1. Non-communicable diseases (NCDs)

2. Non-communicable diseases (NCDs)
Is a disease which is not infectious. Such diseases may result from genetic or lifestyle factors.
A non-communicable disease is an illness that is caused by something other than a pathogen.
It might result from hereditary factors, improper diet, smoking, or other factors. Those resulting from lifestyle factors are sometimes called diseases of affluence.
Examples include hypertension, diabetes, cardiovascular disease, cancer, and mental health problems, asthma, atherosclerosis, allergy etc.
The non-communicable diseases are spread by: heredity, surroundings and behavior.

3. The risks of high blood pressure and high blood cholesterol, tobacco and alcohol consumption, obesity and physical inactivity were more commonly associated with affluent societies.
Warning: becoming dominant in all middle and low income countries and not limited to the effluent countries.
NCDs, is responsible for almost 60% of world deaths (31.7 million deaths) and 43% of the global burden of diseases.

4. This increase is clearly related to changes in global dietary patterns and increased consumption of industrially processed fatty, salty and sugary foods.

5. NCDs Situation in Palestine:
NCDs are the leading cause of death among adult population in the Palestinian society, contribute to more than 50% of causes of death among adults
common Risk factors to NCDs in Palestinian population.
Tobacco consumption is among the highest in the world.
Diet rich in saturated fat, and in simple sugars, with the decreased consumption of fibers and whole grain foods has lead to the increased prevalence of these illnesses.

6. Health services today will not be able to meet the challenges of (NCDs) In Palestine
Weak national data is available on the overall incidence and prevalence of NCDs.
In general we depend on mortality data to estimate the impacts of these diseases.
No classification by age or gender. No any information on disabilities resulting from any of the chronic diseases
The current system counts mainly the visits of the patients to PHC centers, which does not reflect the real prevalence and incidence.
Fragmentation in reporting and managing system regarding NCDs in general.
This lack of information leads to:
- Inability to estimate the cost; resources required e.g. drugs, policy; and decision making regarding prevention and treatment

7. Some Continuing Challenges
Lack of national policies for NCD prevention and control
Low resources for NCD prevention & control.
Lack of NCD surveillance systems
Fragmented and uncoordinated care
PHC capacity to deal with NCDs is poor …
THERE ARE HOWEVER A NUMBER OF CHALLENGES THAT WE STILL HAVE TO OVERCOME:
FIRST THERE IS A CLEAR LACK OF NATIONAL POLICIES FOR THE PREVENTION AND CONTROL OF NCDs AS HIGHLIGHTED BY THE ASSESSMENT OF NATIONAL CAPACITY FOR NCD PREVENTION AND CONTROL CARRIED OUT BY WHO IN IN FACT, THIS SURVEY INDICATED THAT LESS THAN HALF THE COUNTRIES REPORTED HAVING NCD POLICIES (43%).
FEW COUNTRIES HAVE A SPECIAL GOVERNMENT BUDGET ALLOCATION FOR NCD PREVENTION AND CONTROL. AND, LESS THAN HALF OF THE COUNTRIES SURVEYED HAVE CHRONIC DISEASE TREATMENT GUIDELINES. THE AVAILABILITY AND AFFORDABILITY OF ESSENTIAL DRUGS FOR NCDs IS VARIABLE AMONG COUNTRIES. IN GENERAL, THE PRIMARY HEALTH CARE CAPACITY TO DEAL WITH NCDs IS POOR.
THERE IS ALSO A LACK OF GOOD SURVEILLANCE SYSTEMS.
FINALLY, THERE SEEMS TO BE FRAGMENTED AND UNCOORDINATED CARE. THE PRIMARY HEALTH CARE CAPACITY OF MOST NATIONS TO DEAL WITH NCDs IS POOR.

8. CHANGES NEEDED NCD CHALLENGES
Cost Pressures Disease burden, interventions, drugs Quality of Care Care teams, medical records, & financial incentives Prevention Fragmentation, lack of protocols, lack of financial incentives/support Poverty
Comprehensiveness
With policy/legislation support
Coordination
Information flows
Continuity
Organized Care
Communication
Orient. on self management
Community linkages

9. How to strengthen health systems for NCDs?
Financing (increased, better and sustained
Regulation (assured quality and affordability)
Service Delivery (ensured access and availability)
Governance (improved performance)

10. Obesity

13. Obesity is a condition in which people have an excess of body fat.
According to the National Institutes of Health, almost one-third of Americans are obese.
Obesity is growing problem across the globe.
Worldwide, more than 300 million adults are obese, according to (WHO).
Obesity is the second-leading cause of preventable death in the U.S, surpassed only by smoking. At least 300,000 Americans die each year as a result of factors attributed to obesity, American Obesity Association

14. Obesity is a major risk factor for a number of serious health conditions, including:
Coronary heart disease.
Cancer.
Diabetes.
Fatty liver disease.
Gallbladder disease.
High blood pressure..
Osteoarthritis.
Stroke.
Sleep apnea and other breathing problems.

