 2030. The increasing prevalence ofchronic disease in developing countries can be decom-posed into two main trends: rising average age of thepopulation and changing epidemiologic profile of the

aOther diseases designated by the World Health Organization (WHO)as Type II include the following: Noncommunicable conditions are neu-ropsychiatric conditions, some respiratory and digestive diseases, and con-genital anomalies. Communicable diseases are categorized as Type I andinjuries as Type III by the WHO.

Ann. N.Y. Acad. Sci. 1136: 70–79 (2008). C© 2008 New York Academy of Sciences.doi: 10.1196/annals.1425.027 70

Nugent: Chronic Diseases in Developing Countries 71

FIGURE 1. Projected deaths due to noncommunicable diseases by country income level, 2005and 2030. Reprinted with permission from the World Bank.6

Sources: Martorell R, et al. 2000, Obesity in women from developing countries. European Journalof Clinical Nutrition 54: 247–252; WHO Global InfoBase, http://www.who.int/infobase/report.aspx?rid=112&ind=BMI.

FIGURE 2. Overweight and obesity in developing countries. (In color in Annals online.)

population. FIGURE 1 shows that expected improve-ments in age-specific death rates from chronic diseasesin developing countries will not outweigh the mortalityincrease caused by having an older population.

The survey data show increases over time in the pro-portion of the population that is overweight or obese,

a major risk factor associated with chronic diseases.These increases appear across a wide range of devel-oping countries, but with substantial variation amongthose countries in the prevalence levels and rates ofincrease (FIG. 2). These trends illustrate two importantrealities about the global increase in chronic diseases.

72 Annals of the New York Academy of Sciences

First, because of the variability in experiences acrosscountries, a better understanding of the underlyingconditions is needed. Second, we can expect the bur-den of chronic disease to continue rising as the driversspread across and within countries.

Regional BurdenA longstanding assumption has been that chronic

diseases exist primarily in rich countries and thatcommunicable diseases exist primarily in poor coun-tries. This simple division is no longer true. Finland,Taiwan, and South Korea are examples of relativelyrich countries with low prevalence of the major chronicdiseases. Canada and the United Kingdom have higherdeath rates from chronic diseases than from commu-nicable diseases; however, the chronic disease toll inthose countries is still much lower than those prevail-ing in many poor countries. Conversely, even very poorcountries, such as India and Pakistan, and moderatelypoor countries, such as Russia and China, show higherdeath rates from chronic disease than communica-ble disease.2 FIGURE 3 shows current and projectedcountry-level prevalence of overweight. Sub-SaharanAfrica, South Asia, and some portions of SoutheastAsia are the only world regions with fewer than halfof the people facing a serious risk of chronic diseasesoon.

A more nuanced understanding of who is affected bychronic diseases is gained by examining the presenceof various risk factors for chronic disease at differentincome levels—not just at the country level but withincountries as well. On this, the evidence is mixed.

In rich countries, the poor have a higher burdenof both communicable and chronic diseases than thewealthy.3 In the low- and middle-income countries, thedistribution of chronic disease risk factors varies. Asin rich countries, the prevalence of smoking is higheramong the poor in low- and middle-income countries,whereas levels of physical inactivity and type 2 dia-betes are also higher among the poor in some low-and middle-income countries but are higher amongthe wealthy in others. FIGURE 4 shows smoking preva-lence among the poor and rich in selected developingcountries.

On the other hand, obesity is increasing for allincome categories in low- and middle-income coun-tries, with an emerging tendency to shift toward thepoor. These patterns are based on scattered empiri-cal data from a cross-section of developing countries,so strong conclusions are not warranted. Some havefound that countries with an average per capita in-come level above $2500 show a greater likelihood ofobesity among lower-income women in their popula-

tions (and a lower likelihood or no connection betweenincome and obesity among men) than those countriesbelow that income level.4 In a review of national datafrom 37 developing countries gathered between 1992and 2000, Monteiro et al.5 confirm that “obesity startsto fuel health inequities in the developing world whenthe [gross domestic product] reaches a value of about$2500 per capita” (p. 1183). The data are limited toadult women, and education is used as a proxy forsocioeconomic status.

