Public Health 150 Non-communicable Diseases

Public Health 150Non-communicable Diseases

Zuo-Feng Zhang, MD, PhDProfessor of Epidemiology

October 31, 2011

What are NCDs?

• NCD is a medical condition or disease, which is not infectious

• NCDs are diseases or medical conditions with long duration and relatively slow progression

• NCDs are usually called “Chronic Diseases”

Why NCDs Are Important in Public Health?

• 57 million deaths that occurred globally in 2008

• 36 million – 63.2%, almost two thirds – were due to NCDs

• 9 million death that occurred among people under age 60

• mainly cardiovascular diseases, cancers, diabetes and chronic lung diseases

UN High-Level meeting on NCDs, September 19-20, 2011

Number of deaths for leading causes of death in the US

• Heart disease: 631,636• Cancer: 559,888• Stroke (cerebrovascular diseases): 137,119• Chronic lower respiratory diseases: 124,583• Accidents (unintentional injuries): 121,599• Diabetes: 72,449• Alzheimer's disease: 72,432• Influenza and Pneumonia: 56,326• Nephritis, nephrotic syndrome, and nephrosis: 45,344• Septicemia: 34,234

US

Cardiovascular Diseases

• CVDs include diseases of the heart, vascular diseases of the brain and diseases of blood vessels.

• CVDs are responsible for over 17.3 million deaths per year and are the leading causes of death in the world

WHO. Global Atlas on Cardiovascular Disease Prevention and Control. Mendis S, Puska P, NorrvingB editors. World Health Organization, Geneva 2011

Heart and Brain

WHO. Global Atlas on Cardiovascular Disease Prevention and Control. Mendis S, Puska P, NorrvingB editors. World Health Organization, Geneva 2011

Proportion of Death caused by CVDs

WHO. Global Atlas on Cardiovascular Disease Prevention and Control. Mendis S, Puska P, NorrvingB editors. World Health Organization, Geneva 2011

Distribution of CVDs

What Is Tumor/Cancer?

Tumor is a disorder of cells

• A neoplasm (Greek, Neo-New, plasma, thing formed) is the autonomous growth of tissue that have escaped the normal restraints on cell proliferation and exhibit varying degrees of fidelity to their precursors.

• It is usually appears as a tumor ( a swelling) made of mass of cells.“Abnormal growth of cells”, “Unlimited growth of cells”.

Tumors

• In general, neoplasms are irreversible, and their growth is for the most part, autonomous.

Benign versus Malignant Tumors

• Benign tumors do not penetrate (invade) adjacent tissue borders, nor do they spread (metastasize) to distant sites.

• They remain localize overgrowths in the area in which they arise

• Benign tumors are more differentiated than malignant tumors, that is, they are more closely resemble their tissue of origin.

Invasion and Metastasis

• Malignant tumors (cancer) are capable of invasion (spread of the neoplasms into adjacent structures) and metastasis (implantation of the neoplasms into noncontiguous sites).

Oral Leukoplakia

Oral submucous fibrosis

Erythroplakia

Oral Premalignant Lesions

Invasive oral cancer

Second Primary Cancers following a first primary

oral cancer

Esophageal Cancer Oral Cancer Lung Cancer

Cancer Statistics

• 12.7 million new cases in 2008• 7.6 million deaths from cancer (13.3% of

overall deaths) in 2008

Incidence and Mortality, World 2008

Cancer

Cancer

Cancer

Projected demographic effects on cancer incidence and mortality

New cancers (in 1,000,000s) of all cancersNew cancers (in 1,000,000s) of all cancers  RegionRegion 20082008 20102010 20202020 20302030WorldWorld 12.6712.67 13.3013.30 16.9316.93 21.3721.37More developed regionsMore developed regions 5.565.56 5.725.72 6.596.59 7.437.43Less developed regionsLess developed regions 7.117.11 7.527.52 9.929.92 12.8812.88AfricaAfrica 0.680.68 0.720.72 0.950.95 1.281.28Asia (Japan)Asia (Japan) 0.620.62 0.640.64 0.740.74 0.790.79Asia (Other)Asia (Other) 5.485.48 5.755.75 7.607.60 9.899.89EuropeEurope 3.213.21 3.293.29 3.673.67 4.064.06Latin America/CaribbeanLatin America/Caribbean 0.910.91 0.960.96 1.281.28 1.691.69North AmericaNorth America 1.601.60 1.671.67 2.082.08 2.502.50OceaniaOceania 0.140.14 0.140.14 0.180.18 0.230.23