15. Classification
Obesity, in absolute terms, is an increase of body adipose tissue (fat tissue) mass.
BMI
Body mass index or BMI is a simple and widely used method for estimating body fat mass.

16. BMI is an accurate reflection of body fat percentage in the majority of the adult population. It is less accurate in people such as body builders and pregnant women in whom body composition is affected.
BMI is calculated by dividing the subject's weight by the square of his or her height:
BMI = kg / m2

17. Classification
BMI
underweight
Less than 18.5
normal weight
18.5–24.9
overweight
25.0–29.9 is
class I obesity
30.0–34.9 is
class II obesity
35.0–39.9

18. Questions ??

19. The literature breaks down "class III" obesity into further categories:
Any BMI > 40 is severe obesity
A BMI of 40.0–49.9 is morbid obesity
A BMI of >50 is super obese
Finish

20. Cancer

21. Cancer
medical term: (malignant neoplasm) is a class of diseases in which a group of cells display uncontrolled growth, invasion and sometimes metastasis (spread to other locations in the body via lymph or blood).

22. Cancer may affect people at all ages, even fetuses, but the risk for most varieties increases with age.
Cancer causes about 13% of all deaths.
According to the American Cancer Society, 7.6 million people died from cancer in the world during 2007.

27. 2006 Estimated US Cancer Deaths* (last)
Men
Women
Lung & bronchus 31%
Colon & rectum 10%
Prostate 9%
Pancreas 6%
Leukemia 4%
Liver & intrahepatic 4% bile duct
Esophagus 4%
Non-Hodgkin % lymphoma
Urinary bladder 3%
Kidney 3%
All other sites %
Lung & bronchus %
Breast %
10% Colon & rectum
Pancreas %
Ovary %
4% Leukemia
Non-Hodgkin % lymphoma
Uterine corpus %
Multiple myeloma %
Brain/ONS %
All other sites %
Lung cancer is, by far, the most common fatal cancer in men (31%), followed by colon & rectum (10%), and prostate (9%). In women, lung (26%), breast (15%), and colon & rectum (10%) are the leading sites of cancer death.
ONS=Other nervous system.
Source: American Cancer Society, 2006.

28. Cardiovascular Disease28

29. Introduction
Non communicable disease account for a large and increasing burden of disease worldwide. It is currently estimated that non communicable disease accounts for approximately 59% of global deaths and 43% of global disease burden. This is projected to increase to 73% of deaths and 60% of disease burden by 2020.

30. Introduction, cont.
The worldwide burden of cardiovascular disease is substantial. In most industrialized countries, cardiovascular disease are the leading cause of disability and death. Developing countries, with previous low rate are now seeing increased rates as economic develop, infectious disease are controlled and life expectancy improves.

31. Definition
Cardiovascular disease refers to the class of diseases that involve the heart or blood vessels (arteries and veins). While the term technically refers to any disease that affects the cardiovascular system, it is usually used to refer to those related to atherosclerosis (arterial disease). 31

32. CVD are present in many forms and have
different categories and include:-
Hypertension (high blood pressure)
Coronary heart disease (heart attack)
Cerebrovascular disease (stroke)
Peripheral vascular disease
Heart failure
Rheumatic heart disease
Congenital heart disease
Cardiomyopathies

33. Risk factors for cardiovascular disease
Non-modifiable Risk Factors
Age
Gender, men under the age 64 are much more likely to die of coronary heart disease than women, although anyone can die from it.
Genetic factors/Family history of cardiovascular disease.
Race (or ethnicity), Studies show that blacks are twice as likely to develop high blood pressure as Caucasians.
Environment, your chances can increase because of areas with a lot of smog or other form of air pollution, including passive smoking

34. Risk factors, cont. Modifiable Risk Factors
cigarette smoking, high cholesterol and high blood
Pressure, lack of exercise, diabetes, obesity, alcohol,
certain infections and inflammation, estrogens,
androgens, and certain psychosocial factors.

35. Risk factors for CVD in Palestine
There is little published information on the cardiovascular disease risk factors of Palestinian population.
A study done to identify the most common coronary heart disease risk factors among adult population in Gaza Strip to develop preventive health education and health promotion programs

36. This study showed that the most common identified CHD risk factors were physical inactivity 53%, hypertension and obesity 43% for each, family history 38%, diabetes mellitus 34%, high LDL 34%, elevated cholesterol level 33%, smoking 29%, low HDL 27%, hyperuricemia 25%, and elevated triglycerides level 14%

37. The result of previous study seems to be that most of the identified CHD risk factors could be preventable.
These results may highlight the problem as a public in nature that need community-based intervention programs integrated to health education programs.

38. Global Burden of Cardiovascular Disease
Cardiovascular disease is the number one cause of death globally and is projected to remain the leading cause of death.
An estimated 17.5 million people died from cardiovascular disease in 2012, representing 31% of all global deaths.
Of these deaths, 7.4 million were due to heart attacks and 6.7 million were due to stroke. 38

39. Statistics, cont
Around 82% of these deaths occurred in low and middle income countries .
If appropriate action is not taken, an estimated 20 million people will die from cardiovascular disease every year, mainly from heart attacks and strokes.
People with cardiovascular disease or who are at high cardiovascular risk need early detection and management using counselling and medicines, as appropriate. 39

40. Cardiovascular disease in Palestine
Cardiovascular disease (CVDs), principally heart diseases is the first leading cause of death among population in Palestine in the year 2005 exactly as it is in the whole world.