Other have found a lack of clear evidence abouteconomic status and various risk factors. Suhrcke et al.

examined the relationship between average incomeand average body mass index (BMI) across countries.3

They found that average BMI appears to increase ata decreasing rate as gross domestic product (GDP) percapita rises—a positive relationship between BMI andincome up to a relatively high level of income per capita($22,000 per year in 2002). Beyond about $22,000 an-nual income, BMI drops with increasing income. Theyfind wide variation around the mean. For example, atsimilar per capita income levels, Micronesia has anaverage BMI level of 32.6 among its male adult popu-lation, whereas Namibia has an average BMI of 21.5 inthe same population. However, for other chronic dis-ease risk factors, such as alcohol consumption or highblood pressure, a weak or no apparent relationship toincome level can be found.

The conclusion is that conditions have changed indeveloping countries in recent years such that un-healthy behaviors that lead to chronic diseases are com-mon among people of all income levels. Such behaviorsare increasingly more likely among lower-income peo-ple in countries above a certain income threshold.

The demographic influence on the rise in chronicdiseases across the world was mentioned earlier. Somebelieve that there is an unstoppable aspect to the riseof chronic diseases simply due to population aging.6

Although this may be true, the economic effect ofchronic diseases will be different if the diseases af-fect people primarily during their productive work-ing years versus after retirement and if the diseaseis treated versus left undetected or untreated. Again,there is a difference in the burden imposed by chronicdiseases in rich versus poor countries. More morbid-ity and mortality from chronic diseases occurs beforeage 60 in low- and middle-income countries than inhigh-income countries. About one-third of deaths inmiddle-income countries and 44% of deaths in low-income countries attributable to chronic disease occurbefore age 60.3

This overview should make clear that the growingpresence of chronic diseases among the populations of

Nugent: Chronic Diseases in Developing Countries 73

FIGURE 3. Prevalence of overweight by country, 2005 and 2015. Reprinted with permission fromWHO.2 (In color in Annals online.)

the world is complex—with some common factors andimportant differences. The next section will expand onthe particular implications of chronic diseases for thepoor in developing countries.

Causes of Chronic Diseaseamong the Poor

A complex constellation of social, economic, andbehavioral factors is behind the rise in chronic diseases.

With the luxury of hindsight, we can apply some of thelessons learned in developed countries to developingcountries, but only to a limited extent. The three mainrisk factors for chronic diseases—overnutrition, lackof physical activity, and tobacco use—are increasinggenerally in developing countries, just as in developedcountries. The alarming aspect in regard to the publichealth and economic agendas of these countries is thespeed with which unhealthy habits have taken hold indeveloping countries, with little indication of slowing.2

74 Annals of the New York Academy of Sciences

Source: World Health Survey (http://www.who.int/healthinfo/survey/en; accessed July 20, 2006).Reprinted with permission from WHO.2

FIGURE 4. Prevalence of daily smokers in the poorest and richest income quintiles in selected low- andmiddle-income countries. Countries are ordered by smoking prevalence in the poorest quintile. (In colorin Annals online.)

Personal Lifestyle ChangesThe chronic diseases addressed in this chapter

are often called lifestyle diseases. That terminologysuggests that people adopt unhealthy habits—suchas energy-dense diets, smoking, and reduced activitylevel—from personal preference. The extent to whichunhealthy behaviors and harmful exposures are vol-untary is a complex issue still being explored by re-searchers.3 Exposures to secondhand smoke and mar-keting of junk food and sugared beverages to childrenare two areas of enhanced disease risk where personalfreedom is limited. Less clear is how much choice isinvolved in other unhealthy behaviors and environ-mental conditions.

