1. Noncommunicable Diseases: Epidemiology and Pubic Health
Dr Nick Banatvala
Sixth International WHO IUMSP NCD Managers Seminar
May 2012

2. Global Status

3. Structure of the presentation
Mortality
Morbidity
Risk factors
Behavioral
Metabolic/physical
Chronic infections
Public health impact and reducing the burden of NCDs
What do we need to do to tackle the problem?

4. World Health Organization
25 May 2018
NCDs
Raised blood pressure
Overweight/obesity
Raised blood glucose
Raised lipids
Tobacco use
Unhealthy diet
Physical inactivity
Harmful use of alcohol
Globalization
Urbanization
Population ageing
Metabolic/
physiological
risk factors
Underlying drivers
Behavioural
Causal links
The roots of the rising magnitude of the NCD problem starts with the underlying drivers which include the social determinants in addition to population ageing, urbanization which is in many cases unplanned and rapid and globalization of trade and marketing, resulting in increasing rates of the four lifestyle and behavioural risk factors, which in turn cause rising levels of NCDs.
Social Determinants
of Health

5. 1. Mortality

6. 57 million deaths in 2008
36 million (63%) were NCDs – principally CVD, diabetes, cancer and chronic respiratory diseases
80% of these deaths in LMICs
44% NCD deaths before the age of 70 (48% LMIC, 26% HIC)
Women are affected

7. World Health Organization
25 May 2018
The top-10 leading causes of death
Source:
Low-income countries
Middle-income countries
Lower respiratory infections
Coronary heart disease
Diarrhoeal diseases
HIV/AIDS
Stroke and cerebrovascular disease
Chronic pulmonary disease
Tuberculosis
Neonatal infections
Malaria
Premature and low birth weight
Lower respiratory infection
Trachea, bronchus, lung cancers
Road traffic accidents
Hypertensive heart disease
Stomach cancer
Diabetes mellitus
Heart disease
Stroke

8. World Health Organization
25 May 2018
10 leading causes of deaths in females (2004)
Source: WHO's report on "Women and Health: today's evidence, tomorrow's agenda"

9. Non-Communicable Diseases (NCDs): 36 million deaths (63% of global mortality)
10 M
20 M
30 M
40 M;
50 M
60 M
28%
16%
47% 9%
Globally, 58 million people died in 2005.
35 million of these deaths were a result of chronic diseases.
This means that 60% of all deaths in 2005 were due to chronic diseases.
2008 estimates
Communicable, maternal, perinatal
and nutritional conditions
NCDs < 60
NCDs > 60
Injuries

10. World Health Organization
25 May 2018
NCD deaths by WHO region (2008 estimates)
2 M
4 M
6 M
8 M
10 M
12 M
14 M
16 M
AFR
AMR
EMR
EUR
SEAR
WPR
Communicable conditions
NCDs < 60
NCDs > 60
Injuries

11. NCD deaths by World Bank income groups (2008 estimates)
World Health Organization
25 May 2018
NCD deaths by World Bank income groups (2008 estimates)
0 M
5 M
10 M
15 M
20 M
25 M
30 M
35 M
Low-income
Countries
Lower-
Middle-income
Upper- Middle-income
High-income
My second point is to stress the magnitude of premature deaths. If we take the age of 60 to define premature death then almost 30% of NCD deaths in LMICs are premature, compared to only 13% in HICs. Using the age of 70 as the cut-off point almost half of NCD deaths occur before the age of 70 in LMICs compared to one quarter in HICs. The key message: in Lower income populations, NCDs place a much bigger burden on younger age groups than in HICs.
Communicable conditions
NCDs < 60
NCDs > 60
Injuries

12. Global burden of NCDs (Millions of deaths in 2008)
World Health Organization
25 May 2018
Global burden of NCDs (Millions of deaths in 2008)
18M
Males
Females
16M
14M
12M
10M 8M 6M
If we look at mortality by the world bank income groups, this is what get: 80% of NCD mortality which you see in orange occur in LMICs – the popular belief that NCDs affect mostly affluent populations is not true. These figures tell us a different story. The rate of increase in magnitude is interesting. Looking at current trends it is estimated that the percentage increase in cancer incidence by 2030 will be greater in low income countries *82%) compared with only 40% in high income countries. 4M 2M
Low-
Lower-
Upper-
High-
Low-
Lower-
Upper-
High-
income
middle-
middle-
income
income
middle-
middle-
income
income
income
income
income
Communicable, maternal, perinatal and nutritional conditions
NCDs
Injuries