New deaths (in 1,000,000s) of all cancersNew deaths (in 1,000,000s) of all cancers  RegionRegion 20082008 20102010 20202020 20302030WorldWorld 7.577.57 7.967.96 10.2210.22 13.1613.16More developed regionsMore developed regions 2.752.75 2.842.84 3.323.32 3.863.86Less developed regionsLess developed regions 4.824.82 5.115.11 6.836.83 9.109.10AfricaAfrica 0.510.51 0.540.54 0.720.72 0.970.97Asia (Japan)Asia (Japan) 0.340.34 0.360.36 0.430.43 0.470.47Asia (Other)Asia (Other) 3.733.73 3.923.92 5.245.24 6.986.98EuropeEurope 1.721.72 1.771.77 1.991.99 2.262.26Latin America/CaribbeanLatin America/Caribbean 0.540.54 0.580.58 0.780.78 1.051.05North AmericaNorth America 0.640.64 0.660.66 0.840.84 1.061.06OceaniaOceania 0.060.06 0.060.06 0.080.08 0.100.10

0 1 2 3 4 5 6 7 8 9 10

North America

Latin America

Europe

Asia (Other)

Asia (Japan)

Africa

Number of new cases (in millions)

2008 2010 2020 2030

0 1 2 3 4 5 6 7 8 9 10

North America

Latin America

Europe

Asia (Other)

Asia (Japan)

Africa

Number of deaths (in millions)

2008 2010 2020 2030

Projected demographic effects on cancer incidence and mortality

New cancers (in 100,000s)New cancers (in 100,000s)

  Cancer siteCancer site 20082008 20102010 20202020 20302030

LungLung 16.116.1 17.017.0 22.122.1 28.728.7

BreastBreast 13.813.8 14.514.5 17.917.9 21.721.7

Colon/rectumColon/rectum 12.312.3 13.013.0 16.816.8 21.921.9

StomachStomach 9.99.9 10.410.4 13.513.5 17.417.4

ProstateProstate 9.09.0 9.59.5 12.812.8 17.117.1

LiverLiver 7.57.5 7.97.9 10.010.0 12.512.5

CervixCervix 5.35.3 5.55.5 6.66.6 7.87.8

EsophagusEsophagus 4.84.8 5.15.1 6.66.6 8.48.4

New deaths (in 100,000s)New deaths (in 100,000s)

  Cancer siteCancer site 20082008 20102010 20202020 20302030

LungLung 13.813.8 14.514.5 19.019.0 24.924.9

StomachStomach 7.47.4 7.87.8 10.110.1 13.213.2

LiverLiver 7.07.0 7.37.3 9.39.3 11.811.8

Colon/rectumColon/rectum 6.16.1 6.46.4 8.38.3 11.011.0

BreastBreast 4.64.6 4.84.8 6.06.0 7.57.5

EsophagusEsophagus 4.14.1 4.34.3 5.65.6 7.27.2

CervixCervix 2.82.8 2.92.9 3.63.6 4.34.3

ProstateProstate 2.62.6 2.72.7 3.63.6 5.05.0

0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000

Esophagus

Cervix

Liver

Prostate

Stomach

Colon/rectum

Breast

Lung

Number of new cases

2008 2010 2020 2030

0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000

Prostate

Cervix

Esophagus

Breast

Colon/rectum

Liver

Stomach

Lung

Number of deaths

2008 2010 2020 2030

Cancer Incidence and Mortality in China and World, 2008

China New Cases

Incidence Deaths Mortality

Male 1,622,502 (24.5%)

211.0 1,222,199 (28.9%)

158.6

Female 1,194,708 (19.8%)

152.4 736,148(22.0%)

91.6

Total 2,817,210 (22.2%)

181.0 1,958,347 (25.88%)

124.6

World

Male 6,617,844 203.8 4,219,626 128.6

Female 6,044,710 165.1 3,345,176 87.6

Total 12,662,554 181.6 7,564,802 106.1

Globocan, 2008

Incidence and Mortality are per 100,000Population: China: 1,331,460,000; World: 6,775,235,700; China/World: 19.65%

Age Standardized Incidence Rates (/100,000)Age Standardized Incidence Rates (/100,000)