Survey research shows that the primary chronic dis-ease risk factors are becoming increasingly commonin developing countries and are gravitating toward thepoor and urban. The appropriateness of public pol-icy in attempting to stop this trend relies on under-standing why this is happening. A significant body ofliterature around poor health and its relationship toinequity dating from 30 years ago is relevant here,7

although studies in developing countries have not yetbeen performed to measure the role of socioeconomicstatus and health. More recent work has confirmedthat a strong inverse relationship between income andcardiovascular health in developed countries can bealmost completely explained by adverse risk factors,suggesting that a great savings to society would occurif socioeconomic gradients were reduced.8 That con-clusion applies most strongly where society bears someburden of ill health through health system costs or lossof productive lifetime. In poor countries, the immedi-ate costs of chronic ill health rests with the ill individualand his family, but longer-term health and economicconsequences may increasingly affect health systemsand other units in society, such as workplaces.

DietThe dramatic changes occurring in people’s diets

around the world have been referred to as the nu-trition transition.9 The model suggests that countriespass through a continuum of dietary, economic, andhealth stages (among other categories) as they modern-ize and urbanize. At a late (but not the final) stage of the

Nugent: Chronic Diseases in Developing Countries 75

transition, people consume more fats, more animal-based products, and more sugar, as well as more pro-cessed foods and less fiber.10 Each factor can be, butdoes not have to be, a precursor to overweight andobesity, leading to chronic diseases.b

A combination of economic and social factors iscontributing to these dietary changes. One factor isrelative food prices: The 20-year trend in global pricesof edible oils, animal-based products, and sweetenershas been downward, contributing along with increasedincomes to greater consumption of those foods in de-veloping countries.11 Recent research in the UnitedStates suggests that nutrient-deficient obesogenic dietsmay be more common among the poor because theyare more affordable than diets of high quality.12 As-faw13 shows that government subsidies in Egypt lowerprices of energy-dense, nutrient-poor foods, such asoils, sugar, and bread, both in absolute terms and rela-tive to healthier foods. The result is that large segmentsof the Egyptian population who rely on the subsidyprograms for a large share of their total calories have apoor-quality diet. Other researchers provide a theoreti-cal underpinning for increases in obesity that are basedon changes in food prices and leisure opportunities.14

Some argue that socioeconomic class determines dietand risk of obesity, as driven by the relative cost of dif-ferent types of foods. Drewnowski concludes that priceis an obesogenic factor, rather than any specific foodingredient.15

Social factors are also responsible for changes indiet in developing-country populations. Increasing ur-banization and the trends that accompany it (higherincomes, exposure to mass media and marketing cam-paigns, greater female employment, and less leisuretime) contribute to the nutrition transition describedearlier. Although these trends are global, they are pro-ceeding at various rates across regions, and the ef-fect on food and eating patterns is not uniform.16

Latin Americans rely heavily on supermarkets for theirfood purchases—a reliance that rose fourfold between1990 and 2000.17 This trend is occurring in otherdeveloping-country regions but has been less well doc-umented.18 The most obvious effect of supermarketsales is greater availability of processed foods, whichare higher in fat, salt, and sugar than foods from moretraditional retail food outlets. Similarly, fast-food out-lets and other away-from-home food purveyors can be

bThere is a strong correlation between obesity and overweight andchronic diseases, with a relative risk of 2.1 or greater for obese people todevelop diabetes and a 15%–20% greater frequency of heart problemsthan nonobese people (Pena and Bacallao18a).

found anywhere in the world, but their effect on dietsis not well understood.

In Africa, urbanization has greatly influenced howpeople eat. New habits are arising that include snack-ing on foods that are higher in fat and starch as Westernfood becomes increasingly available. The rise in untra-ditional diets has been linked to diseases previouslyseen in regions of greater affluence.19

The presence of concurrent over- and undernutri-tion has significance for chronic disease trends. Someresearch has suggested that micronutrient malnutri-tion and early childhood growth stunting may con-tribute to a greater disposition for chronic disease inlater life.20 The developing world bears a simultaneousdual burden of under- and overnutrition and thus maybe strongly predisposed to suffer from chronic diseaseand accompanying health and economic burdens laterin life. A similar trend is seen in countries undergoingepidemiologic and economic transition, where obeseadults live in the same household with stunted chil-dren.21 The National Family Health Survey of Indiashowed that 36% of women had a BMI characteristicof undernutrition, whereas 11% had a BMI charac-teristic of obesity.22 In Indonesia, 10% of householdsexperience simultaneous obesity and undernutritionamong family members.23