13. World Health Organization
25 May 2018
Percentage of women who die from NCDs before the age of 60 (2008) 0%
10%
20%
30%
40%
50%
60%
70%
Sierra Leone
Afghanistan
Equatorial Guinea
Nauru
Papua New Guinea
Gambia
Angola
Kiribati
Ethiopia
Andorra
Norway
Spain
Japan
Germany
Austria
Switzerland
San Marino
Sweden
Italy

14. World Health Organization
25 May 2018
What are the causes of these NCD deaths? The global picture
28%
34% 8% 3%
11%
16%
27%
39% 9% 4%
12%
Under the age of 60
Under the age of 70
This is a breakdown of premature deaths below the age of 60 and under 70 according to the type of NCDs. As you can see the cardiovascular diseases are leading responsible for more than a third. About 30% of these deaths are caused by cancer and the four groups of diseases are collectively responsible for 75-80% of all deaths.
Cancers
Cardiovascular disease
Chronic respiratory diseases
Diabetes
Digestive diseases
Other NCDs

15. 2. Morbidity

16. Prevalence of diabetes
15%
men
Men
Women
10% 5%
Africa
Americas
Eastern-
Mediterranean
Europe
South- East Asia
Western Pacific
Age-standardized prevalence of diabetes in adults aged 25+ years (2008)
Source: WHO Global Status Report on NCDs (2010)

17. World Health Organization
25 May 2018
NCDs
Raised blood pressure
Overweight/obesity
Raised blood glucose
Raised lipids
Tobacco use
Unhealthy diet
Physical inactivity
Harmful use of alcohol
Globalization
Urbanization
Population ageing
Metabolic/
physiological
risk factors
Underlying drivers
Behavioural
Causal links
The roots of the rising magnitude of the NCD problem starts with the underlying drivers which include the social determinants in addition to population ageing, urbanization which is in many cases unplanned and rapid and globalization of trade and marketing, resulting in increasing rates of the four lifestyle and behavioural risk factors, which in turn cause rising levels of NCDs.
Social Determinants
of Health

18. 3. Metabolic/physical risk factors

19. Metabolic/physical risk factors
Raised blood pressure
≥140mmHg and/or ≥ 90mmHg
40% adults over 25 have raised BP
Causes 7.5 million (13%) all deaths
3.7% total DALYs
Major risk factor for CHD, ischaemic and hemorrhagic stroke
CVD risk doubles for each increase of 20/10 mmHg
Other complications: heart failure, PVD, renal disease, retinal hemorrhage

20. High blood pressure continues to go up
40%
30%
High-income countries
Upper Middle-income countries
% of population
Lower middle-income countries
20%
Low-income countries
10%
1980
2008
Raised blood pressure (2008)
Source: WHO NCD Country Profiles (2010)

21. World Health Organization
25 May 2018
Prevalence of raised blood pressure (2008 estimates) 0%
10%
20%
30%
40%
50%
AFR
AMR
EMR
EUR
SEAR
WPR
Low-
income
Lower-
middle-
Upper-
Middle-
income-
High-
Blood pressure
Raised BP is estimated to cause about 7.5 million deaths every year. The overall prevalence in adults 25 years and over at the global level is 40%, highest in the African region and lowest in the American region. Across all income groups the lowest estimated prevalence of 35% was seen in high income countries.
Men
Women
Both Sexes

22. Metabolic/physical risk factors
b) Overweight and obesity
BMI ≥ 25 kg/m2, BMI >= 30 kg/m2
Population goal: kg/m2
Individual goal: 18.5 to 24.9 kg/m2
35% adults aged 20+ overweight
Worldwide prevalence doubled over the last 30y

23. Risks are widespread: % overweight (BMI 25+), 2008, ages 20+, age adjusted

24. World Health Organization
25 May 2018
Obesity among adult men and women (2008)
Worldwide, at least 2.8 million people die each year as a result of being overweight or obese, and an estimated 35.8 million (2.3%) of global DALYs are caused by overweight or obesity.
In 2008, 35% of adults aged 20+ were overweight.
The worldwide prevalence of obesity has more than doubled between 1980 and 2008.
In 2008, 10% of men and 14% of women in the world were obese, compared with 5% for men and 8% for women in 1980.
An estimated 205 million men and 297 million women over the age of 20 were obese – a total of more than half a billion adults worldwide.