  US China World

Site Males Females Males Females Males Females

Stomach 7.2 3.3 41.4 19.2 22.0 10.3

Lung 61.9 36.1 42.4 19.0 35.5 12.1

Liver 5.5 2.0 37.9 14.2 15.7 5.8

Esophagus 4.9 1.3 27.4 12.0 11.5 4.7

Colon/Rectum 44.6 33.1 13.6 9.2 20.1 14.6

Breast ─ 101.1 ─ 18.7 ─ 37.5

Leukemia 11.2 7.4 5.7 4.1 5.9 4.1

Pancreas 8.3 6.3 3.9 2.6 4.6 3.3

Cervix 0 7.7 0 6.8 0 16.2

Brain 6.5 4.5 3.9 2.8 3.7 2.6

Prostate 124.8 0 1.6 0 25.3 0

Source: GLOBOCAN 2002

COPD• Chronic obstructive pulmonary disease (COPD) is a life-threatening lung disease

that interferes with normal breathing – it is more than a “smoker’s cough”.• An estimated 64 million people have COPD worldwide in 2004.1

• More than 3 million people died of COPD in 2005, which is equal to 5% of all deaths globally that year.

• Almost 90% of COPD deaths occur in low- and middle-income countries. • The primary cause of COPD is tobacco smoke (through tobacco use or second-

hand smoke).• The disease now affects men and women almost equally, due in part to

increased tobacco use among women in high-income countries.• COPD is not curable, but treatment can slow the progress of the disease.• Total deaths from COPD are projected to increase by more than 30% in the

next 10 years without interventions to cut risks, particularly exposure to tobacco smoke.

COPD

Diabetes

Diabetes

• More than 346 million people worldwide have diabetes.

• There is an emerging global epidemic of diabetes that can be traced back to rapid increases in overweight, obesity and physical inactivity.

Diabetes

Diabetes is predicted to become the seventh leading cause of death in the world by the year 2030.

• Total deaths from diabetes are projected to rise by more than 50% in the next 10 years.

Diabetes

There are two major forms of diabetes.• Type 1 diabetes is characterized by a lack of

insulin production and type 2 diabetes results from the body's ineffective use of insulin.

A third type of diabetes is gestational diabetes.• This type is characterized by hyperglycaemia, or

raised blood sugar, which has first appeared or been recognized during pregnancy.

Diabetes

Type 2 diabetes is much more common than type 1 diabetes.

• Type 2 accounts for around 90% of all diabetes worldwide. Reports of type 2 diabetes in children – previously rare – have increased worldwide. In some countries, it accounts for almost half of newly diagnosed cases in children and adolescents.

Diabetes

• Cardiovascular disease is responsible for between 50% and 80% of deaths in people with diabetes.

• Diabetes has become one of the major causes of premature illness and death in most countries, mainly through the increased risk of cardiovascular disease (CVD).

Diabetes

Diabetes is a leading cause of blindness, amputation and kidney failure.

• Lack of awareness about diabetes, combined with insufficient access to health services and essential medicines, can lead to complications such as blindness, amputation and kidney failure.

Diabetes

Type 2 diabetes can be prevented. • Thirty minutes of moderate-intensity physical

activity on most days and a healthy diet can drastically reduce the risk of developing type 2 diabetes. Type 1 diabetes cannot be prevented.

Percentage of Cancer Deaths Attributed to Various Factors (Doll R and Peto R, JNCI, 1981)

• Tobacco Use: 30% (25%-40%)• Diet:35% (10%-70%)• Infection: 10%? (1%-?)• Reproductive & Sexual Behavior: 7% (1%-13%)• Occupation: 4% (<2%-8%)• Alcohol: 3% (2%-4%)• Geophysical factors (natural radiation): 3% (2-4%)• Pollution: 2% (<1% – 5%)• Food additive: <1% (-5% – 2%)• Medicines and Medical Procedures: 1% (0.5%-3%)• Industrial consumer products <1% (<1%-2%)• Unknown: ?, ?

Lichtenstein P, Holm NV, Verkasalo PK, Iliadou A, Kaprio J, Koskenvuo M, Pukkala E, Skytthe A, Hemminki K. NEJM, 2000

Study Design in GWA Studies

• Multistage approach to reduce the amount of genotyping required, without sacrificing power.

• In stage 1, a full set of SNPs is genotyped, and a p-value threshold is used to identify a subset of SNPs with putative associations.