Physical ActivityThe level of physical activity is another important

risk factor for chronic diseases that is undergoing pro-found change in developing countries. Caused by someof the same sweeping trends that have led to dietarychanges—urbanization, modernization, and changesin occupational behaviors—physical activity in gen-eral appears to be declining. Reports from the UnitedStates estimate that the population-attributable risk ofphysical inactivity is responsible for 12% of type 2 di-abetes and 22% of coronary heart disease, as well assignificant shares of other poor health conditions.24

Such attributable risk studies are not yet available fromdeveloping countries; nonetheless, evidence about theepidemiologic transition points to declining physicalactivity as a cause of greater chronic disease preva-lence.25

The data on physical inactivity are scarce andfragmented, so at this stage it is not feasible to at-tribute health outcomes to specific behavioral shifts.Self-reported data on physical activity are subject tobias, and the use of pedometers and other monitoringtechnologies is not yet widespread, even in developedcountries. Limited research suggests the importance ofchanges taking place in workplace technology (moremechanization, less manual labor) and behavior within

76 Annals of the New York Academy of Sciences

the home (more television viewing, greater use of au-tomobiles). Much more information is needed to get afull picture of what factors determine people’s physicalactivity, but declining prices for more passive leisureand transportation alternatives and greater affordabil-ity of cars and other mechanized equipment, alongwith competitive forces driving workplace changes,are not expected to reverse course. Thus, there maybe a permanent downward shift in people’s energyexpenditure.

Poor Health CarePoor health care is an important risk factor for the

development of chronic diseases. In poor developingcountries, lack of access and affordability of preven-tive care is the general rule facing people. Also, pri-mary care systems are weak and often ill-equipped torespond to emerging disease symptoms. Treatmentsthat are extremely cost-effective in developed coun-tries, such as antihypertensive and cholesterol-loweringdrugs, are unaffordable to most affected people in de-veloping countries. More than 80% of diabetes careis provided in the rich countries where only 20% ofdiabetics live.26

Those least likely to get regular preventive care orto afford primary treatment are the low-income pop-ulation. When the poor can afford and access somemedical care for diabetes, for example, it is for controlof high blood sugar rather than preventive care againstheart disease and other complications. But more often,even blood sugar control through insulin is not avail-able. In the poorest countries, however, the poor arestill far more likely to be suffering from a communi-cable disease burden, whereas the wealthy have accessto reasonable health care. It is therefore the middle-income quintiles that may be most vulnerable to theeffects of chronic disease. Their access to health caredepends on where they live, their occupations, andwhether the public health system functions well.

To illustrate the point about how chronic diseasesburden a health system, recent statistics show the de-mands placed on the UK Health System from chronicdisease patients.27

• Around 80% of general practitioner consultationsrelate to chronic disease.

• Patients with a chronic disease or complicationsuse more than 60% of hospital bed days.

• Two-thirds of patients admitted as medical emer-gencies have exacerbation of chronic disease orhave chronic disease.

• For patients with more than one condition, costsare six times higher than those with only one.

• Evidence from the United States shows that thecare of people with chronic conditions consumesabout 78% of all healthcare spending.

People in developing countries make far different useof health care than people in the United Kingdom, sothe comparison should not be overstressed. Nonethe-less, with chronic diseases soon to exceed 50% of thedisease burden in developing countries, it is clear thatthe demand from even a small proportion of the peoplein need of care would overwhelm most health systems.To keep costs as low as possible, and the sacrifice of nor-mal living to a minimum, it is desirable to treat thosewith chronic diseases in the least intensive care settingpossible. Early diagnosis and disease management iskey to slowing disease progression and maintaining anability to function in everyday life—something mostcritical for the poor.

