Chronic diseases: the silent global epidemic

Abstract

In most industrialized nations and many developing countries chronic diseases or non-communicable diseases (NCDs) are the leading cause of death. In 2005, chronic diseases, such as cardiovascular disease, cancer, respiratory disease and diabetes caused 58 million deaths worldwide (World Health Organization, 2005). Despite strong evidence for the magnitude of this burden, the preventability of NCD causes and the threat they pose to already strained healthcare systems, national and global responses have been slow. This article provides a global overview of chronic diseases. It further explores the impact of globalization as an important determinant of NCD epidemics. Finally, in addition to working alongside policy-makers, the fundamental roles of nursing to promote health, prevent disease and alleviate suffering call for expression of caring for humanity and environment through political activism at all levels to bring about reforms of current global economic order.

Full text

Chronic diseases: the silent
global epidemic
Chronic diseases are those that have
been, or are likely to be, present for
at least 3–6 months, and can only be
controlled and not, at present, cured
(O’Halloran et al, 2004).
While international agencies have been
spending their funds in controlling infectious
diseases, evidence of non-communicable
diseases reveals an alarming global pandemic
and associated fatalities (Strong et al, 2005).
For example, it was estimated that globally,
approximately 58 million people died in 2005
from chronic diseases such as cardiovascular
disease (Figure 1), and this figure has been
predicted to rise to 64 million in 2015 (Strong
et al, 2005). The projected number of chronic
disease deaths and age-specific death rates for
people between 2005 and 2015 is shown in
Table 1. Chronic diseases are slow to develop
but lead to devastating complications, resulting
in premature death and poor quality of life.
Global burden of chronic diseases
The high incidence of chronic NCDs presents
a challenge not only to the NHS, but also
Western world half a century ago (Popkin,
2002). This accelerated rate of change with
the increasing burden of the disease is causing
a major public health threat, which necessitates
immediate and effective action.
Chronic diseases are the most common
cause of death, led by cardiovascular disease
(17 million deaths in 2002 worldwide, mainly
from ischaemic heart disease and stroke),
followed by cancer (7 million deaths), chronic
lung diseases (4 million) and diabetes mellitus
(1 million) (World Health Organization
[WHO], 2005). These diseases share key
risk factors: tobacco use, unhealthy diet,
physical inactivity and alcohol consumption
(Figure 3). Disturbances in mental health,
which also contribute to the burden of
chronic diseases, remain not only neglected
but also deeply stigmatized across societies.
Stigma often leads to discrimination in the
provision of services for physical health in
those who are mentally ill (Fang and Rizzo,
2007). This is partly because the WHO
(2002) has not backed its optimistic message
of ‘new understanding, new hope’ with
resources. And partly because the WHO has
been unable to build a sustainable mechanism
across global and country institutions to
hold itself and others accountable for its
recommendations.
Abstract
In most industrialized nations and many developing countries chronic diseases or
non-communicable diseases (NCDs) are the leading cause of death. In 2005, chronic
diseases, such as cardiovascular disease, cancer, respiratory disease and diabetes
caused 58 million deaths worldwide (World Health Organization, 2005). Despite
strong evidence for the magnitude of this burden, the preventability of NCD causes
and the threat they pose to already strained healthcare systems, national and global
responses have been slow. This article provides a global overview of chronic diseases.
It further explores the impact of globalization as an important determinant of NCD
epidemics. Finally, in addition to working alongside policy-makers, the fundamental
roles of nursing to promote health, prevent disease and alleviate suffering call for
expression of caring for humanity and environment through political activism at all
levels to bring about reforms of current global economic order.
Key words: Chronic diseases n Education n Globalization n Multidisciplinary
Danny Meetoo is Lecturer in Adult Nursing
and Programme Leader for MSc Collabotaive Health
and Social Care, University of Salford, Salford
Accepted for publication: September 2008
society worldwide. The original reference
to chronic diseases as ‘diseases of affluence’
(Ezzati et al, 2005) or a ‘Western disease’
(Trowell and Burkitt, 1981; McKeown, 1988)
is fast becoming a misnomer. Such conditions
emerge both in economically disadvantaged
countries and poorer population groups in
richer countries, and among those with high
or low incomes (Figure 2).
