Non-Communicable Disease: Epidemiology, Prevention & Control

1. Non-Communicable Disease: Epidemiology, Prevention & Control Ahmed Mandil, Hafsa Raheel Dept of Family & Community Medicine KSU College of Medicine

2. Objectives • By the end of the session students should be able to; • Appreciate the burden of NCDs globally, regionally, and in the Kingdom of Saudi Arabia • Enlist the risk factors for NCDs • Understand the concept and application of primary, secondary, and tertiary prevention with regard to NCDs NCD Epi

3. Definitions (I) • Chronic health-related state: a state which lasts for a long time, usually more than 3 months • Chronic exposure:prolonged (long term), usually of low intensity. • Chronic diseases: those diseases that have uncertain etiology, multiple risk factors, a prolonged course, do not resolve spontaneously, and for which a complete cure is rarely achieved. • Non-communicable diseases (NCD): a miscellaneous group of health-related conditions, usually not communicated through infective pathogens, and may cause impairment, disability, handicap or even premature death. NCD Epi

4. Defintions (II) • Risk factor: an aspect of personal behavior / life-style, an environmental exposure, an inborn / inherited characteristic, which on the basis of epidemiologic evidence, is known to be associated with health-related condition(s) considered important to prevent. • Modifiable risk factor: a determinant that can be modified by intervention, thereby reducing the probability of occurrence of disease or other specified outcomes. • Latent period: delay between exposure to a disease-causing agent and the appearance of manifestations of the disease. E.g. after exposure to ionizing radiation, there is a latent period of 5 years, on the average, before development of leukemia, and > 20 years before development of certain other malignancies. NCD Epi

5. Definitions (III): Exceptional NCD • Some NCD were recently proven to be of infectious origin, e.g. peptic ulcer (Helicobacter pylori), liver carcinoma (HCV), cancer cervix (Human Papilloma Virus), leukemia (oncogenic viruses), etc. • The term chronic may not apply to conditions as: angina pectoris, Acute Myocardial Infarction (AMI), anxiety, acute depression • Some infectious diseases are chronic: e.g. T.B., HIV / AIDS NCD Epi

6. NCD Examples (I) • Congenital anomalies • Malnutrition (pediatric, geriatric) • Endocrinal / metabolic disorders (e.g. diabetes, gout) • Cardiovascular diseases (e.g. hypertension; atherosclerosis; ischemic heart disease [IHD]: angina, myocardial infarction) . • Locomotor system problems: e.g. arthritis (acute, chronic) • Chronic respiratory conditions (e.g. bronchial asthma) NCD Epi

7. NCD Examples (II) • Occupational-related conditions (e.g. pneumoconiosis) • Neoplasms (benign / malignant; childhood / adult) • Injuries (intentional / non-intentional) • Sensory loss (e.g. deafness, blindness) • Diseases of senescence (degenerative diseases) • Psychiatric disorders (neuroses, psychoses) NCD Epi

8. misconceptions NCD Epi

9. Reality: chronic diseases are concentrated among the poor NCD Epi

10. Reality: almost half in people under age 70 NCD Epi

11. Reality: chronic diseases affect men and women almost equally NCD Epi

12. Reality: 80% of premature heart disease, stroke and type 2 diabetes is preventable, 40% of cancer is preventable NCD Epi

13. Reality: inexpensive and cost-effective interventions exist NCD Epi

14. Magnitude of the problem NCD Epi

15. Magnitude of the Problem (I) • NCD are considered the leading causes of death and disability on a global scale, (for at least the last two decades of the 20th century). • Disease rates (morbidity and mortality) from these conditions are accelerating globally, advancing across regions and social classes • Special burden in less developed nations. NCD Epi

16. Magnitude of the Problem (II) Among the many NCDs that contribute importantly to the global burden of disease, disability and death, cardiovascular disease (CVD), cancer, diabetes and chronic respiratory diseases are four of the most prominent. These four conditions are linked by common lifestyle determinants such as imbalanceddiet, physical inactivity and tobacco consumption. They together contribute to 50% of global mortality. NCD are expected to account for an increasing share of disease burden, rising globally from 43% in 1998 to 73% by 2020. The expected increase is likely to be particularly rapid in less developed nations. NCD Epi

17. The Regional Situation • The WHO Region for the Eastern Mediterranean, NCD - 52% of all deaths and 47% of the disease burden in EMR during the year 2005 • This burden is likely to rise to 60% in the year 2020 NCD Epi

18. Chronic Respiratory Disease Cardiovascular Type 2 Diabetes Cancer Chronic Diseases result in percent of deaths 4 52 EMR Adult Population NCD Epi

