Non-Communicable Disease

1. Non-Communicable Disease Epidemiology, Control & Prevention CHP300 Mohamed M.B. Alnoor

2. Non-Communicable Disease Content • Definition and Risk Factors for Non- Communicable Disease (NCDs) • Increasing medical cost of NCDs in KSA • Objectives &Responsibilities of NCDs in KSA • NCDs programs in KSA • Risk Factors for the common NCDs in KSA • Natural History and prevention of NCDs

3. Non-Communicable Disease Non-Communicable Disease Definitions: An impairment of bodily structure or function that necessitates a modification of the patient’s normal life, over an extended period of time.

4. Non-Communicable Disease Non-Communicable Disease Definitions: Diseases comprising all impairments or deviations from normal, which have one or more of the following characteristics: • are permanent • leave residual disability • are caused by non reversible pathological alterations • require special rehabilitation training • require a long period of supervision, observation or care Examples: DM, Cancer, Hypertension, Asthma, etc.

5. Non-Communicable Disease Leading Causes of Death and Disability 1990 2020 Rank Cause % Rank Cause % 1 Lower respiratory infections 8.2 1 Ischemic heart disease 5.9 2 Diarrhoeal diseases 7.2 2 Major depression 5.7 3 Perinatal conditions 6.7 3 Road traffic accidents 5.1 4 Major depression3.74 Cerebrovascular disease 4.4 5 Ischemic heart disease3.45 COPD 4.2 6 Cerebrovascular disease2.86 Lower respiratory infections 3.1 7 Tuberculosis 2.8 7 Tuberculosis 3.0 8 Measles 2.7 8 War 3.0 9 Road traffic accidents 2.5 9 Diarrhoeal diseases 2.7 10 Congenital abnormalities 2.4 10 HIV 2.6 Global Burden of Disease Study, 1996

6. Non-Communicable Disease Deaths by cause Global Situation Infectious diseases: Non-communicable diseases: HIV/AIDS 4.9% Tuberculosis 2.4% Cardiovascular disease 30.2% Malaria 1.5% Total: 58Million Other Infectious Diseases 20.9% Cancer 15.7% Diabetes 1.9% Injuries 9.3% Other chronic diseases 15.7% (WHO, 2004)

7. Non-Communicable Disease Risk Factors for Non-Communicable Disease Non Modifiable Risk Factors Modifiable Risk Factors • Cigarette smoking • Life style changes (dietary • patterns, physical activity) • Overweight/Obesity • Stress factors • Alcohol abuse • Age • Gender • Family History • Genetic factors • Personality (type A) • Race

8. Non-Communicable Disease Multiple RF Cardiovascular risk factors Hypertension (195 mmhg SBP) Smoking 3 4.5 1.6 16 6 9 4 Elevated Cholesterol (330 mg/dl)

9. Non-Communicable Disease How High is the Risk ? Risk for various NCD After the age of 35 years: • 1 out of 6 may develop diabetes • 1 out of 3 may develop hypertension • 2 out of 3 are overweight • 1 out of 2 may have dyslipidemia • 2 out of 5 are obese • 1 out of 3 is a smoker(adult males)

10. Non-Communicable Disease Increasing medical costs:The need for prevention Gulf Cooperation Countries • Total Health Expenditure(THE) per capita ranges between US$ 325 to 2750 • Out of pocket spending:18-23% THE • Advanced epidemiological and demographic transitions will result in a several fold increase in health care spending in the coming 2 decades • Prevention has to be taken seriously Sources: WHO WHR 2008,- WHO NHA database, WHO-EMRO, Mapping health care financing, EMR countries

11. Non-Communicable Disease NCDs Directorate NCDs in KSA General Directorate of Non-communicable diseases established in 2004, under the Preventive Medicine Objectives &Responsibilities • Surveillance of NCDs • Planning NCDs policies and control measures • Collaboration with other departments and specific committees responsible for preparation of NCDs protocols and guidelines • Capacity building for health professionals • Research and studies • Development of community participation

12. Non-Communicable Disease Core of national NCDs strategy NCDs in KSA 1. Integrating NCD prevention into the (10 years) national development plan 2. Launching NCDs programs according to priorities 3. Targeting risk factors for NCDs 4. Conducting research 5. Surveillance system for NCD at National Level 6. Coordination and cooperation with other concerned sectors

13. Non-Communicable Disease NCDs programs in KSA NCDs in KSA • NCDs stepwise surveillance • Prevention of diabetes • Prevention of cardiovascular diseases • Prevention of cancer • Diet and Physical activity • Premarital screening • Newborn screening • Prevention of injuries and road traffic accidents • Control of osteoporosis

14. Non-Communicable Disease Obesity Obesity

15. Definition of Obesity Non-Communicable Disease Obesity Obesity Obesity is defined as an increased body weight in relation to height, when compared to some standard of acceptable or desirable weight.