This shift in the pattern of disease is occurring
at a faster rate in countries undergoing
economical development than it did in the
Danny Meetoo
1320 British Journal of Nursing, 2008, Vol 17, No 21
Cardiovascular
diseases 30%
Diabetes mellitus 2%
Cancer 13%
Chronic respiratory diseases 7%
Other chronic diseases 9%
Injuries 9%
Communicable, maternal
and perinatal conditions and
nutrional deficiencies 30%
Figure 1. Projected global distribution of total deaths (58 million) by major cause (2005) (Strong et al, 2005).

excess of 100% in those aged 45–54 years
(Bumgarner, 2004). During the same period,
cancer death rates increased between 100–
200% in those aged 35–44 years and 100–
160% in those aged 45–54 years.
Shouldering the double burden
Chronic diseases have not simply displaced
infectious ones in economically developing
countries (Mascie-Taylor and Karim, 2003).
It seems that such countries continue to
experience a polarized and protracted double
burden of disease (Frenk et al, 1989). For
example, India, the second most populous
country, has the highest number of people with
diabetes in the world, and annual coronary
deaths are expected to reach 2 million by
2010 (Basnayar and Rajapasha, 2004). At the
same time, around 2.5 million children in
India die from infections such as pneumonia,
diarrhoea, and malaria every year. In South
Africa, infectious diseases account for 28% of
lives lost while chronic diseases account for
25% (Steyn et al, 2008).
It has been predicted that over the next
two decades the global pattern of chronic
disease will continue to increase, particularly
in developing countries (Yach et al, 2004).
Cardiovascular diseases are already the leading
cause of mortality in developing countries
(WHO, 2003). By 2020, mortality from
ischaemic heart disease in these countries
(developing) is expected to rise by 120%
for women and 137% for men (Leeder et al.
2004). Predictions for the next two decades
include a near tripling of ischaemic heart
disease and stroke mortality in Latin America,
the Middle East and Sub-Saharan Africa.
The global number of people with diabetes
in 2000 was estimated to be 171 million
(2.8% of the world’s population), and this
figure is projected to increase to 366 million
(6.5%) by 2030 to – 298 million of whom
will live in less prosperous countries (Wild
et al, 2004; Meetoo et al, 2007). According
to these authors, this increase will be due
to population growth, ageing, urbanization,
obesity and physical inactivity. Between 1990
and 2000, there was a 19% rise in cancer
mainly in low-income countries (Stewart and
Kleihaus, 2003).
Further death and disability caused by
chronic obstructive pulmonary disease
(COPD) (WHO, 2002a) is increasing across
most regions. Risks for chronic disease are
also escalating. Smoking and obesity among
adolescents in less prosperous countries have
risen over the past decade and portend rapid
increases in chronic diseases (Popkin, 2002).
Many economically developing countries,
and low income countries about to make
such a developmental transition, have
witnessed a rapid deterioration of their
chronic disease risk and mortality profiles
(WHO, 2002b). For example, in China, age-
specific death rates from circulatory disease
increased between 200–300% in those aged
35–44 years between 1986 and 1999, and in
Economic implications
The increased burden of chronic diseases
in countries that also have a high infectious
disease burden is putting a strain on health
services. In all countries, it is also leading to
growing economic costs, best documented
with respect to tobacco-related diseases
(Jha and Chaloupka, 1999), with increasing
evidence emerging for cardiovascular disease
(Leeder et al, 2004), diabetes (International
Diabetes Federation [IDF], 2003) and obesity
(Thompson and Wolf, 2001). Many developed
nations have focused considerable efforts on
addressing the burden of chronic diseases. In
contrast, the rising burden of chronic diseases
in countries with low financial status has
received inadequate attention (Beaglehole
and Yach, 2003).
In the absence of policy actions, economic
development leads to increased tobacco use
and obesity which later results in chronic
diseases (Popkin and Doak, 1998). Unlike
infectious diseases, which generally decline
with economic growth, chronic disease risks
do not begin to fall until high levels of wealth
and literacy are reached (McKeown, 1988)
when governments are more likely to respond
to public health concerns and use a broad
range of policy instruments to influence
consumption trends.
Thus far, however, declines in chronic
disease risks have only been achieved by the
Organisation for Economic Cooperation and
Development countries (Leeder et al, 2004).
Therefore, the challenge policy makers face
is how to implement policies that support
continued economic development while
simultaneously reducing the rates of increase
in chronic diseases.