Joel N. Hirschhorn & Mark J. DalyNature Reviews Genetics 6, 95-108, 2005

Published Genome-Wide Associations through 06/2011,

1,449 published GWA at p≤5x10-8 for 237 traits

National Human Genome Research Institute (NHGRI) GWA Catalogwww.genome.gov/GWAStudies

Tobacco causes 10% of CVD death

Diseases Caused by Tobacco Use

Cigarette smoking increases the risk of: Coronary heart disease Atherosclerotic peripheral vascular disease Cerebrovascular disease Cancers of the lung, larynx, mouth, esophagus, bladder, pancreas,

kidney, and cervix Chronic obstructive pulmonary disease Intrauterine growth retardation, premature rupture of membranes Low-birthweight babies, perinatal mortality Cataract, macular degeneration; hip fracture Peptic ulcer disease

Possibly liver, stomach, and colorectal cancers and acute myelocytic leukemia

Disease Caused by Tobacco Use

Involuntary smoking (environmental tobacco smoke) is a cause of: Lung cancer and coronary heart disease in nonsmokers Respiratory infections and symptoms in the children of

parents who smoke

Smokeless tobacco causes: Oral Cancer Oral leukoplakia Dental caries (possibly)

Cigars cause: Cancers of the mouth, larynx, and lung Coronary heart disease COPD

Physical Activities

The Benefits of Physical ActivityRegular physical activity is one of the most

important things you can do for your health.

• Control your weight• Reduce your risk of cardiovascular disease• Reduce your risk for type 2 diabetes and metabolic syndrome• Reduce your risk of some cancers (colon, breast,

endomentrial and lung cancers)• Strengthen your bones and muscles• Improve your mental health and mood• Improve your ability to do daily activities and prevent falls, if

you're an older adult• Increase your chances of living longer

CDC, 2011

Harmful Use of Alcohol

Obesity

Key facts

• Worldwide obesity has more than doubled since 1980.• In 2008, 1.5 billion adults, 20 and older, were

overweight. Of these over 200 million men and nearly 300 million women were obese.

• 65% of the world's population live in countries where overweight and obesity kills more people than underweight.

• Nearly 43 million children under the age of five were overweight in 2010.

• Obesity is preventable.

Obesity

• Globally, 44% of diabetes, 23% of ischaemic heart disease and 7–41% of certain cancers are attributable to overweight and obesity.

Obesity

• Body Mass Index (BMI) is a number calculated from a person's weight and height. BMI provides a reliable indicator of body fatness for most people and is used to screen for weight categories that may lead to health problems.

• http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html

BMI Classification

• Body Mass Index (BMI) is a simple index of weight-for-height that is commonly used to classify underweight, overweight and obesity in adults. It is defined as the weight in kilograms divided by the square of the height in metres (kg/m2). For example, an adult who weighs 70kg and whose height is 1.75m will have a BMI of 22.9.

• BMI = 70 kg / (1.75 m2) = 70 / 3.06 = 22.9

The International Classification of adult underweight, overweight and obesity according to BMI

Fattest Countries in the World

Diet

Exhibit 16–1 American Cancer Society (ACS) Guidelines on Nutrition and Physical Activity for Cancer Prevention ACS Recommendations for Individual Choices 1. Eat a variety of healthful foods, with an emphasis on plant sources.

Eat five or more servings of a variety of vegetables and fruits each day. Choose whole grains in preference to processed (refined) grains and sugars. Limit consumption of red meats, especially those high in fat and processed. Choose foods that help maintain a healthful weight.

2. Adopt a physically active lifestyle. Adults: engage in at least moderate activity for 30 minutes or more on five or more days

of the week; 45 minutes or more of moderate-to-vigorous activity on five or more days per weekmay further enhance reductions in the risk of breast and colon cancer.

Children and adolescents: engage in at least 60 minutes per day of moderate-to-vigorous physical activity at least five days per week.

3. Maintain a healthful weight throughout life. Balance caloric intake with physical activity. Lose weight if currently overweight or obese.

4. If you drink alcoholic beverages, limit consumption. ACS Recommendations for Community Action Public, private, and community organizations should work to create social and physical environments that support the adoption and maintenance of healthful nutrition and physical activity behaviors.

Increase access to healthful foods in schools, worksites, and communities Provide safe, enjoyable, and accessible environments for physical activity in schools, and

for transportation and recreation in communities. Source: Reprinted with permission from T Byers, et al., American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention: Reducing the Risk of Cancer with Healthy Food Choices and Physical Activity. CA: A Cancer Journal for Clinicians , Vol 52, pp. 92-119, © 2002, Lippincott Williams & Wilkins.