Behavioral and Biological Risk Factors of Non Communicable Diseases Prof. Dr. M. S. A. Mansur Ahmed Professor Dept. of Public Health DIU

Global scenario of NCD Of 56 million global deaths in 2012, 38 million, or 68%, were due to noncommunicable diseases. The four main NCDs are cardiovascular diseases, cancers, diabetes and chronic lung diseases. The burden of these diseases is rising disproportionately among lower income countries and populations. In 2012, nearly three quarters of noncommunicable disease deaths million -- occurred in low- and middle-income countries with about 48% of deaths occurring before the age of 70 in these countries.

Leading causes of NCD deaths in 2012 The cardiovascular diseases (17.5 million deaths, or 46% of all NCD deaths), cancers (8.2 million, or 22% of all NCD deaths), and respiratory diseases, including asthma and chronic obstructive pulmonary disease (4.0 million). Diabetes caused another 1.5 million deaths.

Contd. The importance of addressing noncommunicable diseases at the global level has also become a major element of the ongoing discussion concerning the post-2015 development goals, which is being steered by the United Nations. Noncommunicable diseases were omitted from the Millennium Development Goals in 2000, A consensus is emerging among the various United Nations agencies and other international organizations that A life-course perspective must be adopted, with an emphasis on noncommunicable diseases as part of the health goal to be included in the set of post-2015 Sustainable Development Goals.

Bangladesh scenario NCDs have already appeared as a major public health problems. Major NCDs (DM,CVDs,Cancer,COPD &Accidents)were among the top twenty causes of deaths in 2000(BBS 2000).

NCD risk factor survey 2010 NCD may account for 61% of the total disease burden. Among adults(15+years) 97% had at least one risk factor half of whom had 2 risk factors. 40 million (app.25%) people are tobacco users 17 million (nearly 20%) are not doing adequate physical activities. 18% adults with Hypertension 4% documented Diabetes.

Risk factorsMenWomenBoth sexes Current smoker Smokeless tobacco user Tobacco user (any form) Low vegetable/Fruits intake a Low physical activity b Overweight (BMI > 25 kg/m 2 ) Large waist circumference c Hypertension d Diabetes Mellitus e Table 1: Findings of Bangladesh NCD risk factor Survey 2010 at a glance. Prevalence (%) with selected risk factors among the adult population aged ≥25 years

Behavioral and Biological Risk Factors of Non Communicable Diseases Behavioural risk factors, including tobacco use, physical inactivity, and unhealthy diet, are responsible for about 80% of coronary heart disease and cerebrovascular disease.

Biological risk factors Biological risk factors comprise raised blood pressure, raised blood glucose, raised total serum cholesterol, Dyslipidemia overweight and obesity, fat intake and salt intake.

Current status and trends in risk factors 10 Common, preventable risk factors underlie most NCDs. These risk factors are a leading cause of the death and disability burden in nearly all countries, regardless of economic development. The leading risk factor globally for mortality is: 1.raised blood pressure (responsible for 13% of deaths globally), 2.followed by tobacco use (9%), 3.raised blood glucose (6%), 4.physical inactivity (6%), 5.overweight and obesity (5%).

Current status and trends in risk factors contd. 11 The prevalence of these risk factors varied between country income groups, with the pattern of variation differing between risk factors and with gender. High-, middle- and low-income countries had differing risk profiles. Several risk factors have the highest prevalence in high-income countries. These include: 1.physical inactivity among women, 2.total fat consumption, 3.raised total cholesterol. Some risk factors have become more common in middle- income countries. These include: 1.tobacco use among men, 2.overweight and obesity.

Parameters for estimation of behavioural and metabolic risk factors 12 current daily tobacco smoking current daily tobacco smoking: the percentage of the population aged 15 or older who smoke tobacco on a daily basis. physical inactivity physical inactivity: the percentage of the population aged 15 or older engaging in less than 30 minutes of moderate activity per week or less than 20 minutes of vigorous activity three times per week, or the equivalent. raised blood pressure raised blood pressure: the percentage of the population aged 25 or older having systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥90 mmHg or on medication to lower blood pressure.

contd. 13 raised blood glucose raised blood glucose: the percentage of the population aged 25 or older having a fasting plasma glucose value ≥ 7.0 mmol/L (126 mg/dl) or on medication for hyperglycemia. overweight overweight: the percentage of the population aged 20 or older having a body mass index (BMI) ≥ 25 kg/m2. obesity obesity: the percentage of the population aged 20 or older having a body mass index (BMI) ≥30 kg/m2. raised cholesterol raised cholesterol: the percentage of the population aged 25 or older having a total cholesterol value ≥ 5.0 mmol/L (190 mg/dl).