41. There are no available data to suggest the overall prevalence or incidence of cardiovascular disease and hypertension, we depend on mortality data from the different health centers to estimate the impact of theses diseases on society. finish

42. Diabetes Mellitus

43. Definition of DM
Diabetes is a chronic disease that occurs when the pancreas does not produce enough insulin, or alternatively, when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar

44. Glucose Tolerance Categories
FPG
2-hr PG on OGTT
mg/dL
mg/dL
126
Diabetes Mellitus
200
Diabetes Mellitus
100 and <126
Prediabetes
140 and <200
Prediabetes
Glucose
Tolerance
<100
Normal
<140
Normal
Slide 6
Glucose Tolerance Categories
Normal and abnormal glucose levels are defined here
FPG <110 mg/dL and a 2-hour plasma glucose (PG) <140 mg/dL following glucose challenge are normal
FPG between 110 and 126 mg/dL is now defined as a category of impaired glucose, while the 2-hour plasma glucose challenge levels between 140 and 199 mg/dL are defined as impaired glucose tolerance
3 principal criteria have been cited by the ADA to signify the presence of diabetes mellitus, and results from each must be confirmed by repeat testing on a subsequent day
Symptoms of diabetes and a casual plasma glucose 200 mg/dL
FPG 126 mg/dL
2-hour plasma glucose 200 mg/dL during an OGTT
Casual plasma glucose is measured without regard to the time of the last meal
Measurement of FPG requires no caloric intake for 8 hours. This test is recommended for routine clinical use
Once diagnosis is confirmed, A1C, which provides a measure of average blood glucose level over the preceding 2 to 3 months, is used to help monitor glycemic control
The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2002;25:S5
The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2002;25(suppl):S5

45. Etiologic Classification of Diabetes Mellitus
b-cell destruction with lack of insulin
Type 1
Insulin resistance with insulin deficiency
Type 2
Genetic defects in b-cell exocrine pancreas diseases drug- or chemical induced, and other rare forms
Other specific types
Insulin resistance with b-cell dysfunction
Gestational
Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:

46. Complications of Diabetes
Macrovascular
Microvascular
Brain
Cerebrovascular disease
Transient ischemic attack
Cerebrovascular accident
Cognitive impairment
Eye
Retinopathy
Cataracts
Glaucoma
Heart
Coronary artery disease
Coronary syndrome
Myocardial infarction
Congestive heart failure
Kidney
Nephropathy
Microalbuminuria
Gross albuminuria
Kidney failure
Extremities
Peripheral vascular disease
Ulceration
Gangrene
Amputation
Nerves
Neuropathy
Peripheral
Autonomic

47. Epidemiology
Diabetes is in the top 10 and perhaps the top 5 of the most significant diseases in the developed world.
"Diabetes is a major threat to global public health that is rapidly getting worse, and the biggest impact is on adults of working age in developing countries. At least 171 million people worldwide have diabetes. This figure is likely to more than double by 2030 to reach 366 million."

48. GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC: 2003-2030 (millions)
World
2003 = 194 million
2030 = 366 million
Increase 75%

49. Prevalence of DM in Palestine
The prevalence of DM in Palestine is about 9% in It is around the reported prevalence rate in Egypt and Tunisia (9%) and less than in Saudi Arabia (12%) and Oman (13%).
Palestinian diabetes mellitus prevalence estimated by the model (for adults aged 25 or more) was 9.7% in 2000, increasing to 15.3% by 2010 (BMJ Open, 2013).

50. Diabetes prevalence projections
The forecasts were 20.6% for 2020 and 21.5% for 2030.The estimated number of patients with diabetes is expected thus to reach 215 000 in 2015, 289 000 in 2020 and 444 000 in 2030 (BMJ Open, 2013).

51. Diabetes prevalence forecasting between 2000 and 2030.
Niveen M E Abu-Rmeileh et al. BMJ Open 2013;3:e003558
©2013 by British Medical Journal Publishing Group

52. The gap between the expected prevalence rates of DM and cases under supervision reflects under registration and underreporting and also requires special efforts to accelerate early case finding activities in order to avoid high cost of treating the complications and disability consequences of the disease.

53. Major risk factors Family history Obesity Age (older than 45)
History of gestational diabetes
High cholesterol
Hypertension

54. Prevention of effects combination approach
Increased exercise
Decreases need for insulin
Reduce calorie intake
Improves insulin sensitivity
Weight reduction
Improves insulin action

55. Triad of Treatment Diet Medication Exercise Oral hypoglycemics
Insulins
Exercise

56. Diet Lower calorie Fewer foods of “high glycemic index”
Spread meals evenly

57. Diabetic Meal Plan Using the Food Guide Pyramid

58. Anti-Diabetic medications
Oral hypoglycemic agents
Insulin

60. Thanks …