Cost-effective Interventionsfor Chronic Disease

Cost-effectiveness analysis assists decision makersand healthcare providers to select among interventionsin responding to the growing problem of chronic dis-ease, as well as in establishing appropriate expectationsabout the costs of changes in health outcomes throughboth targeted and population-wide interventions. Itis especially important in resource-limited countriesthat health interventions not rely heavily on healthcaresystems that are already overburdened by communi-cable disease demands. Therefore, population-basedapproaches are especially appealing, but the evidencebase for such interventions is particularly weak.

Only a few studies have described interventions forlifestyle diseases in developing countries, about half ofwhich include cost data and provide conclusions aboutcost-effectiveness. The limited literature is probablyrelated to the newness of chronic diseases in devel-oping countries, the multitude of possible health end-points and interventions, the multisectoral sources ofthe problem, and the limited knowledge of means ofchanging individual and population behavior. The re-sults of studies from developed countries cannot beassumed to apply well to developing-country settings,where population-attributable risk for individual riskfactors, as well as effectiveness of interventions, canvary widely.28 Efforts are under way to improve theevidence base for cost-effective chronic disease in-terventions that are designed for developing-countrysettings.29

Two major chronic disease primary preventionstrategies and one secondary prevention strategy arecost-effective across a broad range of developing

Nugent: Chronic Diseases in Developing Countries 77

countries. Other prevention and treatment approachesmay be cost-effective but have not been adequatelyimplemented and evaluated at this time. The two pri-mary prevention strategies are tobacco control andsalt reduction. The combined cost of these two popu-lation interventions would be about $0.36 per personaffected per year in the 23 high–chronic disease burdencountries studied.30 Costs would be slightly higher inmiddle- and upper-income countries and lower in low-and low-to-middle-income countries. The highly cost-effective secondary prevention measure is a multidrugregimen for high-risk cardiovascular patients. Such pa-tients can be effectively treated to avert adverse eventsfor about $300 per life-year saved across the groupof countries, whereas primary prevention for high-riskindividuals (a larger but less targeted group) can beachieved for $825–$900 per life-year saved in low- andlow-to-middle-income countries.29 The overall cost ofthe multidrug regimen for both groups would be about$1.10 per person in those countries.

Other feasible interventions that appear to be cost-effective in developing countries include reducing sat-urated fat in manufactured products and removingtrans fats from the food supply and replacing themwith polyunsaturated fat.31 Cost-effectiveness ratios forthese interventions are based on various modeling ef-forts that do not yield a clear result because of differentassumptions about the costs of the interventions.

Although there is a clear need—and move-ment toward—improved information on the cost-effectiveness of chronic disease interventions indeveloping-country settings, a strong case can be madethat the existing evidence is sufficient for immediateaction on several fronts. Poor country health systemscan scarcely keep up with the basic healthcare needsof their citizens and often do not do an adequate job.The added burden of screening, diagnosing, and treat-ing the growing numbers of people with or at highrisk of chronic disease threatens to cause a completebreakdown of public health services and so is generallyneglected. In the realm of private health delivery, theability to provide appropriate-quality care will growwith demand, but only for the well-off. The middleclasses and poor will not be served.

Economic Implications

Public health experts and policy makers began torecognize a close link between health and macroeco-nomic outcomes during the 1990s, after the publica-tion of the World Bank’s World Development Report 1993

that focused on the economic returns to investmentsin health.32 This Report was followed in 2001 by the

Report of the Commission on Macroeconomics andHealth to the WHO and other studies.33 The consen-sus has been that both macroeconomic and microeco-nomic arguments can be made for improving healthand preventing chronic diseases.

Estimates of the nationwide costs of chronic diseaserange from 0.02% up to 6.77% of GDP in a country.c

Most of these results come from studies in developedcountries.c In the United States, for example, the na-tionwide cost of treatment for seven major chronic dis-eases was $277 billion in 2003—roughly $100 per yearfor every person in the country—or 5% of GDP.34,c

Another study estimates global treatment costs for di-abetes alone at between $232 billion and $421 billionin 2007, about 52% of it in the United States. Thetreatment costs for diabetes in developing countriesare estimated to be 9% of the global total, with In-dia accounting for the largest amount at $2 billion in2007.26

