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INSIDE KOFIH
EXPERT'S PERSPECTIVE

Chronic disease management is important for developing countries, too.
Chronic diseases such as high blood pressure, diabetes, heart disease and stroke are important health problems in Korea. Before mortality rate from communicable diseases significantly increased with COVID-19, the statistics showed that less than 10% of deaths were caused by communicable diseases and more than 80% were caused by chronic diseases. However, chronic diseases are not limited to Korea. They pose severe concerns to developing countries, as well.

- Article: Professor Kim Jang-rak (Dept. of Preventive Medicine, College of Medicine, Gyeongsang National University)
Surge in chronic disease patients in developing countries
Most of the mortality from chronic diseases in the world (4 out of 5 deaths) comes from low-income developing countries (hereinafter referred to as developing countries). Nevertheless, chronic diseases seem to attract less attention in developing countries as they focus more on communicable diseases that require urgent response from the public health perspective.

It is also because chronic diseases have lower recognition and diagnosis rate as their early symptoms are normally subtle. Now, with increased life expectancy, a surge in chronic diseases is becoming a serious health problem in developing countries, too. Even within the same country, poor people have a higher risk of developing and dying from chronic diseases than the rich. Moreover, economic burden for them is much greater once they have chronic diseases. In nother words, the socioeconomic level is a fundamental factor that affects countries and individuals in terms of chronic diseases.

Non-communicable diseases caused by lifestyle
Chronic diseases can be characterized with long-term morbidity (typically longer than a year) and slow progression. Communicable diseases such as tuberculosis, HIV/AIDS are not usually classified as chronic diseases, even though they show chronic progress to patients. The World Health Organization (WHO) refers to chronic diseases as non-communicable diseases (NCDs).

Typical chronic diseases include heart disease and stroke - the main causes of death from circulatory system failure; cancer - the leading cause of death; chronic respiratory diseases such as chronic bronchitis and emphysema; diabetes and arthritis. The direct causes of chronic diseases are high blood pressure or blood sugar, abnormal blood lipids, or physiological abnormalities caused by an increase in mast cells (overweight/obesity). If they exceed a certain standard, it can be considered to be a chronic disease.

In a prior stage, there are common risk factors for chronic diseases. Some are uncorrectable (age, genetic predisposition) and the others are correctable (lifestyle such as smoking, unhealthy diet, lack of physical activities and excessive drinking). This explains why chronic diseases are often referred to as lifestyle diseases. Considering such phased risk factors, various levels of preventive measures are needed for the society to manage chronic diseases.

The primary-level of approaches to prevent diseases themselves include education for smoking cessation, proper diet, increased physical activities and abstinence from alcohol, as well as promotion of health. Secondary prevention aims to prevent early death through early detection and treatment of diseases at an asymptomatic stage. It is important for high blood pressure and high blood sugar (diabetes resulting from it), which are the intermediate stage of the diseases. Since such diseases are not accompanied with pain or other symptoms, it is difficult to recognize them before complications develop.

For that reason, treatment and control are not performed properly, and serious complications, such as heart disease and stroke occur later. That is why they are dubbed silent killers. According to the latest statistics in Korea where disease management becomes better than before, more than half of patients with hypertension do not properly manage their condition, with 70% of them perceiving their hypertension (recognition rate), 65% taking anti-hypertensive drugs (treatment rate), and 50% well-controlling their blood pressure (control rate). The level of diabetes management is far worse than that of hypertension.

This shows that more efforts are needed for early detection of adult patients with asymptomatic high blood pressure and diabetes. The tertiary prevention indicates establishment of an emergency medical system, in which patients with early symptoms of heart disease or stroke can be transferred to a facility where medical procedures can be immediately performed.

Heavy burden for chronic disease management on developing countries
A periodontal disease (gum disease) is a critical health issue in developing countries, clearly representing characteristics of chronic diseases among the low income group and sharing common risk factors of chronic diseases such as smoking. Periodontal diseases are the most prevalent among adults in Korea. Although the disease is not a direct cause of death, it severely lowers the quality of life as it leads to pain and loss of tooth. As a periodontal disease brings no pain in its early stage, managing it is more difficult in underdeveloped countries.

When you watch TV shows about rural areas in developing countries such as Southeast Asia, you might be surprised to see many people merely aged 50 or so have just few teeth left. Isn't this visually indicating the prevention and management level of chronic diseases including lack of access to oral hygiene education or dental facilities in the region? Serious chronic diseases like heart disease and stroke require a high level of medical facilities, medical workforce, and higher costs, posing huge economic burden on developing countries.

On the other hand, measures against chronic diseases can be inexpensively taken throughout the whole stages, if done before the disease is developed. If well-known major risk factors are eliminated, 80% of heart disease and stroke can be prevented. Disease can be prevented with health education for smoking cessation, proper diet, increased physical activities and abstinence from alcohol, as well as health promotion. Given the characteristics of silent chronic diseases, early detection and treatment during asymptomatic periods can prevent premature death. The primary and secondary prevention of chronic diseases can be provided with establishment of the primary healthcare system, which is accessible and affordable to all.