Non-Communicable Disease

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

• Definition of 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

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Non-Communicable Disease
Non-Communicable Disease
Definitions
An impairment of bodily structure or function
that entails a modification of the patients
normal life, over an extended period of time.
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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.
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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 Majo
r depression 5.7 3 Perinatal conditions 6.7 3 Road
traffic accidents 5.1 4 Major depression 3.7 4 Ce
rebrovascular disease 4.4 5 Ischemic heart
disease 3.4 5 COPD 4.2 6 Cerebrovascular
disease 2.8 6 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 Congeni
tal abnormalities 2.4 10 HIV 2.6
Global Burden of Disease Study, 1996
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Deaths by cause
Non-Communicable Disease
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)
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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

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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)
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How High is the Risk ?
Non-Communicable Disease
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)

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Increasing medical costsThe need for prevention
Non-Communicable Disease
Gulf Cooperation Countries

• Total Health Expenditure(THE) per capita ranges
  between US 325 to 2750
• Out of pocket spending18-23 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
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NCDs Directorate
Non-Communicable Disease
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

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Core of national NCDs strategy
Non-Communicable Disease
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
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NCDs programs in KSA
Non-Communicable Disease
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

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Non-Communicable Disease
Obesity
Obesity
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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.
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Obesity
Non-Communicable Disease
Obesity
Obesity in KSA ( 2013 estimates)
  Males Females Children
overweight 30.7 28.4 -----
obese 23.6 14.0 18
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Risk Factors
Non-Communicable Disease
Obesity
Obesity

• Genes
• Metabolism
• Behavior
• Environment
• Culture
• SES

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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.
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Non-Communicable Disease
Obesity
Obesity
The health consequences
Cancer
Gall-bladder disease
Respiratory disease
Obesity
Renal failure
Hyper-tension
Type 2 diabetes
Stroke
Heart failure
Athero- sclerosis
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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 fizzy drinks
• Decrease consumption of high energy dense,
  nutrient poor, foods
• Decrease television viewing

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Smoking
Non-Communicable Disease
Smoking
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Smoking
Non-Communicable Disease
Smoking
Composition of tobacco

• About 4000 toxic substances are present in
  tobacco
• Most important and dangerous constituents
• Nicotine
• Carbon Monoxide
• Tar

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Non-Communicable Disease
Smoking and Diseases
Smoking

• 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

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Non-Communicable Disease
Smoking and Diseases
Smoking

• 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

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Effects of Second Hand (Passive) Smoking(SHS)
Non-Communicable Disease
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.

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Treatment
Non-Communicable Disease
Smoking

• Drugs
• Nicotine replacement therapy
• Hypnotics
• Group therapy
• Motivation
• Commitment
• Determination
• Effort and support in the struggle to quit
  smoking.

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Preventive measures
Non-Communicable Disease
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.

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Preventive measures
Non-Communicable Disease
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

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When smokers quit
Non-Communicable Disease
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.

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When smokers quit
Non-Communicable Disease
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.

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When smokers quit
Non-Communicable Disease
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.

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When smokers quit
Non-Communicable Disease
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.
• (Source American Cancer society)

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Diabetes
Non-Communicable Disease
Type 2 Diabetes Mellitus
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Diabetes
Non-Communicable Disease
Type 2 Diabetes Mellitus
Diabetes diagnostic criteria
HbA1c 2 HG mmol/l(mg/dl) FG mmol/l(mg/dl)
lt6.0 lt7.8 (lt140) lt6.1 (lt110) Normal
6.06.4 lt7.8 (lt140) 6.1- 6.9(111-125) IFG
6.06.4 7.8 (140) lt7.0 (lt126) IGT
6.5 11.1 (200) 7.0 (126) DM
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Diabetes
Non-Communicable Disease
Estimated prevalence of diabetes and number of
cases in millions.
Region
2025
Year
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
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54.8
72.2
Number (millions)
Prevalence
3.3
4.9
3.5
Developing countries
Number (millions)
227.7
84.3
99.6
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Diabetes
Non-Communicable Disease
Diabetes mellitus in Saudi Arabia
Al-Nozha MM et al. Diabetes mellitus in Saudi
Arabia. Saudi Med J 200425 (11) 1603-1610
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Non-Communicable Disease
Diabetes
Why is the prevalence of Type 2 diabetes
increasing?