Study findings in Bangladesh

BANGLADESH MEDICAL RESEARCH COUNCIL Project Title: Prevalence of NCD Related Risk Factors Among Population Aged in Dhaka City. Principal Investigator(s): Prof. Dr. M. S. A. Mansur Ahmed, Head, Dept. of Community Medicine, Bangladesh Institute of Health Sciences, Dhaka. Co-investigator(s): 1.Dr. Md. Shahjahan, Assistant professor, Dept of Epidemiology and Biostatistics, BIHS, Dhaka. 2. Mr. Moniruzzaman,Senior Research Fellow, Dept. of Community Medicine, BIHS, Dhaka. Place of the study/ Institution(s): Bangladesh Institute of Health Sciences Date of Commencement: January, 2011 Date of Completion: June, 2011

VariablesNumberPercent Age yrs yrs =>55 yrs (Mean = 43.4, SD ± 6.9 yrs) Sex Male Female Levels of education Junior school certificate and below SSC HSC Graduation and above Occupation GOB Employee NGO Employee Businessman Technician41.0 Monthly Income (TK) ≤ Mean income: ±17705 /=TK Table 1. Distribution of respondents according to their socio- demographic characteristics (n=400).

Smoking habit About 25 percent of the respondents were currently exposed to smoking during time of conducting the survey. The mean number of stick per day was 10 with SD ±6 (Table 2).

VariableNumberPercent Current Smoker (male) Yes No Current Smoker (Female) Yes No History of smoking (n=301) Ex smoker Never smoked Duration of Smoking in yrs (n=99) Mean Duration : ± 9.0 yrs No. of stick per day (n=99) Mean no. of sticks: 10 ±6 Table 2. Distribution of respondents according their smoking habits (n= 400).

Mean Duration of current users: 9 ±8 yrs and mode: 10 yrs Figure 1. Distribution of the respondents according to the habit of smokeless tobacco consumption (Betel nut, Zarda and Gool)

VariableNumberPercent Drinking of alcohol Yes102.5 No Table 3. Distribution of respondents according to the habit of alcohol consumption (n=400).

VariablesNumberPercent Have any physical exercise Yes No Total Maintained recommended physical exercise No yes Total Table 4. Distribution of respondents according to the status of doing physical exercise (n=400).

BMI (Mean ±SD): 24.6 ±3.3 kg/m 2 Figure 2: Distribution of the respondents according to BMI categories (n=400)

No.of servings FrequencyPercent <5 servings =>5 servings 1.2 Total Table 5: Number of servings of fruits taken by the respondents per day

No. of servings FrequencyPercent < 5 servings =>5 servings 51.2 Total Table 6: Number of servings of vegetables taken by the respondents per day

Conclusion Majority of the study population are in economically productive age group. Mean Duration of smoking was found to be17.58± 9.0 yrs and the mean number of stick perday was 10 with SD ±6 compared to higher rates in some industrialized and developed countries About one third of the respondents reported doing any form of physical exercise. Among them, 22% maintained recommended physical exercise (minimum 30 min of physical exercise for at 5 days a week). The recommended fruits intake of at least 5 servings per day by respondents was very low (0.2%).and the recommended vegetable intake of at least 5 servings per day by respondents was very low (1.2%). Building awareness for behavioral and lifestyle related risk factors should be an agenda for advocacy of the policy planners. Further studies needed.

CARDIOVASCULAR RISK ASSESSMENT AMONG URBAN POPULATION AGED YEARS USING WHO/ISH RISK PREDICTION CHART SPONSOR: MINISTRY OF SCIENCES AND TECHNOLOGY,GOV’T OF BANGLADESH Principal investigator: Prof. Dr. M. S. A. Mansur Ahmed, Dept. of Community Medicine,BIHS Co-investigators Dr.Shahanaz Choudhury, Asstt.professor, Community Medicine,BIHS M.Moniruzzaman,Sr. Lecturer, Community Medicine, BIHS NAME AND ADDRESS OF THE CONTRACTING INSTITUTE: Bangladesh Institute of Health Sciences (BIHS) Duration of the Project: 1 year Date of Commencement: July 2012 Date of Completion: June, 2013

