1. H.I. GHOSH1 Challenges of NCDs in Palestine *** Heidar Abu Ghosh Director of Chronic Diseases Program *** Palestinian Medical Relief Society

2. H.I. GHOSH2 NCDs of Interest.. Heart HTN Diabetes CVD Cancer (Breast) Dyslipidemia Obesity ?!

3. H.I. GHOSH3 Targeted Diseases High prevalence An increasing morbidity and mortality burden An increasing economic, social, and psychological burden Early detection improves prognosis Public awareness is crucial for prevention Comprehensive management is generally absent

4. H.I. GHOSH4 How High is the Risk ? After the age of 35 years: –1 out of six may develop diabetes –1 out of 3 may develop hypertension –1 out of 2 have dyslipidemia –2 out of 3 are overweight –2 out of 5 are obese –1 adult male out of 3 is a smoker

5. H.I. GHOSH5 Global Trends

6. H.I. GHOSH6 Estimated prevalence of diabetes and number of cases of diabetes in millions. (Adapted from King et al, 1998). 202520001995Year Region 5.44.24.0Prevalence %World 300154.4135.3Number (millions) 7.66.25.9Prevalence %Developed countries 72.254.851Number (millions) 4.93.53.3Prevalence %Developing countries 227.799.684.3Number (millions)

7. H.I. GHOSH7 NCDs in LD Countries In LD countries –like Palestine- that experience the double burden of diseases, NCDs contributed to more than half of total mortality and 40% of total disease burden The large burden of NCDs in these countries is characterized both by the increased incidence of diseases and the relatively early age at which they appear NCDs also contribute largely to disability in both the developed and developing countries. Source: World health report 2003

8. H.I. GHOSH8 NCDs in Palestine

9. H.I. GHOSH9 Current Status Demographic and Epidemiological Transition Progressive Urbanization  Caloric Excess  Less Physical Activity  Increased Tobacco Consumption  Predominance of Overweight and Obesity  Qualitatively Poor Diet

10. H.I. GHOSH10 Demographic & Epidemiological Transition Better control of communicable diseases Relative increase ageing of populations Decrease in IMR Socio-economic transformation

11. H.I. GHOSH11 Demographic Characteristics Number of people in WBG is 3,117,290 – WB: 1,992,105 –Gaza: 1,125,185 Children under the age of 15years comprises 47% of the population Those under 30 years old comprise 70% The proportion of elderly (65years and older) is 3.3% (PCBS: 2000)

12. H.I. GHOSH12

13. H.I. GHOSH13 Risk Factors Modifiable:  Caloric excess- obesity  Diet  Physical inactivity  Smoking Non- modifiable:  Age  Gender  Ethnic group  Family history  Personal history  STRESS

14. H.I. GHOSH14 Nutrition Traditional nutrition –High fibers, whole grains –Less animal fat –More complex carbohydrate Modern diet”: –Less fibers,refined grains –More animal fat –More simple sugar

15. H.I. GHOSH15 Qualitatively Poor Diet High-fat (cholesterol ) Unsaturated fatty acids Rapidly absorbed carbohydrates Fiber Salt Vitamins

16. H.I. GHOSH16 Urbanization  Caloric Excess  Less Physical Activity  Increased Tobacco Consumption  Predominance of Overweight and Obesity  Qualitatively Poor Diet

17. H.I. GHOSH17 Duality of Health Problems Modern diseases - Diabetes Mellitus - Hypertension - Coronary heart diseases - Cancer. Diseases of underdevelopment - Infectious diseases - Malnutrition - Poor housing conditions

18. H.I. GHOSH18 Leading Causes of Death DiseasePalestine Israeli Arabs Global Infectious diseases 6.6533 CVD304230 Cancer191812 D.M.2.32.72

19. H.I. GHOSH19 Adult mortality in Palestine (2002) MoH:2004

20. H.I. GHOSH20 Diabetes Mellitus Diabetes is more prevalent than in Europe and North America It is estimated that the prevalence in the population aged 20years and above is more than 10% Our data showed a prevalence of 19% for people of 35years and above

21. H.I. GHOSH21 Cancer Rare published reports It is becoming a major public health concern The second reported cause of death after CVDs –The most common: Breast in females and lung in smoking males