25. World Health Organization
25 May 2018
Prevalence of overweight in adults (2008 estimates) 0%
10%
20%
30%
40%
50%
60%
70%
AFR
AMR
EMR
EUR
SEAR
WPR
Overweight and obesity
raised BMI increases the risk of cardiovascular disease, type 2 diabetes and certain cancers and mortality rates increase with increasing degree of overweight. in 2008, 35% of adults 20 years and over were overweight . The prevalence is highest (estimated at 62%) in the American region and lowest in SEA. More than 50% of women are overweight in the Americas, Europe and the EM.
Men
Women
Both Sexes

26. Overweight over the last 30 years
70%
60%
50%
High-income countries
40%
Upper Middle-income countries
% of population
Lower middle-income countries
30%
Low-income countries
20%
10% 0%
1980
2008
Overweight (2008)
Source: WHO NCD Country Profiles (2010)

27. Metabolic/physical risk factors
c) Raised cholesterol
5.0mmol/l or 190mg/dl or higher
Increases the risk of heart disease and stroke
Third of IHD attributible to high cholesterol
Cause of 2.6 million deaths (4.5% of the total)
10% reduction in men aged 40 would result in 50% reduction in heart disease over 5 years (and at age 70, 20% over 5y
Global prevalence of raised total cholesterol 39%

28. World Health Organization
25 May 2018
Modifiable causative metabolic/physical risk factors
Obesity
Raised BP
Raised glucose
Abnormal lipids
Noncommunicable diseases
Heart disease and stroke 
Diabetes
Cancer
Chronic lung disease
We are focusing on the four major groups of NCDs and the four major risk factors.
Current evidence indicates that four major groups of diseases make the largest contribution to mortality in the majority of countries. These are CVDs, cancers, diabetes and CLD. They share more or less the same risk factors: tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol and they can therefore be addressed using the same preventive strategies. It does not mean that there are no other risk factors, infections such as those causing hepatitis B and C and human papilloma virus can also cause a substantial proportion of cancer and can also be prevented.

29. 4. Behavioral risk factors

30. Behavioral risk factors
a) Tobacco
1 billion smokers
4000 chemicals, 50 carcinogenic
Smoked and unsmoked forms
6 million die from tobacco use and exposure
6% all female deaths, 12% male
10% deaths attributable to second-hand smoke
Causes 71% lung cancer deaths, 42% chronic respiratory deaths, 10% CVD deaths
7.5 million deaths by 2020

31. Prevalence of daily tobacco smoking (2008 estimates)
World Health Organization
25 May 2018
Prevalence of daily tobacco smoking (2008 estimates) 0%
10%
20%
30%
40%
50%
AFR
AMR
EMR
EUR
SEAR
WPR
Tobacco slide:
Almost 6 million people die from tobacco use every year. Currently there are about 1 billion smokers in the world. The prevalence varied widely among WHO regions in the highest in both sexes which you see in the red bars is estimated at nearly 29% in the European region. If we look at men alone (brown bars), the highest prevalence of smoking (46%) is seen in the western pacific where china is. Among women (green bars) the highest 20% is in Europe.
Men
Women
Both Sexes

32. Behavioral risk factors
b) Insufficient physical activity
Less than x5 30 min moderate activity per week (or x3 20 min vigorous activity)
Globally, 31% those 15y+ insufficiently active
3.2 million deaths
20-30% increased risk all-cause mortality
Adequate activity reduces risk of IHD by 30%, diabetes 27%, breast and colon cancer by 21-25%

33. World Health Organization
25 May 2018
Percentage of insufficient physical activity (2008 estimates) 0%
10%
20%
30%
40%
50%
AFR
AMR
EMR
EUR
SEAR
WPR
PA slide
people who are physically inactive have a substantially increased risk of all cause and NCD mortality. According to 2008 estimates, globally over 30% of people over 15 are insufficiently active. The highest rates of insufficient PA is seen in the American and EM regions where almost 50% of women are insufficiently active.
Men
Women
Both Sexes

34. Behavioral risk factors
c) Harmful use of alcohol
Responsible 2.3 million deaths and disabilities
3.8% of all deaths – 50% from NCDs
Low-risk patterns of consumption may have a beneficial effect
45% global population never consumed alcohol

35. Behavioral risk factors
d) Unhealthy diet
Overall estimates of unhealthy diet not possible
But 1.7 million deaths (2.8% of the total) attributable to low fruit and low vegetable consumption
Adequate fruit and vegetable intake reduces risk of CVD, stomach and colorectal cancer
Salt consumption important determinant of blood pressure and CVD risk
Recommendation is less than 5g per person
Saturated and trans-fat increase risk of CHD and type 2 diabetes.
Poly-unsaturated fat from vegetables is protective

36. World Health Organization
25 May 2018
Modifiable causative behavioural risk factors
Tobacco use
Unhealthy diets
Physical inactivity
Harmful use of alcohol
Noncommunicable diseases
Heart disease and stroke 
Diabetes
Cancer
Chronic lung disease
We are focusing on the four major groups of NCDs and the four major risk factors.
Current evidence indicates that four major groups of diseases make the largest contribution to mortality in the majority of countries. These are CVDs, cancers, diabetes and CLD. They share more or less the same risk factors: tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol and they can therefore be addressed using the same preventive strategies. It does not mean that there are no other risk factors, infections such as those causing hepatitis B and C and human papilloma virus can also cause a substantial proportion of cancer and can also be prevented.