A fuller economic measure combines those directtreatment costs with the indirect costs of chronic ill-ness, such as lost work and earning ability and thecosts of caregivers. The indirect costs of those sevenchronic diseases in the United States amounted to fivetimes the direct costs. The WHO projected the losteconomic output from diabetes, stroke, and cardiovas-cular disease in developing countries at $1.25 trillionby 2015 in five major developing countries. This fig-ure includes $557 billion in China, $300 billion in theRussian Federation, and $336 billion in India.26 Thisanalysis incorporates some measure of reduced sav-ings and investment because of lost work but does notinclude adverse effects on children’s education or theloss of well-being from morbidity or social value oflosing a human life beyond labor value of that life.Such aspects should be included in a comprehensivemeasure of how chronic disease affects the macroecon-omy, but such studies have not been carried out. Eachmethod has weaknesses, and the continuing tendencyof researchers to use different methods means that theresults have different interpretations.

A middle-ground approach was recently used in The

Lancet analysis of lost economic output across 23 high-burden developing countries. The cost of doingnothing about the growth of three major chronic dis-eases is estimated at $84 billion.35 This estimate wasobtained by projecting the numbers of prematuredeaths in those countries from three major chronic

cThe seven chronic diseases are certain cancers, diabetes, hypertension,stroke, heart disease, pulmonary conditions, and mental disorders. Thefigures exclude institutionalized patients.

78 Annals of the New York Academy of Sciences

diseases (coronary heart disease, stroke, and diabetes)and then calculating the loss in economic output thatoccurs because those deaths reduce the amount of pro-ductive labor available to the country. The differencein economic output between a scenario of no chronicdisease deaths and continuing current trends is the es-timated lost GDP from chronic diseases. The methodused conservatively excludes household effects men-tioned earlier, as well as increased morbidity.

In developed countries, the measured direct costs ofchronic disease tend to be much higher than in devel-oping countries, primarily because of different accessto treatment. In developing countries much chronicillness goes untreated, particularly among the poorand middle class. Therefore, it is important to mea-sure indirect costs of chronic disease in a developing-country setting—a challenge that cannot be met withcurrent prevalence information. The indirect costs in-clude functional loss and/or death that results in re-duction or loss in wages, reduced savings, inability tocare for the family, and significant pain and suffering.Other consequences at the household level may in-clude children’s dropping out of school to care for aparent, reduced food available to the family, and per-manent loss of well-being. In the early stage, perhapseven before a disease is diagnosed, the indirect eco-nomic effects may be minor, but if treatment is notavailable, they are likely to mount over a longer pe-riod. This long-term economic drain contrasts withcommunicable diseases that may bring about a short-term crisis and could even result in death but is morelikely to resolve without a continuing care burden onthe other family members. Exceptions to the extendedcost burden may be cases of untreated diabetes, wherethe patient often does not survive acute hyperglycemia,and acute myocardial infarctions. In both cases, deathmay quickly follow diagnosis.

In all the economic approaches used to estimatethe effects of chronic diseases, some measure of lostproductivity is calculated, either based on lost work-days at various wages or based on modeling economicrelationships more fully. The preceding figures incor-porated these losses into macroeconomic effects fromchronic disease mortality. The effect of chronic diseaseon work and workers can also be viewed from a mi-croeconomic level: Chronic diseases reduce the eco-nomic productivity of those affected and may affecttheir wages or income. Both direct and econometricefforts exist to measure that effect.

The evidence from developed countries again pointsto significant effects on wages, earnings, workforce ef-fort, and retirement.36 Direct measurements taken indeveloping countries of changes in productivity are

relatively small, but econometric evidence suggest thatworkers in Central Asia may reduce their labor effortby 7%–30% because of limitations put on their activ-ity by chronic diseases.37 Some evidence from Russiashows that people in good health are paid substantiallymore (22% for women and 18% for men) than peoplein poor health. For those specifically burdened withchronic illness, per capita income is expected to be5.6% lower.38