• Aging of the population.
• Urbanization especially in the developing
  countries.
• More sedentary lifestyle.
• Food consumption patterns, more foods with high
  fat content and more refined carbohydrates.

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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

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Proportion of family income devoted to diabetes
care
Diabetes
Non-Communicable Disease
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Risks of CVD death in diabetics and non-diabetics
Non-Communicable Disease
Diabetes
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Diabetes
Non-Communicable Disease
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  
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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.

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

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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 reduction in the risk of CHD.

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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

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Non-Communicable Disease
Ca Cervix
Ca cervix
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Non-Communicable Disease
Ca Cervix
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

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Non-Communicable Disease
Ca Cervix
Stages of Ca cervix
Stage 0 carcinoma in situ Stage I
tumor confined to the cervix Stage II
extension beyond the cervix not pelvic
sidewall or lower one-third of vagina
Stage III extension to pelvic sidewall or lower
one-third of vagina Stage IV
extension to bladder or rectal mucosa
or beyond the pelvis
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Non-Communicable Disease
Ca Cervix
Risk Factors of Ca Cervix

• Human papilloma virus infection

• Smoking

• Immunosuppression

• Chlamydia infection

• Diet

• Overweight

• Oral contraceptives

• Multiple full-term pregnancies

• Young age at the first full-term pregnancy

• Poverty

• Family history of cervical cancer

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Non-Communicable Disease
HPV disease incidence by patient age
Ca Cervix
Cancer
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Non-Communicable Disease
Ca Cervix
Risk Factors of HPV

• Having many sex partners
• Having a partner who has had many partners
• Being younger than 25 years of age
• Starting to have sex at an early age (16 years or
  younger)
• Having a male partner who is not circumcised .

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Non-Communicable Disease
Ca Cervix
Cervical Cancer Prevention
( Papanicolaou)
1- The Pap test (or Pap smear) 2- The human
papilloma virus (HPV) test

• Regular starting 21.
• If normal after 3 years.
• If 30 HPVPap test.
• If both normal after 5 years.
• 2165 continue Pap test.
• gt65 years

(no need for Pap test anymore.)

• with normal Pap test
• cervix removed

3- HPV vaccine (Pap test should continue after
vaccination)
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Non-Communicable Disease
Ca Breast
Breast cancer
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Non-Communicable Disease
Ca Breast
Breast cancer
Breast cancer is the top cancer in women both in
the developed and the developing world.
The incidence of breast cancer is increasing in
the developing world due to

• increase life expectancy
• increase urbanization
• adoption of western lifestyles

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Non-Communicable Disease
Ca Breast
Risk Factors of Ca Breast
Reproductive Risk Factors

• Early menarche.
• Late menopause.
• Being older at the birth of the first child.
• Nulliparous.
• Not breastfeeding.
• Long-term use of hormone-replacement therapy.

Other Risk Factors

• Age.
• Family history of breast cancer
• Being overweight (after menopause).
• Alcohol (more than one drink a day).
• Inactivity.

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Non-Communicable Disease
Ca Breast
Breast Cancer and Early Detection

• Early diagnosis means a better chance of
  successful treatment
• Mammography is the best tool to screen for breast
  cancer
• Mammogram each year, starting at the age of 40
• Regular clinical breast examinations and breast
  self-examinations

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Non-Communicable Disease
Ca Breast
Reducing the risk of breast cancer

• Avoid postmenopausal obesity
• Keep alcohol consumption low
• No smoking
• Regular exercise
• Control weight
• Keep an adequate Vitamin D level
• Avoid long term hormone use
• Consider taking an estrogen-blocking drug
• Breast-feed for as long as possible
• Avoid radiation and environmental pollution

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Non-Communicable Disease
Natural History of Disease
Levels of prevention
Pathological Changes
Usual Time of Diagnosis
Primordial Prevention
Onset of Symptoms
Primary Prevention
Exposure
Stage of Recovery, Disability, or Death
Stage of Susceptibility
Stage of Clinical Disease
Lead time
Stage of Subclinical Disease
Early detection SCREENING Secondary Prevention
Tertiary Prevention
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Non-Communicable Disease
Take home message

• Prevention of the emergence of risk factors in
  the first place

• Raise awareness about the global epidemic of
  chronic diseases

• NCD preventable major risk factors are
  modifiable.

• Slow and reverse trends in common chronic disease
  risk factors such as unhealthy diet and physical
  inactivity

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Non-Communicable Disease
thank you