22. H.I. GHOSH22 Leading cause of cancer mortality in Palestine

23. H.I. GHOSH23 PMRS CHRONIC DISEASES PROGRAMME “ A CALL FOR ACTION”

24. H.I. GHOSH24 A Different Approach A comprehensive approach in the management of diseases: Prevention –Life style modification –Health promotion Early detection Proper treatment Train and support management at PHC level Establish a good referral system

25. H.I. GHOSH25 Implementation The goals are to be met through different activities at: –The Chronic Disease Center –The Mobile Clinic –PMRS health centers

26. H.I. GHOSH26 Components Prevention, Early Detection And Health Promotion Surveillance, Data Collection, And Research Proper Management

27. H.I. GHOSH27 Activities Activities include: –Training –Screening –Health Education –Early diagnosis –Proper Management –Data collection & Research –Coordination and cooperation –Advocacy & Lobbying

28. H.I. GHOSH28 Screening Every male and female over 35 years: –Glucose level in blood –Lipid profile –Blood pressure –Body Mass Index Every female over 25 years: –Breast examination

29. H.I. GHOSH29 Mobile Clinic More than 11,000 people screened fpr NCDs 68% were women 7800 women were screened for breast abnormalities All of them know how to do self breast examination

30. H.I. GHOSH30 The Chronic Diseases Center

31. H.I. GHOSH31 The Chronic Diseases Center A unique center in Palestine with a holistic approach for management of NCDs Management of heart diseases, diabetes, hypertension, and dyslipidemia Risk assessment Early detection of NCD through diagnostic procedures Counseling

32. H.I. GHOSH32 Diagnostic Procedures Patient’s and family history Blood pressure Weight and height Dr’s examination Upon need: –ECG –Echocardiography –Treadmill –Holter Counseling

33. H.I. GHOSH33 Some Results From PMRS Screening Services

34. H.I. GHOSH34 Characteristics of Population BothFemalesMalesCharacteristic 47.246.3349.62Mean age (years) 75.2573.6779.63Mean weight (Kg) 160157170Mean height (cm) 29.2629.8527.63Mean BMI 10.21.434.8Smoking (%) 95.896.992.8High fat nutrition (%) 66.467.264.3 Low physical activity 78.474.6 88.9 Stress (%)

35. H.I. GHOSH35 207.5155MalesTriglycerides (mg/dl) 191135.5Females 210194.7MalesT. cholesterol (mg/dl) 212.9191.3Females 129.2126.9MalesLDL (mg/dl) 130.8114.7Females 3738.6MalesHDL (mg/dl) 4650.1Females Selected factors associated with diabetic status DM

36. H.I. GHOSH36 Cost of chronic diseases Economic Impact of the quality of life Decrease the productivity of individuals

37. H.I. GHOSH37 A CHALLENGE AND AN OPPORTUNITY The rapid rise of noncommunicable diseases represents one of the major health challenges to global development in this century. This growing challenge threatens economic and social development as well as the lives and health of millions of people Source: World health report 2003

38. H.I. GHOSH38 A CHALLENGE AND AN OPPORTUNITY Noncommunicable diseases are estimated to have contributed to almost 60% (31.7 million) of deaths in the world and 43% of the global burden of disease. Based on current trends, by the year 2020 these diseases are expected to account for 73% of deaths and 60% of the disease burden. Source: World health report 2003

39. H.I. GHOSH39 A CHALLENGE AND AN OPPORTUNITY Developing Countries suffer the greatest impact of noncommunicable diseases. The total number of deaths attributable to noncommunicable diseases, 77% occurred in developing countries, The disease burden represents, 85% in these countries. Source: World health report 2003

40. H.I. GHOSH40 LESSONS LEARNED Noncommunicable diseases are to a great extent preventable through interventions against the major risk factors and their environmental, economic, social and behavioural determinants in the population. A comprehensive long-term strategy for control of noncommunicable diseases must necessarily include prevention of the emergence of risk factors in the first place. Source: World health report 2003

41. H.I. GHOSH41 Chronic Disease Management All treatment plans and education programs must be adapted to the cultural and social environment for the patients.