The combined effect of high costs of illness andpotentially significant productivity losses from havingchronic diseases suggest large overall economic effectsin a population with a high chronic disease burden.At the macroeconomic level, this effect can have long-term implications for future growth. The economicmethodology is not yet sufficiently robust to calcu-late effects on long-term growth from the microdataavailable; in fact, there often appear to be large gapsin measured microeffects and measured macroeffectsthat are unexplained. Only one study has tried to es-timate the macroeconomic effects of chronic diseasesacross countries, and it found a small estimated ef-fect (0.1% in high-income countries and insignificantin low- and middle-income countries).35 However, aspopulations age and the prevalence of chronic diseasesrise as expected,1 it may become more apparent whatthe long-term economic costs will be.

Conflicts of Interest

The author declares no conflicts of interest.

References

1. LOPEZ, A.D., C.D. MATHERS, M. EZZATI, et al. 2006.Global Burden of Disease and Risk Factors. World Bank.Washington, DC.

2. WORLD HEALTH ORGANIZATION. 2005. Preventing ChronicDiseases: A Vital Investment. World Health Organizationand the Public Health Agency of Canada.

3. SUHRCKE, M., R.A. NUGENT, et al. 2006. Chronic Disease:An Economic Perspective. Oxford Health Alliance. Lon-don.

4. MONTEIRO, C.A., E.C. MOURA, W.L. CONDE & B.M. POP-KIN. 2004. Socioeconomic status and obesity in adult pop-ulations of developing countries: a review. Bull. WorldHealth Organ. 82: 940–946.

5. MONTEIRO, C.A. et al. 2004. Obesity and inequities in healthin the developing world. Int. J. Obes. 28: 1181–1186.

6. ADEYI, O., O. SMITH & S. ROBLES. 2007. Public Policy andthe Challenge of Chronic Noncommunicable Diseases.World Bank. Washington, DC.

7. MARMOT, M., G. ROSE, M. SHIPLEY & P. HAMILTON. 1978.Employment grade and coronary heart disease in British

Nugent: Chronic Diseases in Developing Countries 79

civil servants. J. Epidemiol. Comm. Health 32: 244–249.

8. KAPLAN, G. & J.W. LYNCH. 1999. Socioeconomic consid-erations in the primordial prevention of cardiovasculardisease. Prev. Med. 29: S30–S35.

9. POPKIN, B.M. 1993. Nutritional patterns and transitions.Popul. Dev. Rev. 19: 138–57.

10. UN Food and Agriculture Organization, World AgricultureToward 2030/2050, Interim Report, Rome. June 2006.Accessed September 5, 2007 at http://www.fao.org/es/esd/gstudies.htm.

11. POPKIN, B.M. & S.J. NIELSEN. 2003. The sweetening of theworld’s diets. Obes. Res. 11: 1325–1332.

12. DREWNOWSKI, A. & N. DARMON. 2005. The economics ofobesity: dietary energy density and energy cost. Am. J.Clin. Nutr. 82(Suppl 1): 265S–273S.

13. ASFAW, A. 2006. Do government food price policies affectthe prevalence of obesity? Empirical evidence from Egypt.World Dev. 35: 687–701.

14. PHILIPSON, T.J. & R.A. POSNER. 1999. The long-run growthin obesity as a function of technological change. ChicagoJohn M. Olin Law & Economics Working Paper No. 78(2nd series).

15. DREWNOWSKI, A. 2007. The real contribution of added sug-ars and fats to obesity. Epidemiol. Rev. 29: 160–171.

16. POPKIN, B.M. 2006. Global nutrition dynamics: the world isshifting rapidly toward a diet linked with noncommunica-ble diseases. Am. J. Clin. Nutr. 84: 289–298.

17. REARDON, T., P.C. TIMMER & J.A. BERDEGUE. 2003. Su-permarket expansion in Latin America and Asia: impli-cations for food marketing systems. New Directions inGlobal Food Markets/AIB-794. Economic Research Ser-vice/USDA.

18. WITHERSPOON, D.D. & T. REARDON. 2003. The rise of su-permarkets in Africa: implications for agrifood systemsand the rural poor. Dev. Policy Rev. 21(3): 333–355.