British Journal of Nursing, 2008, Vol 17, No 21 1321
CHRONIC CONDITIONS
Table 1. Projected global deaths and chronic disease burden
(millions) projected by age, 2005–2015
0–29 years 1.7 1.5 220 219 48 40 6320 5994
30–59 years 7 8 305 349 311 297 13 304 13 375
60–69 years 7 8 101 125 1911 1695 27 965 26 396
≥70 years 20 24 99 116 6467 6469 32 457 31 614
All ages 35 41 725 808 549 577 11 262 11 380
1 DALY (disease adjusted fife years) is considered as 1 lost year of healthy life
Source: Strong et al (2005)
Deaths (millions) DALYs (millions) Deaths per 100 000 DALYs per 100 000
2005 2015 2005 2015 2005 2015 2005 2015
1200
1000
800
600
400
200
0
Death rates (per 100 000)
2005 2005 2005 20052015 2015 2015 2015
Low income Low-middle
income
Upper-middle
income
High income
Group 1
Group 2
Group 3
Figure 2. Projected crude death rates per 100 000 by World Bank income groups for all ages, 2005-2015 (Strong et al, 2005).
Group 1: communicable diseases, perinatal and maternal conditions; group 2: non-communicable diseases; group 3: injuries.

Causes of chronic diseases
The present burden of NCDs results from
exposure to past and cumulative risks to health,
while the future burden will be determined
by the current population exposure to risk
factors (Yach and Beaglehole, 2004). While
age, gender and genetic susceptibility are non-
modifiable, other risk factors are modifiable,
albeit with some difficulty (Tukuitonga, 2006).
The relationship between risk factors and
chronic disease is similar in all regions of the
world and stronger in low-income countries
(Rodgers et al, 2000).
The causes of the main chronic disease
epidemics are well established and well known
(Figure 3). Population aging is an important
underlying causal determinant because
of the strong association between disease
incidence and age (Yach and Beaglehole,
2004). Other underlying determinants are a
reflection of the major forces driving social,
economic and cultural change, including
globalization, urbanization and the general
policy environment (WHO, 2005).
Further, global forces such as those in
trade and marketing are increasing the causal
entrenchment of chronic diseases in all the
regions. For example, one of the health-related
effects of globalization is the trend known
as ‘nutrition transition’, which according
to Popkin (2002) is the replacement of a
traditional diet rich in fruit and vegetables by
a diet rich in calories derived from animal fats,
and lower in complex carbohydrates. Except for
countries with a less developed infrastructure,
this transition is well underway in almost every
corner of the globe (Yach and Beaglehole,
2004). Such a diet, when combined with a low
level of physical activity, regular tobacco use
and alcohol consumption, sets the scene for
1322 British Journal of Nursing, 2008, Vol 17, No 21
a population-wide atherosclerosis and global
distribution of chronic diseases (WHO, 2005).
Impact of globalization
In its broadest term globalization refers to the
increasing interconnectedness of countries, the
openness of borders to ideas, people, commerce
and financial capital (Woodward et al, 2001).
The effect of globalization has been
widely debated (Yach and Bettcher, 1998).
There is an agreement that globalization has
improved health status and lowered mortality
by improving economic prosperity and
income in many countries (United Nations
Conference on Trade and Development, 2002).
Further, the introduction of information
and communication technologies influence
health both positively and negatively. On
the positive side these technologies can be
used in innovative ways to disseminate health
promoting measures.
However, the greatest effects on health
are negative. For example, the marketing of
tobacco, alcohol, salty, sugary and fatty foods
now reaches the majority of countries. In
addition, global marketing often tends to
target children (Hawkes, 2002), who influence
parental spending (McNeal, 2002) with such
common ‘obesogenic’ purchases as fast food
and soft drinks.
Marketers increasingly use sophisticated
means to ensure that their messages ‘slip
below the radar of critical thinking’ (Walsh,
2002), take advantage of weak regulatory
environments, and use false, misleading or
deceptive advertising to reach their targets. It
has, therefore, been argued that globalization
has also promoted a ‘toxic’ (Horgen and
Brownell, 2002) or ‘obesogenic’ environment
that promotes energy-dense, inexpensive and
highly accessible food, tobacco, alcohol and
other products, which when combined with
a sedentary lifestyle adversely impact on the
health of populations (Bettcher et al, 2000).