WHO/ISH risk prediction chart

VariablesNumber(n)Percent (%)Mean±SD History of smoking Current smoker2114 Ex-smoker138.7 Never smoked Duration of smoking (current smoker) 20.14±12.8 years Duration of smoking category <10 years733.3 ≥10 years Number of stick per day 8.1±5.6 Consume smokeless tobacco(betel nut, zorda, gul etc) Yes (current) Occasional Never6342 Duration of smokeless tobacco 17.1±14.5 Number of betel nut/day 6.4±5.6 Consume alcohol Yes85.3 No Fruit taking history/ day Adequate ( at least 5 *servings/day)00 Inadequate Mean fruit servings/day 0.8±0.7 Vegetables intake Adequate (at least 5 servings/day)21.3 Inadequate Mean vegetables intake history in a day 2.03±0.85 Extra table salt intake history Regular Occasional2416 Never5335 Exercise history Yes No Recommended Exercise(at least 30min/day for at least 5 days in a week) Yes No Mean duration of exercise per day(minutes) 33.6±33.3 Table 2: Distribution of respondents according to History of Behavioral Risk Factors (n=150) *1 servings= 80 gm

VariablesNumber(n)Percent (%)Mean±SD Height (cm) 151.2±19 Weight (kg) 62±16 *BMI category(kg/m 2 ) Underweight (<18.5) ±13.8 Normal(18.5 to 23) Overweight (23 to 27.5)2416 Obese(>27.5)96 Waist circumference of the respondents 93.3±11.8 Hip circumference (cm) 98.3±11.7 Waist hip) ratio (WHR) Male High WHR (≥ 90 cm) Female High WHR (≥ 80 cm) BP status Hypertensive (≥140/90 mmHg) Normotensive Systolic mean pressure 120±17 Diastolic mean pressure 80±11 Cholesterol level High (≥200 mmol/dl) ±42 Normal Glycemic status Non Diabetes Diabetes Table 4: Distribution of respondents according to Physical Measurement (n=150) *BMI – Asian cut off has been used

CONCLUSION About 19% of the study population are at moderate to high risk of developing CVD event in next 10 years. The proportion of CVD risk calculated by the chart may be higher if we include other known risk factors (over wt/obesity, physical inactivity, inadequate fruits and vegetable intake, use of extra table salt etc).

TITLE: CARDIOVASCULAR RISK ASSESSMENT AMONG URBAN AND RURAL POPULATION AGED YEARS USING WHO/ISH RISK PREDICTION CHART Principal investigator: Prof. Dr. M. S. A. Mansur Ahmed, Dept of Community Medicine,BUHS Co-investigator: 1, Dr. Shahanaz Choudhury,Asst Prof., Dept of Community Medicine,BUHS. 2. M.Moniruzzaman,Sr.Lecturer, Dept.of Community Medicine,BUHS Sponsor: Ministry of Science and Technology, Gov’t of Bangladesh NAME AND ADDRESS OF THE CONTRACTING INSTITUTE: Bangladesh University of Health Sciences (BUHS), 125/1 Darus Salam, Mirpur 1, Dhaka Duration of the Project: One year Date of Commencement: July 2013 Date of Completion: June, 2014

Urban(244)Rural(264)Both(508) Variables Number(N)/ Percent (%) Number(N)/ Percent (%) Number(N)/ Percent (%) History of smoking Current smoker33(13.1%)36(14.1%)69(13.6%) Ex-smoker19(7.5%)28(10.9%)47(9.3%) Never smoked200(79.4%)192(75%)392(77.2%) Mean Duration of smoking(current smoker) yrs16.7± ± ±12.4 Mean Number of sticks per day8.3±4.39.3±5.58.8±4.9 Consume smokeless tobacco(betel nut, zorda, gul etc) Yes (current)75(29.8%)58(22.7%)133(26.2%) Never177(70.2%)198(77.3%)375(73.8%) Mean Duration of smokeless tobacco yrs11.9± ± ±0.9 Consume alcohol Yes6(2.4%)0(0%)6(1.2%) No246(97.6%)256(100)502(98.8%) Fruit taking history/ day Adequate ( at least 5 *servings/day)1(0.4%)10(3.9%)11(2.2) Inadequate251(99.6%)246(96.1%)497(97.8%) Mean fruit servings/day1.3± ±1.51.7±1.3 Vegetables intake Adequate (at least 5 servings/day)1(0.4%)27(10.5%)28(5.5) Inadequate251(99.6%)229(89.5%)480(94.5) Mean vegetables intake history (no of servings ) in a day1.8± ±1.42.4±1.3 Frequency of mean fast food intake per day2.0±1.11.9±1.42.0±1.2 Fast food intake/day Yes23(9.1%)12(4.7%)35(6.9%) No229(90.9%)244(95.3%)473(93.1%) Frequency of Mean Street Food Intake/week3.1±1.92.4±1.22.7±1.6 Fatty rich food intake/week Yes49(19.4%)46(18%)95(18.7%) No203(80.6%)210(82%)413(81.3%) Frequency of Mean Fatty rich food intake / week1.8±1.21.5±1.11.7±1.2 Empty caloric drink intake/week Yes79(31.3%)59(23%)138(27.2%) No173(68.7%)197(77%)370(72.8%) Frequency of Mean intake of empty caloric drink intake/week 2.7± ± ±1.8 Extra table salt intake history Regular129(51.2%)143(55.9%)272(53.5%) Occasional28(11.1%)23(9%)51(10%) Never95(37.7%)90(35.2%)185(36.4%) Exercise history Yes80(31.7%)128(50%)208(40.9%) No172(68.3%)128(50%)300(59.1%) Recommended Exercise(at least 30min/day for at least 5 days in a week) Yes64(25.4%)96(37.5%)160(31.5%) No188(74.6%)160(62.5%)348(68.5%) Table 2: Distribution of respondents according to History of Behavioral Risk Factors (N=508)

