1. Introduction to Non-Communicable Diseases Ahmed Mandil, Prof of Epidemiology KSU College of Medicine

2. Headlines Definitions Examples Magnitude of the Problem Risk Factors Sources of Data Prevention & Control Challenges Injury epidemiology & prevention 29 February 20162NCD Epi

3. 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. 29 February 20163NCD Epi

4. 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 to 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. 29 February 20164NCD Epi

5. 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 29 February 20165NCD Epi

6. 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) 29 February 20166NCD Epi

7. 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) 29 February 20167NCD Epi

8. Magnitude of the Problem (I) NCD are considered the leading causes of death and disability on a global scale, and appear to have been so, for at least the last two decades of the 20 th century. Disease rates (morbidity and mortality) from these conditions are accelerating globally, advancing across regions and social classes, with special burden in less developed nations. 29 February 20168NCD Epi

9. 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. 29 February 20169NCD Epi

10. The Regional Situation  The WHO Region for the Eastern Mediterranean, NCD account for 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  The conventional risk factors may explain 75% of such NCD 29 February 201610NCD Epi

11. Cardiovascular Chronic Respiratory Disease Type 2 Diabetes Cancer Chronic Diseases result in percent of deaths 4 52 EMR Adult Population 29 February 201611NCD Epi

12. STEPwise data from some EM countries CountryYear of field work Diabetes % Hypertension % Overweight & Obesity % Iraq200610.440.466.9 Jordan20071625.567.4 Saudi Arabia200517.926 Syrian Arab Republic 200319.828.856.3 Kuwait200516.724.681.2 Egypt200516.533.476.4 Sudan200519.223.653.9 29 February 201612NCD Epi

13. Risk Factors 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. 29 February 201613NCD Epi

14. NCD RISK FACTORS, EMR Tobacco use 16-65% Hypertension 12-35% Diabetes 7-25% Overweight-obesity40-70% Dyslipidemia30-70% Physical Inactivity 80-90% 29 February 201614NCD Epi

15. Sources of data on 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) 29 February 201615NCD Epi

16. 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) 29 February 201616NCD Epi

17. 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. 29 February 201617NCD Epi

18. 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). 29 February 201618NCD Epi

19. 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 29 February 201619NCD Epi

20. NCD Prevention and control: (V): Tertiary prevention 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) 29 February 201620NCD Epi

21. NCD Prevention and control: (VI): Role of Different Agencies Public (governmental) agencies: fund/conduct research; establish standards; provide financing for medical care; deliver medical services to the poor; monitor health status of the population. Voluntary (non-governmental): fund research; provide public and professional education; stimulate social and legislative changes; create visibility for prevention and control through their large cadre of volunteers. Medical care sector: delivers services; provides preventive medicine through primary care; establishes professional guidelines that improve the quality of life. 29 February 201621NCD Epi

22. NCD Prevention and control: ( VII) Challenges - 1 Information on NCD (need for establishment /effectiveness of surveillance activities). Applied research Choosing / maintaining healthy behaviors Social and political policies (laws, regulations) 29 February 201622NCD Epi

23. NCD Prevention and control: ( VII) Challenges - 2 Communication of health risk (proper health promotion) High risk and population-based approaches Cost of health care Access to health-care services (cooperation between public / private systems, multi- sectoral cooperation, health insurance initiatives). 29 February 201623NCD Epi

24. References 1 1. Last J. A dictionary of epidemiology. 5 th Edition. Oxford, New York, Toronto: Oxford University Press, 2008. 2. Remington PL, Brownson RC, Wegner MV. Chronic disease epidemiology and control. 3 rd Edition. Washington, D.C.: American Public Health Association, 2010. 3. WHO. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases. Geneva: WHO, 2008 29 February 201624NCD Epi

25. References 2 4. Fadhil I. Diabetes and other non- communicable diseases: An Eastern Mediterranean Perspective. WHO, 2009 5. Kuh D, Ben Shlomo Y. A life course approach to chronic disease epidemiology. Oxford, New York, Toronto: Oxford University Press, 1997. 6. Newcomer RJ, Benjamin AE. Indicators of chronic health conditions. Baltimore, London: The Johns Hopkins University Press, 1997. 29 February 201625NCD Epi