From a healthcare perspective, globalization
cannot be viewed as a passing phenomenon.
In an attempt to improve the health of nations,
nurses should consider how knowledge
and research findings are disseminated and
communicated in globally diffused societies.
Tackling chronic diseases –
a global perspective
The aim of chronic disease prevention is to
delay mortality from these diseases to older
age groups and to promote healthy aging
of global populations. Achieving such a goal
would result in an estimated 36 million fewer
deaths between 2005 and 2015 worldwide,
Figure 3. Causes of chronic diseases (Tukuitonga, 2006).
Globalization
Urbanization
Aging population
Individual specific
Modifiable risk factors
Unhealthy diet
Physical inactivity
Smoking
Alcohol consumption
Individual specific
non-modifiable risk factors
Age
Gender
Heredity
Bio-chemical/physiological risk factor
Hypertension
Hyperglycaemia
Abnormal blood lipids
Overweight/obesity
Cancer
Heart disease
Stroke
Chronic respiratory disease
Diabetes
Socioeconomic
Cultural and
Environmental
Main chronic diseases

British Journal of Nursing, 2008, Vol 17, No 21 1323
CHRONC CONDITIONS
of which 28 million would be averted in
low-income and middle-income countries
(Strong et al, 2005) (Figure 4). In addition, for
people under the age of 70 years, achieving
the global goal would result in 3 million
fewer deaths by 2015 (Figure 5).
The need for action to strengthen control
and prevention measures to counter the
spread of the chronic disease epidemic is now
widely recognized by many countries, but
the developing countries are lagging behind.
Encouragingly, however, efforts to counteract
this are increasingly assigned a higher priority.
In 1998, the need to address chronic disease
prevention from a broad-based perspective
was recognized by the World Health Assembly
(WHA, 1998) and again in 1999 (WHA,
1999). In 2000, the WHA passed a further
resolution on the broad basis of prevention
and control of NCDs (WHA, 2000), and in
2002 adopted a resolution that urged member
states to collaborate with WHO to develop ‘…
a global strategy on diet, physical activity and
health for the prevention and control of non-
communicable diseases, based on evidence
and best practices, with special emphasis on an
integrated approach’ (WHA, 2002).
Several factors ranging from underestimation
of the effectiveness of interventions, the belief
of there being a long delay in achieving any
measurable impact, commercial pressures, and
institutional inertia to inadequate resources
have constrained progress in the prevention of
chronic diseases. Individual countries, however,
are acting as pace-makers in chronic disease
prevention for others to follow. For example,
a recent review of tobacco control in Brazil,
South Africa, Thailand, Poland, Bangladesh
and Canada showed that tobacco prevalence
can be reduced cost-effectively in high-,
middle- and low-income countries (de Beyer
and Brigden, 2003).
In a review of the dietary intake of the
population of North Karelia, Finland, numerous
regulated community-based projects undertaken
over a 25-year period (1972–1998) have
successfully reduced the age-adjusted mortality
rates for coronary heart disease (Puska et al,
1998; Puska, 2002).
Despite economic and social changes,
the Republic of Korea, which has largely
maintained its traditional high-vegetable diet
(Lee et al, 2002), has lower rates of chronic
diseases and lower than expected levels of fat
intake and obesity than other industrialized
countries with similar economic development
(Kim et al, 2002).
Other countries planning to introduce
policy change to tackle chronic disease have
some pioneering regional examples to learn
from. The Pakistan National Action Plan
on NCDs launched in 2003 has integrated
surveillance and intervention for chronic
diseases (Nishtar et al, 2006). Jordan’s
Gateway to the Future has established a
programme aimed at promoting behaviour
change in three key domains – chronic
disease, reproductive health and child health
(Health Communication Partnership, 2006).
In Iran, the Isfahan Healthy Heart Programme
(1999) has established community-based
interventions to increase physical activity,
improve diet and help people stop smoking.
Although the outcome data from these
initiatives are as yet unavailable, they are steps
in the right direction.
Although plans to tackle chronic disease in
individual countries are in their infancy, there
are encouraging signs of independent action
on health advocacy. These capitalize on the
region being mostly Muslim. For example, in
2002 the Hajj (Muslim pilgrimage) was made
tobacco free. Religious teaching suggests that
tobacco is ‘undesirable’ and this point has been
picked up by key regional publications (WHO,
2008).