16. Non-Communicable Disease Obesity Obesity Obesity in KSA ( 2013 estimates)

17. Non-Communicable Disease Risk Factors Obesity Obesity • Genes • Metabolism • Behavior • Environment • Culture • SES

18. Non-Communicable Disease Obesity Obesity Hippocrates The effects of excess weight on mortality and morbidity have been recognized for more than 2,000 years. It was Hippocrates who recognized that “sudden death is more common in those who are naturally fat than in the lean.”

19. Non-Communicable Disease Obesity Obesity The health consequences Cancer Gall-bladder disease Respiratory disease Obesity Hyper-tension Kidney failure Type 2 diabetes Stroke Athero- sclerosis Heart failure

20. Non-Communicable Disease Six target behaviors for the prevention of obesity and other chronic diseases Obesity • Increase physical activity • Increase consumption of fruits and vegetables • Increase breastfeeding initiation, duration, and exclusivity • Decrease consumption of sugar sweetened beverages • Decrease consumption of high energy dense, nutrient poor, foods • Decrease television viewing

21. Non-Communicable Disease Smoking Smoking

22. Non-Communicable Disease Smoking Smoking Composition of tobacco • About 4000 toxic substances are present in tobacco • Most important and dangerous constituents: • Nicotine • Carbon Monoxide • Tar

23. Non-Communicable Disease Smoking Smoking and Diseases • An important causative/risk factor for various diseases. • About 25 diseases caused/aggravated by smoking. e.g. • Lung cancer: 80-90% deaths due to smoking. Incidence 10 times more than non-smokers. • Chronic bronchitis • Emphysema: 80- 95% • Ischaemic heart disease: 20-30% deaths . Risk is twice than non-smokers • Obstructive peripheral vascular disease

24. Non-Communicable Disease Smoking Smoking and Diseases • diseases caused/aggravated by smoking. • Cerebrovascular disease • Cancer of tongue, oesophagus, larynx & pancreas, Gastro-duodenal ulcers • Cancer of the cervix and endometrium • Cancer of the urinary bladder • Still births, abortions • Neonatal deaths • Fracture of hip, wrist and vertebrae

25. Non-Communicable Disease Effects of Second Hand (Passive) Smoking(SHS) Smoking • Children • Sudden infant death • Respiratory distress • Otitis media • Adults • Discomfort, distress to asthmatics • Nicotine is detected in blood and urine of passive smokers. • Passive smoking by adults may lead to Ca-cervix, CA lung, and coronary heart disease.

26. Non-Communicable Disease Treatment Smoking • Drugs • Nicotine replacement therapy • Hypnotics • Group therapy • Motivation • Commitment • Determination • Effort and support in the struggle to quit smoking.

27. Non-Communicable Disease Preventive measures Smoking • Recommendations of WHO Framework Convention on Tobacco Control (FCTC) should be implemented. • Govt.’s responsibility for implementation of recommendations and legislation. • Ascertain the existence of smoking as health problem. • Encourage not to start smoking. • Encourage to stop smoking. • Multi- sectoral approach.

28. Non-Communicable Disease Preventive measures Smoking • Anti-smoking health education to general public but special emphasis to focus on children and to the occupational groups. • Highlighting the positive effects of NOT smoking and QUITING smoking. • Awareness for the rights of non-smokers. • Legislative action

29. Non-Communicable Disease When smokers quit Smoking Just 20 minutes after the smokers have smoked the last cigarette, their body begins an ongoing series of beneficial changes. • After 20 minutes: • Blood pressure drops to normal. • Pulse rate drops to normal. • Temperature of hands becomes normal. • After 8 hours: • Carbon monoxide level in blood drops to normal • Oxygen level in blood increases to normal.

30. Non-Communicable Disease When smokers quit Smoking • After 24 hours: • Chance of heart attack decreases • After 48 hours: • Nerve endings start growing. • Ability to smell and taste is enhanced. • Walking becomes easier. • After 2 weeks –3 months: • Circulation improves. • Lung function increases up to 30%.

31. Non-Communicable Disease When smokers quit Smoking • After 1-9 months: • Coughing, sneezing, congestion, fatigue, shortness of breath decrease. • Cilia re-grow in the lungs, increasing ability to handle mucous, clean the lungs and to reduce infection. • 1 year: • Risk of coronary heart disease is half that of a smoker. • 5 years after: • Stroke risk is reduced to that of a nonsmoker.

