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Faculty of Medicine
Public Health (31505291) العامةالصحة Lecture 14
Global overview of Non-Communicable Diseases (NCDs)
By
Hatim Jaber MD MPH JBCM PhD
10-7-2017
1
1. The global health impact of mental health and mental diseases. Drug abuse and Addictive substances
1. Global overview of communicable diseases
2. Global overview Non- Communicable Diseases(NCDs) 3. The global health impact of Hepatitis, Tuberculosis and HIV/AIDS 4. The global health impact of Cardiovascular Diseases , Diabetes and
Obesity 1. Health service delivery in developing countries 2. Health policy, Health priorities 3. Health systems and financing 4. Quality of care and effectiveness in different health services systems; 5. Health policies and management within a global health perspective 1. Violence and injuries 2. Migration and Travelers' health
Presentation outline
Time
Introduction of concepts 08:00 to 08:10
Current trends an occurrence of global NCDs 08:10 to 08:20
Current trends an occurrence of global NCDs 08: 20 to 08:30
Risk factors associated with NC global diseases.
08:30 to 08:40
Aging populations and chronic illness 08:40 to 09:00
Basic principles and policies for prevention and control at global level
09:00 to 09:15
3
Source: W.H.O. Statistics
Trends in Global Deaths 2002-30
Source: World Health Statistics 2007
“Non - Communicable”
• With rapid urbanization, industrialization and increasing level of affluence (the so called “modernization”), the price that the society is paying is a tremendous load of “Non - Communicable” diseases, also referred to as “Chronic” diseases” and, often, as “Lifestyle Diseases”
World - wide Magnitude of the Problem :
• Chronic diseases represent a huge proportion of human illness. They include: • cardiovascular disease (30% of projected total worldwide deaths
in 2005), • cancer (13%), • chronic respiratory diseases (7%), and • diabetes (2%) Three risk factors underlying these conditions are key to any
population - wide strategy of control – • tobacco use, • physical inactivity and • obesity.
• These risks and the diseases they engender are not the exclusive preserve of rich nations.
• An estimated total of 58 million deaths worldwide in a year, heart disease, stroke, cancer, and other chronic diseases will account for 35 million, more than 15 million of which will occur in people younger than 70 years.
• Approximately four out of five of all deaths from chronic disease now occur in low – income and middle - income countries, and the death rates are highest in middle - aged people in these countries
Socio-Environmental Changes have Led to Increasingly Unhealthy Lifestyles in Populations
• Non-communicable diseases are the leading killer today and are on the increase.
• Nearly 80% of these deaths occurred in low- and middle-income countries.
10
• More than nine million of all deaths attributed to noncommunicable diseases (NCDs) occur before the age of 60.
• Around the world, NCDs
affect women and men
almost equally.
Global status report on noncommunicable diseases
(April 2011 the World Health Organization
(WHO) )
• NCDs are the leading cause of death in the world, responsible for 63% of the 57 million deaths that occurred in 2008.
• The majority of these deaths - 36 million - were attributed to cardiovascular diseases and diabetes, cancers and chronic respiratory diseases.
12
• NCDs are largely preventable by means of effective interventions that tackle shared risk factors, namely: tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol.
• NCDs are not only a health problem but a development challenge as well.
The leading causes of NCD deaths in 2008 were: cardiovascular diseases (17 million deaths, or 48% of NCD deaths);
cancers (7.6 million, or 21% of NCD deaths); and respiratory diseases, including asthma and chronic
obstructive pulmonary disease (COPD), (4.2 million). Diabetes caused an additional 1.3 million deaths. Behavioural risk factors, including tobacco use, physical
inactivity, and unhealthy diet, are responsible for about 80% of coronary heart disease and cerebrovascular disease.
Global status report on noncommunicable diseases
(April 2011 the World Health Organization (WHO) )
14
15
Classifying deaths and diseases (WHO)
• Communicable diseases [Group I] – Those where death is directly due to the action of
a communicable agent
• Non-communicable diseases – Diseases [Group II]
• Cancer, diseases of various organ systems (eg respiratory, cardiovascular etc.), diabetes, mental health etc.
– External causes (injuries, poisonings and violence) [Group III]
16
A global problem
• In 2004 there were 59 million deaths world-wide
• Non-communicable diseases accounted for 60% of these deaths and injuries and violence 10%.