Information about physical exercise should be
equally and actively encouraged among women
as it is in men in Muslim cultures, particularly
among those with chronic conditions. Regional
research priorities should be defined. In the
case of cancer this should include investigation
of the observed association between levels of
depleted uranium (in the wake of the Gulf
War of 1991–2003) and increased incidence
of cancer (Macfarlane et al, 2003). If the six
countries of the Gulf Cooperation Council
promoted research into the management
of chronic disease, this might initiate the
development of a regional and possibly global
partnership on chronic disease.
Infectious disease partnerships have
improved a range of health outcomes (Nishtar,
30
25
20
15
10
5
0
Deaths (millions)
Chronic
respiratory
diseases
DiabetesCancersCardiovascular
diseases
Chronic
diseases
Low-income and middle-income
High-income
Figure 4. Cumulative number of deaths averted from chronic diseases by combined World Bank income, 2006-2015
(Strong et al, 2005).
20
15
10
5
0
Deaths (millions)
Chronic
diseases
Cardiovascular
diseases
Cancers Chronic
respiratory
diseases
Diabetes
2005
2015
Goal 2015
Figure 5: Chronic disease deaths (millions) projected from 2005–2015 with the global goal scenario for people younger
than 70 years of age (Strong et al, 2005).

2004) and such partnerships could do the same
for chronic disease. In the UK, the Wanless
Report (Department of Health [DH], 2002)
recommends that people take responsibility
for their own health. The outcome of
this action plan is perhaps questionable,
particularly at a time when health inequalities
persist, the health gap between rich and poor
is growing, and a generation of overweight
and under exercised individuals is maturing
(Hunter, 2003).
Role of educationalists
Globalization has presented nursing with
many challenges and opportunities. How
nurse educationalists design curricula, for
example to meet the needs of nurses who
manage NCDs, in the 21st century in both
this and other countries, is one of them.
While evidence-based care is essential,
nurse educationalists also need to accept and
incorporate the existence of multiple realities of
the human experience, as opposed to the single,
fixed reality asserted by quantitative research
findings (Watson, 1995). The availability of
any online educational nursing programme
must, therefore, represent reality for the nurses
of that country. Failure to achieve this is likely
to result in what Visvanathan (1999) terms as
‘museumization’ – to portray obliteration of
indigenous knowledge by Western science.
Finally, nurse educationalists need to
ensure that any communication of nursing
knowledge in publications or any other
media is thoughtful, responsible and culturally
sensitive, if the agreed outcomes of care in
NCDs are to be achieved.
Collaboration in chronic disease
management
Viewed globally, the foundations of chronic
disease management rest on a non-hierarchical
partnership between the patient and the
multidisciplinary team, thereby sharing
decisions and responsibilities (Holman and
Lorig, 2000). As members of a multidisciplinary
team, nurses play a valuable role in chronic
disease management due to their ability to
focus on complex actions that address physical,
psychosocial and lifestyle issues (Fireman et
al, 2004). This nursing contribution is vital
when evaluating care at case management
meetings and/or at meetings where agendas
are largely set by patients to discuss concerns
they encounter from their diseases (Holman
and Lorig, 2000).
Further, recognizing the patient as an
expert (DH, 2001) is important in promoting
self-care management that addresses use of
medication, behaviour change, pain control,
adjusting to social and workplace dislocations,
coping with emotional reactions, learning
to interpret changes in the condition and
its consequences, and use of medical and
community resources (Lorig et al, 1999).
Evidence suggests that taking patients’ views
into account is associated with higher satisfaction,
improved adherence and greater continuity
of care (Lorig et al, 1999). Optimizing care
globally, however, requires nurses to engage
in a global health dialogue through sharing
knowledge (Bunkers, 2001; Tanner, 2002) and
research (Anderson and McCann, 2002), and
to ensure that their unique perspective on
health and healing impacts on policy makers
and practices that influence health (Kim, 2001;
Davidson et al, 2003).
Conclusion
The global prevalence and distribution
of chronic diseases is increasing in most
populations. Prevention and control are
improving only slowly and they have not kept
pace with the global burden of NCDs.
Sustained progress will only occur when
governments and influential international
bodies involved in health policy and funding
acknowledge that the scope of global public
health action must be rapidly broadened to
include chronic diseases and their risk factors.