Variables UrbanRuralBoth Number(n) Percent (%)/ Mean±SD Number(n) Percent (%)/ Mean±SD Number(n) Percent (%)/ Mean±SD Height (cm) 155.8± ±8158.2±8.6 Weight (kg) 59.1± ± ±11.3 Mean BMI**24.3±425±424.6±4 *BMI category(kg/m 2 ) Underweight (<18.5) 11(4.4%)9(3.5%)20(3.9%) Normal(18.5 to 23) 99(39.3%)60(23.4%)159(31.3%) Overweight (23 to 27.5) 91(36.1%)134(52.3%)225(44.3%) Obese(>27.5) 51(20.2%)53(20.7%)104(20.5%) Mean Waist circumference of the respondents (cm) 88± ± ±12 Mean Hip circumference (cm) 91.9±10.794±12.893±11.9 Waist hip ratio (WHR) 0.96± ± ±0.124 Blood Pressure status Hypertensive (≥140/90 mmHg) 56(22.2%)62(24.2%)118(23.2%) Normotensive 196(77.8%)194(75.8%)390(76.8%) Systolic mean pressure mmHg 118± ± ±14.7 Diastolic mean pressure mmHg 77±1080.2± ±10 Cholesterol level High (≥200 mgl/dl) 80(31.7%)165(64.5%)245(48.2%) Normal(<200 mg/dl) 172(68.3%) 91(35.5%) 263(51.8%) Glycemic status Non Diabetes 219(86.9%)209(81.6%)428(84.3%) Diabetes 33(13.1%)47(18.4%)80(15.7%) Table 4: Distribution of respondents according to Physical, Biological and biochemical Measurement (N=508) *BMI – Asian cut off has been used, **BMI-Body Mass Index

CONCLUSION Overall 17.5% of the study populations are at moderate to high risk of developing CVD event in next 10 years. The proportion of high risk was more in rural (11.7%) area than in urban (8.7%) area where as the proportion of moderate risk was more in urban (10%) area than in rural (4.7%) area. However, the proportion of moderate to high risk was almost similar in urban (18.7%) and rural (16.4%) area.

References 1.April 2011 the World Health Organization (WHO) report. 2.Bulletin of the World Health Organization 2013;91: doi: Ahmed, MSA M,Shahjahan M, Moniruzzaman M,Prevalence of NCD Risk Factors. BMRC project report, Ahmed,MSA M, Choudhury S,Moniruzzaman M. Cardiovascular Risk Assessment Among Urban Population Aged Years Using WHO/ISH Risk Prediction Chart. Ministry of Science & Technology,Gov’t of Bangladesh, Project report Ahmed,MSA M, Choudhury S,Moniruzzaman M. Cardiovascular Risk Assessment Among Urban And Rural Population Aged Years Using WHO/ISH Risk Prediction Chart.Ministry of Science & Technology,Gov’t of Bangladesh, Project report WHO Global health data, morbidity and mortality 7. Hunter DJ, Reddy KS, Noncommunicable Diseases, N Engl J Med 2013; 369: October 3, 2013DOI: /NEJMra October 3, 2013