• By 2020 it is estimated that non-communicable disease will account for 73% of all deaths
GBD 2004 Update, 2008
17
Non-communicable diseases as % of all deaths by global
region (all ages)
WORLDWIDE 59%
N.America; W Europe 88%
China, W Pacific, + some SE
Asia
75%
Latin America + Caribbean 67%
S E Asia including India 51%
Sub-Saharan Africa 21%
18
Urbanisation
0
10
20
30
40
50
60
70
80
90
100
1950 1960 1970 1980 1990 2000 2010 2020 2030
Urb
an
po
pu
lati
on
as
% o
f to
tal
North AmericaLatin America & Caribbean
Europe
Oceania
Asia
Africa
WORLD
20
07
19
Drivers of the epidemiological transition in low and middle income countries
• Population ageing
• Major socio-economic changes (especially urbanisation)
– changes in risk factors such as diet, physical activity, smoking etc.
Young Children and Older People as a Percentage of Global Population: 1950-2050
The Increasing Burden of Chronic Non-communicable Diseases: 2008 and 2030
Prevalence of Chronic Disease and Disability among Men and Women Aged 50-74 Years in the United
States, England, and Europe: 2004
The Growth of Numbers of People with Dementia in High- income Countries and Low- and Middle-income
Countries: 2010-2050
24
GBD 2001 mortality estimates
• 107 countries had collected “useable” information on cause of death from registration systems
• 55 countries (42 in sub Saharan Africa) no information on adult mortality
• Estimates based on many assumptions and extrapolations
Distribution of deaths in the world by sex, 2004
25 GBD report 2004 update, 2008
Mortality rates among men and women aged 15–59 years, region and cause-of-death group, 2004
26
GBD report 2004 update, 2008
Projected global deaths for selected causes, 2004–2030
27 GBD report 2004 update, 2008
Noncommunicable diseases: country income
28
• About 30% of people dying from NCDs in low- and middle-income countries are aged under 60 years and are in their most productive period of life.
• The prevalence of NCDs is rising rapidly and is projected to cause almost three-quarters as many deaths as communicable, maternal, perinatal, and nutritional diseases by 2020, and to exceed them as the most common causes of death by 2030.
• In most middle- and high-income countries NCDs were responsible for more deaths than all other causes of death combined, with almost all high-income countries reporting the proportion of NCD deaths to total deaths to be more than 70%.
Noncommunicable diseases: Current status and trends in risk factors
29
Common, preventable risk factors underlie most NCDs. These risk factors are a leading cause of the death and disability burden in nearly all countries, regardless of economic development.
The leading risk factor globally for mortality is:
1. raised blood pressure (responsible for 13% of deaths globally),
2. followed by tobacco use (9%),
3. raised blood glucose (6%),
4. physical inactivity (6%),
5. overweight and obesity (5%).
The list of major lifestyle diseases
What are the major components of “Lifestyle”
• Lifestyle diseases or “Non-Communicable Diseases” have common risk factors
Noncommunicable diseases: Current status and trends in risk factors
32
The prevalence of these risk factors varied between country income groups, with the pattern of variation differing between risk factors and with gender. High-, middle- and low-income countries had differing risk profiles.
Several risk factors have the highest prevalence in high-income countries. These include:
1. physical inactivity among women,
2. total fat consumption,
3. raised total cholesterol.
Some risk factors have become more common in middle-income countries. These include:
1. tobacco use among men,
2. overweight and obesity.
Noncommunicable diseases: parameters for estimation of behavioral and
metabolic risk factors
33
• current daily tobacco smoking: the percentage of the population aged 15 or older who smoke tobacco on a daily basis.
• physical inactivity: the percentage of the population aged 15 or older engaging in less than 30 minutes of moderate activity per week or less than 20 minutes of vigorous activity three times per week, or the equivalent.
• raised blood pressure: the percentage of the population aged 25 or older having systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥90 mmHg or on medication to lower blood pressure.
Noncommunicable diseases: parameters for estimation of behavioral and
metabolic risk factors
34
• raised blood glucose: the percentage of the population aged 25 or older having a fasting plasma glucose value ≥ 7.0 mmol/L (126 mg/dl) or on medication for raised blood glucose.