The challenges are enormous and the ongoing
tobacco wars across the world indicate that
progress will continue to be slow unless the
response to the epidemics is scaled up in a
manner commensurate with their burden on
both families and societies.
Economic globalization contributes
significantly to the poverty and global burden of
diseases experienced by people of the developing
world, as well as to escalating environmental
degradation of alarming proportions.
Nursing scholars have drawn implications
from global nursing praxis in research,
education and practice (Davidson et al, 2003).
The fundamental responsibilities of nursing
– to promote health, prevent disease and
alleviate suffering – call for the expression
of caring for humanity and environment
through political activism at local, national and
international levels. Already, opportunities for
global nurse citizens to influence reforms to
the global economic order exist in professional
nursing organizations, international health
organizations, nurse initiated projects, such as
the Nightingale Initiative for Global Health
(Dossey et al, 2005), and with coalitions with
like-minded global citizens, such as People’s
Health Movement (http://www.phmovement.
org/getinvolved.html).
As the global consciousness of nursing evolves,
there will be many more opportunities for
action will present themselves. Therefore, nurses
– the largest group of healthcare providers
worldwide – can and must exercise their
political power to bring about change. Not to
do so, and to simply accept the status quo, is as
much a political activity as trying to bring
about change in the global order (Healy, 2001),
but one that abdicates nursing’s legacy and
moral imperative (Falk-Rafael, 2005) and
consigns millions to live their shortened lives in
abject poverty and ill health.
BJN
Anderson JM, McCann EK (2002) Toward a post-colonial
feminist methodology in nursing research: exploring
the convergence of post-colonial and black feminist
scholarship. Nurs Res 9(3): 7–27
Basnayar B, Rajapasha LC (2004) Cardiovascular and
infectious diseases in South Asia: the double whammy. Br
Med J 328: 781
Beaglehole R, Yach D (2003) Globalisation and the
prevention and control of non-communicable disease:
the neglected chronic diseases of adults. Lancet 362(9387):
903–8
Bettcher DW, Yach D, Guindon (2000) Global trade and
health: Key linkages and future challenges. Bull World
Health Organ 78(4): 521–34
Bumgarner R (2004) China: non-communicable disease
issues and options re-visited. Soc Prev Med 38: 202–10
Bunkers SS (2001) On global health and justice: a nursing
theory-guided perspective. Nurs Sci Q 14(4): 297
Davidson PM, Meleis AI, Daly J, Douglas M (2003)
Globalisation as we enter the 21st century: reflections
and directions for nursing education, science, research and
clinical practice. Contemp Nurse 15(3): 162–74
de Beyer J, Brigden LW (2003) Tobacco Control Policy:
Strategies, Successes and Setbacks. World Bank/Research for
International Tobacco Control, Washington DC: 189
Dossey BM, Selanders S, Beck D, Attewell A (2005)
Florence Nightingale Today: Healing, Leadership, Global Action.
American Nurses Association, Silver Spring, MD
Department of Health (2001) The Expert Patient: A New
Approach to Chronic Disease Management for the 21st
Century. DH, London
Department of Health (2002) Securing Our Future Health:
Taking a Long-term View – the Wanless Report. DH,
London
Ezzati M, Vander-Hoorn S, Lawes CMM et al (2005)
Re-thinking the ‘diseases of affluence’ paradigm: global
patterns of nutritional risks in relation to economic
development. Public Library Sci Med 2(5): e133
Falk-Rafael A (2005b) Speaking truth to power: nursing’s
legacy and moral imperative. ANS Adv Nurs Sci. 28(3):
212–23
Fang H, Rizzo JA (2007) Do psychiatrists have less access
to medical services for their patients? J Ment Health Policy
Econ 10(2): 63–71
Fireman B, Bartlett J, Selby J (2004) Can disease management
reduce health care cost by improving quality? Health Aff
(Millwood) 23(6): 63–75
Frenk J, Bobadilla JL, Sepulveda J, Cervantes LM (1989)
Health transition in middle-income countries: new
challenges for health care. Health Policy Planning 4: 29–39
Hawkes C (2002) Marketing activities of global soft drink
and fast food companies in emerging markets: a review.
