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

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 24 April 2017 NCD Epi

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. 24 April 2017 NCD Epi

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.   24 April 2017 NCD Epi

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 24 April 2017 NCD Epi

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) 24 April 2017 NCD Epi

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) 24 April 2017 NCD Epi

misconceptions 24 April 2017 NCD Epi

Reality: chronic diseases are concentrated among the poor 8. Reality: In all but the least developed countries of the world, the poor are much more likely than the wealthy to develop chronic diseases, and everywhere are more likely to die as a result. Moreover, chronic diseases cause substantial financial burden, and can push individuals and households into poverty. 24 April 2017 NCD Epi

Reality: almost half in people under age 70 7.Reality: Almost half of chronic diseases occur prematurely, in people under 70 years of age. One quarter of all chronic disease deaths occur in people under 60 years of age. In low and middle income counties, middle-aged adults are especially vulnerable to chronic diseases. People in these countries tend to develop disease at younger ages, suffer longer – often with preventable complications – and die sooner than those in high income countries. 24 April 2017 NCD Epi

Reality: chronic diseases affect men and women almost equally 6. Reality: Chronic diseases, including heart disease, affect women and men almost equally. 24 April 2017 NCD Epi

Reality: 80% of premature heart disease, stroke and type 2 diabetes is preventable, 40% of cancer is preventable 4. Reality: the major causes of chronic diseases are known, and if these risk factors were eliminated, at least 80% of all heart disease, stroke and type 2 diabetes would be prevented; over 40% of cancer would be prevented. 24 April 2017 NCD Epi

Reality: inexpensive and cost-effective interventions exist 3. Reality: a full range of chronic disease interventions are very cost-effective for all regions of the world, including sub-Saharan Africa. Many of these solutions are also inexpensive to implement. The ideal components of a medication to prevent complications in people with heart disease, for example, are no longer covered by patent restrictions and could be produced for little more than one dollar a month. 24 April 2017 NCD Epi

Magnitude of the problem 24 April 2017 NCD Epi

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. 24 April 2017 NCD Epi

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 imbalanced diet, 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. 24 April 2017 NCD Epi

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 24 April 2017 NCD Epi

Chronic Diseases result in percent of deaths 4 52 EMR Adult Population Cardiovascular Chronic Respiratory Disease Type 2 Diabetes Cancer 24 April 2017 NCD Epi

Risk factors 24 April 2017 NCD Epi

NCD Causal Pathway 24 April 2017 NCD Epi

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. 24 April 2017 NCD Epi

Risk factors (II) Modifiable Non-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 24 April 2017 NCD Epi

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% 24 April 2017 NCD Epi

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) 24 April 2017 NCD Epi

Prevention & control 24 April 2017 NCD Epi

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) 24 April 2017 NCD Epi

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.   24 April 2017 NCD Epi

NCD Prevention and control (III) Primary prevention Population Strategy High Risk strategy Secondary prevention Tertiary prevention 24 April 2017 NCD Epi

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 24 April 2017 NCD Epi

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 24 April 2017 NCD Epi

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). 24 April 2017 NCD Epi

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 24 April 2017 NCD Epi

NCD Prevention and control: (V): 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) 24 April 2017 NCD Epi

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 24 April 2017 NCD Epi

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. 24 April 2017 NCD Epi