• overweight: the percentage of the population aged 20 or older having a body mass index (BMI) ≥ 25 kg/m2.
• obesity: the percentage of the population aged 20 or older having a body mass index (BMI) ≥30 kg/m2.
• raised cholesterol: the percentage of the population aged 25 or older having a total cholesterol value ≥ 5.0 mmol/L (190 mg/dl).
PREVENTION OF NONCOMMUNICABLE DISEASES: A GLOBAL PERSPECTIVE
Noncommunicable diseases: Prevention and Control of NCDs
36
• Millions of deaths can be prevented by stronger implementation of measures that exist today.
• These include policies that promote government-wide action against NCDs:
1. stronger anti-tobacco controls
2. promoting healthier diets,
3. physical activity,
4. reducing harmful use of alcohol;
5. along with improving people's access to essential health care.
Noncommunicable diseases: The six objectives of the 2008-2013 Action Plan are:
37
• To raise the priority accorded to noncommunicable disease in development work at global and national levels, and to integrate prevention and control of such diseases into policies across all government departments
• To establish and strengthen national policies and plans for the revention and control of noncommunicable diseases
• To promote interventions to reduce the main shared modifiable risk factors for noncommunicable diseases : tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol
Noncommunicable diseases: The six objectives of the 2008-2013 Action Plan are:
38
• To promote research for the prevention and control of noncommunicable diseases
• To promote partnerships for the prevention and control of noncommunicable diseases
• To monitor noncommunicable diseases and their determinants
• Evaluate progress at the national, regional and global levels
First global ministerial conference on healthy lifestyles and noncommunicable disease control
28-29 April 2011, Moscow, the Russian Federation
39
The aim of the conference was to support Member States develop and strengthen policies and programmes on healthy lifestyles and NCD prevention.
The conference had three main goals:
• to highlight the magnitude and socio-economic impact of NCDs;
• to review international experience on NCD prevention and control;
• to provide evidence on the pressing need to strengthen global and national initiatives to prevent NCDs as part of national health plans and sustainable development frameworks
What are the main noncommunicable diseases?
Heart disease and stroke
Diabetes
Cancer
Chronic respiratory disease
NCDs and risk factors
“Lifestyle diseases” caused by “behaviours”
Why is tackling NCDs a priority?
"Among both men and women, most deaths globally are due to noncommunicable conditions"
Out of every 10 deaths:
- 6 are due to noncommunicable conditions
- 3 to communicable, reproductive or nutritional conditions
- 1 is due to injuries
Source: WHO Global Health Estimates 2014 (Year: 2012), Deaths by age group
NCD deaths as a proportion of all deaths, 2012
NCDs and nutritional conditions
Infectious and parasitic diseases, respiratory infections
Maternal and neonatal conditions
Injuries
Ages 0 – 29 11 million deaths
2 million NCD deaths
Ages 30 – 69 20 million deaths
14 million NCD deaths
Ages 70+ 25 million deaths
22 million NCD deaths
Largely preventable deaths
0 10 20 30 40 50 60 70
High-income
Upper middle-income
Lower middle-income
Low-income
Deaths from NCDs before the age of 70 as a percentage of total deaths from NCDs
Source: WHO Global Health Estimates 2014 (Year: 2012), Deaths by age group
The proportion of people who die prematurely from NCDs is highest in poorest countries
NCDs are not a "rich country" problem
The work of WHO in fighting NCDs
NCDs included in the 2030 Agenda for Sustainable Development
“We acknowledge that the global burden and threat of NCDs constitutes one of the major challenges for sustainable development in the twenty-first century ” (paragraph 141)
Why are NCDs relevant to SDGs?
Rio+20: The SDGs can only be achieved in the absence of NCDs
60 50 40 30 20 10
0
Catastrophic expenditures
Impoverishment
Cancer
No cancer
pe
rce
nta
ge
Why are NCDs relevant to development?