In: WHO Globalization, Diets and Non-communicable
Diseases. WHO, Geneva
Health Communication Partnership (2006) Jordan
Communication Program. HCP, Baltimore, USA. Available
at: http://tinyurl.com/6844xl (accessed 20 Nov 2008)
Healy P (2001) Poor performance. Nurs Stand 15(33): 13
Holman H, Lorig K (2000) Patients as partners in managing
chronic disease. Partnership is a prerequisite for effective
and efficient health care. Br Med J (Clinical Research
Editorial) 320(7234): 526–7
Horgen KB, Brownell KD (2002) Confronting the toxic
environment: environmental, public actions in a world
1324 British Journal of Nursing, 2008, Vol 17, No 21

of crisis. In: Wadden TA, Stunkard AJ (eds). Handbook of
Obesity Treatment. Guildford Press, New York: 95–106
Hunter DJ (2003) The Wanless Report and public health.
Br Med J 327(7415): 573–4
International Diabetes Federation (2003) Diabetes Atlas. 2nd
edn. Internal Diabetes Federation, Brussels, Belgium
Isfahan Healthy Heart Programme (1999) Projects.
Available at: http://tinyurl.com/62r4zz (accessed 20
Nov 2008)
Jha P, Chaloupka FJ (1999) Curbing the Epidemic: Governments
and the Economics of Tobacco Control. International Bank
for Reconstruction and Development/World Bank,
Washington, DC
Kim MJ (2001) Nursing in a global village. Chart 98(4):
4–7
Kim S, Moon S, Popkin BM (2002) The nutrition transition
in South Korea. Am J Clin Nutr 71(1): 44–53
Lee M-J, Popkin BM, Kim S (2002) The unique aspect
of nutrition transition in Korea: the retention of helpful
elements in their traditional diet. Public Health Nutrition
5(1A): 197–203
Leeder S, Raymond S, Greenberg H, Liu H, Esson K (2004)
A race against time: the challenge of cardiovascular disease
in developing economies. Columbia University, NY
Lorig KR, Sobel DS, Stewart AL et al (1999) Evidence
suggesting that a chronic disease self-management
program can improve health status while reducing
hospitalization: a randomized trial. Med Care 37(1):
5–14
Macfarlane GJ, Biggs AM, Maconochie N, Hotopf M, Doyle P,
Lunt M (2003) Incidence of cancer among UK Gulf war
veterans: cohort study. BMJ 327(7428): 1373
Mascie-Taylor CGN, Karim E (2003) The burden of
chronic disease. Science 302(5652): 1921–2
McKeown T (1988) The Origins of Human Disease.
Blackwell, Oxford: 233
McNeal J (2002) Children as Consumers of Commercial and
Social Products. Pan American Health Organisation,
Washington DC
Meetoo D, McGovern P, Safadi R (2007) An epidemiological
overview of diabetes across the world. Br J Nurs 16(16):
1002–7
Nishtar S (2004) Public–private ‘partnerships’ in health – a
global call to action. Health Res Policy Syst 2(1): 5
Nishtar S, Bile KM, Ahmed A et al (2006) Process,
rationale, and interventions of Pakistan’s National Action
Plan on Chronic Diseases. Prev Chronic Dis 3(1): A14
O’Halloran J, Miller GC, Britt H (2004) Defining chronic
conditions for primary care with ICPC-2. Family Pract
21(4): 381–6
Popkin BM (2002) The Bellagio conference on the nutrition
transition and its implications for health in the developing
world. Italy. 24 August 20-24. Public Health Nutr 5(1A):
93–280
Popkin BM, Doak CM (1998) The obesity epidemic is a
worldwide phenomenon. Nutr Rev 56(4 Pt 1): 106–14
Puska P (2002) Successful prevention of non-communicable
diseases: 25 year experiences with North Karelia Project
in Finland. Public Health Med 4(1): 5–7
Puska P, Vartiainen E, Tuomilehto J, Salomaa V, Nissinen A
(1998) Changes in premature deaths in Finland: successful
long-term prevention of cardiovascular diseases. Bull
World Health Organ 76(4): 419–25
Rodgers A, Lawes C, MacMahon S (2000) Reducing the
global burden of blood pressure-related cardiovascular
disease. J Hypertens Suppl 18(1): S3–6
Stewart BW, Kleihaus S (eds) (2003) World Cancer Report.