37. Chronic infection as a risk factor
Cervical, liver and stomach cancers all have greatest incidence in LMICs
All caused predominately by chronic infections
2 million cancer cases (18% global cancer burden) attributable to a few specific chronic infections
HPV: 100% cancer cervix, majority of anogenital tract, 20-60% oro-pharyngeal
HBV and HBC: 50-80% primary liver cancer
H. pylori: 80% noncardia carcinomas stomach

38. World Health Organization
25 May 2018
NCDs
Raised blood pressure
Overweight/obesity
Raised blood glucose
Raised lipids
Tobacco use
Unhealthy diet
Physical inactivity
Harmful use of alcohol
Globalization
Urbanization
Population ageing
Metabolic/
physiological
risk factors
Underlying drivers
Behavioural
Causal links
The roots of the rising magnitude of the NCD problem starts with the underlying drivers which include the social determinants in addition to population ageing, urbanization which is in many cases unplanned and rapid and globalization of trade and marketing, resulting in increasing rates of the four lifestyle and behavioural risk factors, which in turn cause rising levels of NCDs.
Social Determinants
of Health

39. 5. Public health impact of NCDs

40. Public health impact of NCDs
Premature mortality, significant morbidity
Quality of life of affected individuals and families
Socioeconomic impact on individuals, families, communities and societies
It is a misunderstanding that chronic diseases would mainly affect high income countries
The reality is that four out of five chronic disease deaths are in low and middle income countries
Looking at the graph you can see that only for the lowest income countries, communicable diseases are a bigger problem than chronic diseases. And even there almost 40% of people die from chronic diseases
For all the other countries, chronic diseases is the main cause of death.

41. NCDs is a development issue
Globalization
Urbanization
Population ageing
Poverty
Populations in low- and middle-income countries
Increased exposure to common modifiable risk factors
Loss of household income
NCDs
Limited access to effective and equitable health-care services
Poverty at household level
More than 8 million people die before the age of 60
in developing countries from noncommunicable diseases

42. NCDs: The poor are affected the most
Percent with and without cancer experiencing catastrophic spending and impoverishment 60 50 40 30 20 10
Cancer
No cancer
percentage
Impoverishment
Catastrophic expenditures

43. NCD risk factors: The poor are affected the most45
Smoking prevalence (2004)
Lowest household income quintiles 40 35 30 25
Highest household income quintiles
(percentage) 20 15 10
Spending on tobacco – the poor in Nepal spend 10% of their income on cigarette 5
Low-income countries
Lower-middle
Upper middle-income
countries
High-income
countries
income countries

44. World Health Organization
25 May 2018
NCDs are the third largest global risk in terms of likelihood
Oil spikes
Retrenching from globalization
Asset price collapse
Food price volatility
Non-communicable diseases
Financial crisis
"A problem neither the developed world nor the developing world can afford"
"Declining development assistance has already led to a significant reduction of public spending on health in many countries. When funds are limited, governments tend to focus on basic health services, in line with the MDGs, at the expense of the prevention and treatment of non-communicable diseases."
(WEF Global Risk 2010 Report)
Infectious diseases
World Economic Forum: Global Risk 2010 Report

45. US$ 7T
is the cumulative lost output in developing countries associated with NCDs between
US$ 11B
is the average yearly cost for all developing countries to scale up action by implementing a combined set of "best buy" priority NCD interventions identified by WHO
Population-based measures: close to US$ 2 billion per year
Low- and lower-middle-income countries: < US$ 0.20 per head
Upper-middle income countries: < US$ 0.50 per head
Individual-based measures: nearly US$ 10 billion per year
Low-income countries: < US$ 1.00 per head
Lower middle-income countries: < US$ 1.50 per head
Upper-middle income countries: ~ US$ 2.50 per head

46. 7. Prevention is possible
Largest part of premature mortality from the four main NCDs can be prevented if risk factors were eliminated
20%
20%
20%
60%
40%
80%
80%
80%
The largest part of the main chronic diseases can be prevented!
80% of type 2 diabetes for example, can be prevented.
(source WHO Chronic disease report from 2005)
Heart disease
Stroke
Type 2 diabetes
Cancer
preventable
not preventable

47. 8. What is needed to tackle this public health problem?