NCDs lead to impoverishment from long-term treatment and care costs
NCDs lead to high burden of disease, low quality of life and lost human potential
By 2030:
Target 3.4: Reduce by one third premature mortality from NCDs by prevention, treatment and promoting mental health and well-being
Target 3.a: Implement the WHO tobacco treaty
Target 3.5: Reduce the harmful use of alcohol
2030 Agenda for Sustainable Development
Guidance provided by the WHO Global NCD Action Plan 2013-2020
Vision: A world free of the avoidable burden of NCDs Goal: To reduce the preventable and avoidable burden of morbidity, mortality and disability due to NCDs by means of multisectoral collaboration and cooperation at national, regional and global levels
Halt the rise in diabetes
and obesity
A 10% relative reduction in prevalence of insufficient physical activity
At least a 10% relative reduction in the harmful use of alcohol
A 25% relative reduction in risk of premature mortality from cardiovascular disease, cancer, diabetes or chronic respiratory diseases
An 80% availability of
the affordable basic
technologies and essential
medicines, incl. generics,
required to treat NCDs
A 30% relative reduction in
prevalence of current tobacco
use
A 30% relative
reduction in mean
population intake of
salt/sodium
A 25% relative reduction in prevalence of raised blood pressure or contain the prevalence of raised blood pressure
At least 50% of eligible
people receive drug therapy and counselling to prevent
heart attacks and strokes
Where to focus: 9 global NCD targets to be attained by 2025 (against a 2010 baseline)
Best buys
Tobacco • Reduce affordability of tobacco products by
increasing tobacco excise taxes • Create by law completely smoke-free environments
in all indoor workplaces, public places and public transport
• Warn people of the dangers of tobacco and tobacco smoke through effective health warnings and mass media campaigns
• Ban all forms of tobacco advertising, promotion and sponsorship
Harmful use of alcohol • Regulate commercial and public availability of
alcohol • Restrict or ban alcohol advertising and promotions • Use pricing policies such as excise tax increases on
alcoholic beverages
WHO Global NCD Action Plan 2013-2020
Best buys
Diet and physical activity
• Reduce salt intake
• Replace trans fats with polyunsaturated fats
• Implement public awareness programmes on diet and physical activity
• Promote and protect breastfeeding
Cardiovascular diseases and diabetes
• Drug therapy and counselling to individuals who have had a heart attack or stroke and to persons with high risk of a cardiovascular event in the next 10 years
• Acetylsalicylic acid (aspirin) for people at risk of suffering an acute myocardial infarction (heart attack)
Cancer
• Prevention of liver cancer through hepatitis B immunization
• Prevention of cervical cancer through screening and timely treatment of pre-cancerous lesions
WHO Global NCD Action Plan 2013-2020
1
2
3
4
Adoption of national NCD targets and indicators
Mortality data
Risk factor surveys
National integrated NCD strategy/action plan
5 Tobacco demand-reduction measures taxation smoke-free policies health warnings advertising bans
10 Progress Monitoring Indicators
6
7
8
9
10
10 Progress Monitoring Indicators
Harmful use of alcohol reduction measures availability regulations advertising and promotion bans pricing policies
Unhealthy diet reduction measures salt/sodium policies saturated fatty acids and trans-fats policies marketing to children restrictions marketing of breast-milk substitutes restrictions
Public awareness on diet/physical activity
Guidelines for the management of major NCDs
Drug therapy/counselling for high-risk persons
The Global Strategy on Diet, Physical Activity and Health (DPAS) implementation toolkit includes: • A Framework to monitor and evaluate
implementation • Global recommendations on physical
activity for health • Guide for population-based approaches
to increasing levels of physical activity • Recommendations on the marketing of
food and non-alcoholic beverages to children
• Population-based prevention strategies for childhood obesity
• Reducing salt intake in populations • School policy framework • Preventing noncommunicable diseases in
the workplace
http://www.who.int/dietphysicalactivity/implementation/toolbox/en/
Global Strategy on Diet, Physical Activity and Health
WHO Toolkit on Salt Reduction
WHO Commission on Ending Childhood Obesity
who.int/end-childhood-obesity/final-report
• life-course approach • importance of prevention • change in attitudes that perpetuate stigma and discrimination • comprehensive, integrated mental health and social care services in community-based settings • strategies for promotion • more effective leadership and governance • strengthened information systems, evidence and research
Mental Health Action Plan
• Manual to teach psychological interventions in simplified form so that they can be quickly learned not only by professionals but also by people who are not mental health professionals.
• simplified, scalable “low-intensity” psychological interventions”, their delivery requires a less intense level of specialist human resource use - the intervention has been modified to use fewer resources than conventional psychological interventions. People without previous training in mental health care can effectively deliver low-intensity versions of CBT and IPT as long as they are trained and supervised.