IARC Press, Lyon, France
Steyn K, Bradshaw D, Norman R, Laubscher R (2008)
Determinants and treatment of hypertension in South
Africans: the first Demographic and Health Survey. S Afr
Med J 98(5): 376–80
Strong K, Mathers C, Leeder S, Beaglehole R (2005)
Preventing chronic diseases: how many lives can we save.
Lancet 366(9496): 1578–82
Tanner C (2002) Global perspectives in nursing education.
J Nurs Educ 41(7): 287–8
Thompson D, Wolf AM (2001) The medical-care cost
burden of obesity. Obes Rev 2(3): 189–97
Trowell HC, Burkitt DP (eds) (1981) Western Diseases,
Their Emergence and Prevention. Harvard University Press,
Cambridge, Massachusetts: 456
Tukuitonga C (2006) WHO strategy on diet, physical
activity & health targets global chronic-disease burden.
Policy Beat 14(1): 1–3
Visvanathan S (1999) Western science, power and the
marginalisation of indigenous modes of knowledge
production. Interpretive minutes of the discussion held
on ‘debates about knowledge: developing country
perspectives’ CHET and CSD, 7th April, 1999. Available
at: http://tinyurl.com/5rpzs4 (accessed 20 Nov 2008)
Walsh D (2002) Slipping Under the Radar: Advertising and
the Mind. Paper presented at the WHO Symposium:
Marketing to Young People, April 2002. Treviso, Italy
Watson J (1995) Postmodernism and knowledge
development in nursing. Nurs Sci Q 8(2): 60–4
World Health Assembly (1998) Health promotion. In: Fifty-
first World Assembly. Geneva, 11–16 1998. Volume 1:
Resolutions and Decisions, Annexes. WHO, Geneva
World Health Assembly (1999) Active ageing. In: Fifty-
second World Health Assembly. Geneva, 17–25 May,
1999. Volume 1: Resolutions and Decisions, Annexes.
WHO, Geneva
World Health Assembly (2000) Prevention and control
of non-communicable diseases. In: Fifty-third World
Health Assembly. Geneva, 15–20 May, 2000. Volume 1:
Resolutions and Decisions, Annexes. WHO, Geneva
World Health Assembly (2002) Diet, physical activity and
health. In: Fifty-fifth World Health Assembly. Geneva,
13–18 May, 2002. Resolutions and Decisions, Annexes.
WHO, Geneva
World Health Organization (2001) Innovative Care for Chronic
Conditions: Building Blocks for Action. WHO, Geneva
World Health Organization (2002a) The World Health Report
2002. WHO, Geneva
World Health Organization (2002b) WHO Strategy for
Prevention and Control of Chronic Respiratory Diseases.
WHO, Geneva
World Health Organization (2003) The World Health Report
2003: Shaping the Future. WHO, Geneva
World Health Organization (2005) Preventing Chronic Disease:
A Vital Investment. WHO, Geneva
World Health Organization (2008) Tobacco-free Initiative.
Religion and Tobacco. WHO, Geneva
Wild S, Roglic G, Green A, Sicree R, King H (2004) Global
prevalence of diabetes: estimates for 2000 and projections
for 2030. Diabetes Care 27(5): 1047–53
Woodward D, Drager N, Beaglehole R, Lipson D (2001)
Globalization and health: a framework for analysis and
action. Bull World Health Organ 9(9): 875–81
Yach D, Beaglehole R (2004) Globalization of risks for
chronic diseases demands global solutions. Perspectives
Global Dev Technol 3(1-2): 213–33
Yach D, Bettcher D (1998) The globalisation of public
health I: Threats and opportunities. Am J Public Health
88: 735–8
Yach D, Hawkes C, Gould CL, Hofman KJ (2004)
The global burden of chronic diseases: overcoming
impediments to prevention and control. J Am Med Assoc
291(21): 2616–22
KEY POINTS
n Chronic disease is the most common cause of death in the world.
n Chronic diseases emerge in less prosperous countries and under-privileged population
groups in richer countries.
n The causes of the main chronic diseases are well established and well known.
n The aim of chronic disease prevention is to delay mortality and promote healthy aging
of global populations.
n Through global consciousness, nurses and educationalists play a key role in influencing
reforms, promoting health, preventing disease and alleviating suffering.
CHRONC CONDITIONS
British Journal of Nursing, 2008, Vol 17, No 21 1325