32. Non-Communicable Disease When smokers quit Smoking • After 10 years: The lung cancer death rate is about half that of a continuing smoker's. The risk of cancer of the mouth, throat, esophagus, bladder, kidney, and pancreas decreases. • After 15 years: The risk of coronary heart disease is that of a nonsmoker’s. (Source: American Cancer society)

33. Non-Communicable Disease Diabetes Type 2 Diabetes Mellitus

34. Non-Communicable Disease Diabetes Type 2 Diabetes Mellitus Diabetes diagnostic criteria

35. Non-Communicable Disease Diabetes Estimated prevalence of diabetes and number of cases in millions. Region Year 2025 1995 2000 Prevalence % 4.0 4.2 5.4 World 135.3 154.4 300 Number (millions) Prevalence % 5.9 6.2 7.6 Developed countries 54.8 72.2 51 Number (millions) Prevalence % 3.3 3.5 4.9 Developing countries Number (millions) 227.7 84.3 99.6

36. Non-Communicable Disease Diabetes Diabetes mellitus in Saudi Arabia Al-Nozha MM et al. Diabetes mellitus in Saudi Arabia. Saudi Med J 2004;25 (11): 1603-1610

37. Non-Communicable Disease Diabetes Why is the prevalence of Type 2 diabetes increasing? • Aging of the population. • Increased incidence due to urbanization especially in the developing countries. • More sedentary lifestyle. • Food consumption patterns, more foods with high fat content and more refined carbohydrates.

38. Non-Communicable Disease Diabetes Different Diabetes Complications • Macro vascular • Micro vascular • Neuropathy • Infections • Ischemic heart disease • Cerebrovascular disease • Peripheral vascular disease • Eye Complications • Diabetic Nephropathy • Sensorimotor neuropathy • Autonomic neuropathy • Altered immunity

39. Proportion of family income devoted to diabetes care Non-Communicable Disease Diabetes

40. Non-diabetics Diabetics CHF CHD Stroke All CVD All cause Non-CVD Other CVD Non-Communicable Disease Risks of CVD death in diabetics and non-diabetics Diabetes

41. Non-Communicable Disease Diabetes Top 7 Risk Factors for Type 2 Diabetes 1. Obesity 2. Sedentary Lifestyle 3. Unhealthy Eating Habits 4. Family History and Genetics 5. Age 6. Hypertension and High Cholesterol 7. History of Gestational Diabetes

42. Non-Communicable Disease Why should we prevent diabetes? Diabetes • To reduce human suffering. • To alleviate the economic burden. • To prevent morbidity and mortality from diabetes-related CVD.

43. Non-Communicable Disease Diabetes Levels of prevention in Type 2 diabetes • Primary prevention • Secondary prevention • Tertiary prevention Behavioral and/or Pharmacological interventions Early diagnosis and effective control Measures against complications

44. Non-Communicable Disease Hypertension Primary Hypertension

45. Non-Communicable Disease Primary Hypertension Hypertension Definitions and classification of blood pressure levels (mmHg) Category Systolic Diastolic Optimal < 80 < 120 Normal 120-129 80-84 High normal 130-139 85-89 Grade 1 htsn (mild) 140-149 90-99 Grade 2 htsn (moderate) 160-179 100-109 Grade 3 htsn (sever) > 110 > 180

46. Non-Communicable Disease Primary Hypertension Hypertension Risk Factors • Age • Alcohol • Cigarette Smoking • Diabetes Mellitus • Elevated serum lipids • Excess Na+ in diet • Gender • Family History • Obesity • Sedentary Lifestyle • Stress

47. Non-Communicable Disease Primary Hypertension Hypertension Framingham Heart Study: 2 mmHg reduction in the pop. average DBP ( 35 to 64 years) would result in: • 17 % decrease in the prevalence of hypertension • 14 % reduction in the risk of stroke and TIA (transient ischemic attacks) • 6 percent reduction in the risk of CHD.

48. Non-Communicable Disease Primary Hypertension Hypertension Primary prevention of hypertension is a combination of lifestyle changes: • weight loss in overweight persons • increased physical activity • moderation of alcohol intake • diet • high in fruits, vegetables • low-fat dairy products • low sodium content

49. Non-Communicable Disease CaCervix Ca cervix

50. Non-Communicable Disease CaCervix Ca cervix • Worldwide, cervical cancer is the 2nd leading cause of cancer death in women • During the sexual lifespan of a woman, approximately 70% will have been exposed to HPV • HPV is endemic among sexually active humans