• People experiencing severe levels of depression can benefit from low-intensity interventions.
Mental Health Action Plan
WHO brings diabetes into the public eye
http://www.who.int/campaigns/world-health-day/2016/en
World Health Day - 22 March 2016
Global Strategy on the harmful use of alcohol
• Regulating and restricting availability of alcoholic beverages
• Reducing demand through taxation and pricing mechanisms
• Regulating the marketing of alcoholic beverages;
• Enacting appropriate drink-driving policies
• Raising awareness and support for effective policies
• Implementing screening programmes and brief interventions for hazardous and harmful use of alcohol
Actions for alcohol
• 3.3 million deaths globally are attributable to alcohol consumption (5.9% of deaths, all age groups)
• 5.1% of the global burden of disease is attributable to alcohol consumption (139 million DALYs)
Global Burden of Disease 2012 (WHO, 2014))
Evidence on alcohol and health
Properties of ethanol : Psychoactive and intoxicating Toxic with high mortality in overdoses Carcinogenic Dependence-producing
64
% of deaths aged 35-69 years attributable to smoking in 2000
Men Women
Belarus 33% 0%
Russia 33% 3%
Ukraine 32% 3%
Central Asia (8) 23% 4%
Estonia 31% 3%
Latvia 30% 2%
Lithuania 29% 0%
United Kingdom 25% 21%
Germany 29% 11%
Source : http://www.deathsfromsmoking.net/
65
Risk of myocardial infarction increases with every single cigarette smoked per day
Number of cigarettes smoked per day
Od
ds
Rat
io o
f M
yoca
rdia
l In
farc
tio
n
Never 1-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16 17-18 19-20 >=21
Source : K. K. Teo et al Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study Lancet 368 (9536):647-658, 2006.
INTERHEART study 52 countries
12 461 cases, 14 637 controls
66
1912: Isaac Adler (Germany) proposed smoking might be behind the alarming increase in lung cancers
1920s: Other hypotheses for lung cancers were offered:
industrial air pollution, poison gasses used in WWI, or the 1919 influenza pandemic
1940s and 1950s: Multiple studies from the USA and
Germany found a probable direct link between smoking and lung cancer. Cell pathology science and experiments on animals helped prove it.
1960: only a third of US doctors believed that smoking
caused lung cancer
Science finds smoking is harmful
Pseudo science
"medical science"
"nationwide survey" "three outstanding
independent research
organisations" "T-zone test"
"Doctors"
"a longer, healthier life … thank your doctor for that"
Tobacco as a crop
Tobacco is a labour-intensive cash crop Child labour is common
Green tobacco sickness Effects on unborn babies
Non-smoking tobacco harvesters show similar cotinine and nicotine levels to active smokers in the general population
NM Schmitt et al, Health risks in tobacco farm workers—a review of the literature, Journal of Public Health, August 2007, Vol. 15, Issue 4, pp 255–264
70
Tobacco industry is global and monolithic
The globalization of the tobacco epidemic is facilitated by:
• Trade liberalization
• Foreign direct investment
• Transnational tobacco advertising, promotion and sponsorship
The WHO Framework Convention on Tobacco Control
World No Tobacco Day - 31 May 2016
Regulation vs attitude change
Laws are not as popular as free choice
How do we encourage people to choose health?
WHO engagement beyond Member States
WHO engages with non-State actors such as: - NGOs - Private sector entities - Philanthropic foundations - Academic institutions - Well-known persons as ambassadors while protecting itself from potential reputational risks, conflicts of interest, and undue influence from external actors.
WHO publishes a register of NGOs in official relations with WHO
Some non-communicable diseases have infectious aetiology
74
Trends in stomach cancer mortality
75 Source : WHO HFA database
Age
sta
nd
ard
ised
mo
rtal
ity
pe
r 1
00
,00
0
76
Helicobacter pylori bacterium - a causal factor for stomach cancer
Summary
• Non-communicable diseases are now the most common cause of death world wide
• Increasing rates in low and middle income countries because of change in lifestyles (urbanisation)
• Key risk factors have very large effects
• Interventions are effective and can reduce burden
• The need to combine results and have large studies
77
