Non-Communicable Diseases Control Program _________________________________ K R Thankappan MD, MPH Additional Professor and Head Achutha Menon Centre for Health Science Studies Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum

Death, by broad cause group, 1999 Noncommunicable conditions (59.8%) Communicable diseases, maternal and perinatal conditions and nutritional deficiencies (31.1%) Injuries (9.1%) Source: WHO Report 2000

Global burden of disease in disability-adjusted life years (DALYs), 1999 Noncommunicable conditions (43.2%) Communicable diseases, maternal and perinatal conditions and nutritional deficiencies (42.8%) Injuries (13.9%) Source: WHO Report 2000

Deaths, by broad cause group and WHO Region, 1999 % Noncommunicable conditions 75 Injuries Communicable diseases, maternal and perinatal conditions and nutritional deficiencies 50 25 AFR EMR SEAR WPR AMR EUR Source: WHO 2000

DALYS, by broad cause group and WHO Region, 1999 DALY = Disability adjusted life-year % 75 Noncommunicable conditions Injuries Communicable diseases, maternal and perinatal conditions and nutritional deficiencies 50 25 AFR EMR SEAR WPR AMR EUR Source: WHO 2000

DALYs, by broad cause group 1990 - 2020 in developing countries (baseline scenario) DALY = Disability-Adjusted Life Year % % Communicable diseases, maternal and perinatal conditions and nutritional deficiencies 22 49 21 Injuries 14 15 Neuropsychiatric disorders 9 43 Noncommunicable conditions 27 Source: WHO, Evidence, Information and Policy, 2000

Low- and middle-income countries suffer the greatest impact on non-communicable diseases 77% of the total number of deaths attributable to NCDs occurred in developing countries 85% of the global NCD disease burden borne by low- and middle-income countries Source: WHO:, 2000

Distribution of causes of death in South-East Asia, 1999 (000s) Injuries (1301) Other causes (236) Perinatal conditions (851) Nutritional deficiencies (159) Malaria (69) HIV/AIDS (360) Noncommunicable conditions (7370) Tuberculosis (723) Diarrhoeal diseases (978) Respiratory infections (1523) Childhood diseases (542) Maternal conditions (158) Source: WHO 2000

in disability-adjusted life years (DALYs) Burden of disease in disability-adjusted life years (DALYs) in South-East Asia,1999 (000s) Other causes (19693) Injuries (65289) Perinatal conditions (32715) Nutritional deficiencies (16866) Malaria (3071) HIV/AIDS (8866) Tuberculosis (14101) Diarrhoeal diseases (30017) Noncommunicable conditions (156536) Respiratory infections (38144) Childhood diseases (19449) Maternal conditions (7733) Source: WHO 2000

-----1940-----1950-----1960-----1970-----1980-----1990-----2000----- Cardiovascular (CVD) epidemic in countries of different stages of development -----1940-----1950-----1960-----1970-----1980-----1990-----2000----- High Income Economies Reach the peak Progressive decline Rapid increase Remains as first cause of death & disability Economies in Transition Slow increase Rapid Reach the peak in some countries First cause of death & disability Middle and Low Income Countries Low rates Slow increase Rapid in most countries First cause of death & disability in most countries

DALYs, by broad cause group 1990 - 2020 in developing countries (baseline scenario) % 50 1990 2020 25 DALY = Disability adjusted life-year Communicable diseases, maternal and perinatal conditions and nutritional deficiencies Injuries Noncommunicable conditions Source: WHO, Evidence, Information and Policy, 2000

Source: K S Reddy. Lancet 1998.

Coronary Heart Disease Prevalence Studies in India (Urban) Study Year Sample CHD Prevalence Agra 1960 1046 11 1.05 Delhi 1962 1642 17 1.04 Chandigarh 1968 2030 134 6.60 Rohtak 1975 1407 51 3.63 Delhi 1990 13723 1327 9.67 Jaipur 1995 2212 168 7.59 Moradabad 1995 152 13 8.55 Trivandrum 1995 506 41 12.65 ________________________ Source: Gupta et al. Indian Heart Journal 1995.

Source. Hypertension study group AMCHSS of SCTIMST. WHO Bulletin 2001. Prevalence Of Hypertension in the elderly Loacation % 95% CI Kerala Urban 69 (63-75) Kerala Rural 55 (49-61) Maharashtra Urban 72 (69-75) Dhaka Urban 65 (62-67) Dhaka Rural 53 (47-59) ___________________________________ Source. Hypertension study group AMCHSS of SCTIMST. WHO Bulletin 2001.

Prevalence of Hypertension (40-60 Yrs) Trivandrum City Age group Prevalence of Hypertension (40-60 Yrs) Trivandrum City Age group Prevalence 40-44 42.2 45-49 55.3 50-54 55.7 55-60 67.2 Total 54.5 Manu Zachariah, Thankappan K R et al. Indian Heart Journal 2003

Cardiovascular risk factors Non-modifiable Risk Factors Age Male gender Genetic predisposition Hypertensive heart disease Coronary Cerebrovascular disease (Stroke) Peripheral vascular disease Endpoints Modifiable Risk Factors Hypertension Elevated LDL cholesterol Decreased HDL cholesterol Diabetes Insulin resistance Obesity Smoking Unhealthy diet -High in saturated fat & salt -Inadequate intake of fruits and vegetables Excessive alcohol use Sedentary life-style Behavioural Risk Factors Adverse Socio-economic, Cultural & Environmental Conditions

Tobacco: deaths by World Bank regions estimates for 1990 and 2020 8.4 million Middle Eastern Crescent Latin America & Caribbean Sub-Saharan Africa Other Asia and Islands China India 3 million Former Socialist Countries Established Market Economies Source: Murray CJL, Lopez AD 1996

Tobacco use and educational level among females in Bombay 1992-1994 Users % Source: Gupta, 1996

Body Mass Index in Indian Women 15-49 Years. State BMI <18.5 BMI 25+ BMI 30+ Delhi 12.0 33.8 9.2 Punjab 16.9 30.2 9.1 Kerala 18.7 20.6 3.8 Orissa 48.0 04.4 0.6 Assam 27.1 04.2 0.7 Bihar 39.3 03.7 0.5 India 35.8 10.6 2.2 Urban 22.6 23.5 5.8 Rural 40.6 05.9 0.9 Source: NFHS 1998-99.

No National Program for NCD More than 50% of disease burden in India is due to NCDs Many National Programs for Communicable diseases

How to address Monitoring of Risk factors Tobacco Use Diet (Fruits and Vegetables) Body Mass Index Physical activity Blood Sugar Blood Lipid levels

Disease Specific Program Cancer Diabetes Bronchial Asthma Hypertension?

Need to develop a Program Sentinel Health Monitoring Centres Assam Delhi Kerala Maharashtra Tamil Nadu

Address Risk factors and determinants at community level Inter-sectoral coordination

Legislation For example Tobacco Control Alcohol Diet, salt restriction Exercise

Global strategy for Diet and Physical activity

Primary Health Care System Need to re-orient focus Training of health workers Monitoring of blood pressure and urine sugar can be done at grass root level Health education programs

Capacity Building Manpower -PH specialists New Public Health Schools Social Science components MPH-SCTIMST, Allahabad PGI Chandigarh, CMC Vellore, EHA Expand the current MD programs FETP Programs- MAE at NIE

Start From Children

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