18a. PENA, M. & J. BACALLAO. 2000. Obesity and Poverty. A NewPublic Health Challenge.. Pan-American Health Organi-zation. Washington, DC.

19. ONIANG’O, RK. et al. 2003. Contemporary African foodhabits and their nutritional and health implications. AsiaPac. J. Clin. Nutr. 12: 231–236.

20. GARRETT, J. & M.T. RUEL. 2005. The coexistence of childundernutrition and maternal overweight: prevalence, hy-potheses, and program and policy implications. Matern.Child Nutr. 1: 185–196.

21. DOAK, C., L.S. ADAIR, C. MONTEIRO & B.M. POPKIN. 2000.Overweight and underweight co-exists in Brazil, China,and Russia. J. Nutr. 130: 2965–2980.

22. Indian Institute of Population Sciences. National FamilyHealth Study 1998–99. Mumbai, India: Indian Instituteof Population Sciences, 2000; 1–328.

23. FAO. 2006. The double burden of malnutrition: case studiesfrom six developing countries. Food and Nutrition Paper84.

24. COLDITZ, G.A. 1999. Economic costs of obesity and in-activity. Med. Sci. Sports Exerc. 31(11 Suppl): S663–S667.

25. ALBALA, C., F. VIO, J. KAIN & R. UAUY. 2002. Nutritiontransition in Chile: determinants and consequences. Pub-lic Health Nutr. 5(A): 123–128.

26. The Economic Impacts of Diabetes, Chapter 5, DiabetesAtlas, International Diabetes Federation, 2007.

27. COLIN-THOME, D. & G. BELFIELD. 2004. UK HealthService, Improving Chronic Disease Management. Ac-cessed at: http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/index.htm, January 30, 2008.

28. SUHRCKE, M. et al. 2005. The contribution of health to theeconomy in the European Union. European Commission.Brussels.

29. BEAGLEHOLE R., S. IBRAHIM, S. REDDY, et al., ON BEHALF OF

THE CHRONIC DISEASE ACTION GROUP. 2007. Preventionof chronic diseases: a call to action. Lancet 370: 2152–2157.

30. GAZIANO, T.A., G. GALEA & K.S. REDDY. 2007. Scaling upinterventions for chronic disease prevention: the evidence.Lancet 370: 1939–1946.

31. WILLETT, WC., J.P. KOPLAN, R. NUGENT, et al. 2006.Prevention of chronic disease by means of diet andlifestyle changes. In Disease Control Priorities in Devel-oping Countries, 2nd ed. D.T. Jamison, J.G. Breman,A.R. Measham, et al., Eds.: 833–850. Copublication by:World Bank. Washington, DC, and Oxford UniversityPress, New York.

32. WORLD BANK. 1993. World Development Report 1993. In-vesting in Health. Oxford University Press. New York.

33. REPORT OF THE COMMISSION ON MACROECONOMICS AND

HEALTH. 2001. Macroeconomics and Health: Investing inHealth for Economic Development. World Health Orga-nization. Geneva.

34. DEVOL, R. & A. BEDROUSSIAN. An Unhealthy America: TheEconomic Burden of Chronic Disease. Milken Institute,October 2007.

35. ABEGUNDE D., C. MATHERS, et al. 2007. The burden andcosts of chronic diseases in low-income and middle-incomecountries. Lancet 370: 1929–1938.

36. SUHRCKE, M. & D. URBAN. 2006. Are cardiovascular dis-eases bad for economic growth? CESIFO Working PaperNo. 1845.

37. SUHRCKE, M., L. ROCCO & M. MCKEE. 2007. Health: a vitalinvestment for economic development in Eastern Europeand Central Asia. World Health Organization EuropeanOffice for Investment for Health and Development (2007)on behalf of the European Observatory on Health Systemsand Policies.

38. SUHRCKE, M., L. ROCCO, M. MCKEE, et al. 2007. Eco-nomic consequences of noncommunicable diseases andinjuries in the Russian federation. European Observa-tory on Health Systems and Policies, World HealthOrganization.