19. Risk factors NCD Epi

20. NCD Causal Pathway NCD Epi

21. Risk Factors (I) • Aging of the population • Use of motor vehicles (automobiles) • Life-style changes • Poor / unbalanced / unhealthy nutrition • Tobacco consumption / addiction • Physical inactivity • Harmful use of alcohol consumption • Obesity • Other social and behavioral factors. NCD Epi

22. Modifiable Cigarette smoking High Blood pressure Elevated serum Cholesterol Diabetes Life style changes (dietary patterns, physical activity) Stress factors Alcohol abuse Non-Modifiable Age Sex Family Hx Genetic factors Personality? Race Risk factors (II) NCD Epi

23. Risk factors (III): EMR • Tobacco use 16-65% • Hypertension 12-35% • Diabetes 7-25% • Overweight-obesity 40-70% • Dyslipidemia 30-70% • Physical Inactivity 80-90% NCD Epi

24. Sources of NCD Data • Mortality statistics • Hospital records (especially discharge) • Disease registries (e.g. cancer / diabetes / hypertension registries) • Interview surveys • Occupational medical records • Sickness and disability insurance statistics • Drugs' dispensing statistics (prescribed, over-the-counter) NCD Epi

25. Prevention & control NCD Epi

26. NCD Prevention and control (I) Goals: • To reduce disease incidence • To prevent / delay onset of disability • To alleviate severity of disease • To prolong the individuals’ life (Inshaa-Allah) NCD Epi

27. NCD Prevention and control (II) Important issues: • One of the most important objectives of NCD control is the change of the public's perception of NCD from one of "inevitability" to that of "preventability". • NCD control is based on avoidance of the most important risk factors (e.g. tobacco addiction, physical inactivity, poor nutrition), all of which are behavioral factors, often difficult to change. • Healthy behaviors should be promoted early on in life through comprehensive school health education and efforts to change behavior in children and young people. NCD Epi

28. NCD Prevention and control (III) • Primary prevention • Population Strategy • High Risk strategy • Secondary prevention • Tertiary prevention NCD Epi

29. Population strategy • Health promotion & education • Behavioral changes: balanced healthy diet, tobacco control, physical activity, weight reduction, especially children & adolescents • Blood pressure control • Self care • Stress management NCD Epi

30. High Risk approach • Identify high risk people and families, e.g. those with family history with an NCD (e.g. DM, hypertension); high serum cholesterol, etc • Providing specific advice: helping them to exercise, reduce weight, diet control, etc NCD Epi

31. NCD Prevention and control: (III) Primary prevention • Directed at susceptible persons, before they develop a certain NCD, thus aims at reducing incidence. • Needs establishment of risk factors, before-hand (community-specific). • Examples: tobacco prevention programs, promotion of physical activity, dietary recommendations (for balanced diets suitable for age, gender, physical activities, growth & development, weather, community). NCD Epi

32. NCD Prevention and control:(IV): Secondary prevention • Directed at asymptomatic individuals, but have developed biological changes resulting from the disease, thus aims at reducing prevalence. • Goal: early detection, management, avoiding / reducing undesirable consequences / complications. • Examples:screening programs (e.g. for diabetes, hypertension, cancer), recommended when: natural history permits early detection, available screening tests for early detection, acceptable to the population at risk; effective management regimens NCD Epi

33. NCD Prevention and control:(V): Tertiary prevention Tertiary prevention: • Directed at preventing disability in people who have symptomatic disease, thus aims at trying to improve quality of life. • Goal: prevention of progression of a disease and its complications; provision of rehabilitation. • Examples: screening for / management of diabetic complications (e.g. retinopathy); orthopedic prosthesis (e.g. for fracture-hip); physiotherapy (e.g. for cardiovascular stroke / paralysis / sports injuries’ victims) NCD Epi

34. References 1 • Last J. A dictionary of epidemiology. 5th Edition. Oxford, New York, Toronto: Oxford University Press, 2008. • Remington PL, Brownson RC, Wegner MV. Chronic disease epidemiology and control. 3rd Edition. Washington, D.C.: American Public Health Association, 2010. • WHO. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases. Geneva: WHO, 2008 NCD Epi

35. References 2 • Fadhil I. Diabetes and other non-communicable diseases: An Eastern Mediterranean Perspective. WHO, 2009 • Kuh D, Ben Shlomo Y. A life course approach to chronic disease epidemiology. Oxford, New York, Toronto: Oxford University Press, 1997. • Newcomer RJ, Benjamin AE. Indicators of chronic health conditions. Baltimore, London: The Johns Hopkins University Press, 1997. NCD Epi