1. Non-Communicable Disease: Epidemiology, Prevention & Control
Ahmed Mandil, Hafsa Raheel
Dept of Family & Community Medicine
KSU College of Medicine

2. Objectives By the end of the session students should be able to;
Appreciate the burden of NCDs globally, regionally, and in the Kingdom of Saudi Arabia
Enlist the risk factors for NCDs
Understand the concept and application of primary, secondary, and tertiary prevention with regard to NCDs
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3. Definitions (I)
Chronic health-related state: a state which lasts for a long time, usually more than 3 months
Chronic exposure:prolonged (long term), usually of low intensity.
Chronic diseases: those diseases that have uncertain etiology, multiple risk factors, a prolonged course, do not resolve spontaneously, and for which a complete cure is rarely achieved.
Non-communicable diseases (NCD): a miscellaneous group of health-related conditions, usually not communicated through infective pathogens, and may cause impairment, disability, handicap or even premature death.
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4. Defintions (II)
Risk factor: an aspect of personal behavior / life-style, an environmental exposure, an inborn / inherited characteristic, which on the basis of epidemiologic evidence, is known to be associated with health-related condition(s) considered important to prevent.
Modifiable risk factor: a determinant that can be modified by intervention, thereby reducing the probability of occurrence of disease or other specified outcomes.
Latent period: delay between exposure to a disease-causing agent and the appearance of manifestations of the disease. E.g. after exposure to ionizing radiation, there is a latent period of 5 years, on the average, before development of leukemia, and > 20 years before development of certain other malignancies.
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5. Definitions (III): Exceptional NCD
Some NCD were recently proven to be of infectious origin, e.g. peptic ulcer (Helicobacter pylori), liver carcinoma (HCV), cancer cervix (Human Papilloma Virus), leukemia (oncogenic viruses), etc.
The term chronic may not apply to conditions as: angina pectoris, Acute Myocardial Infarction (AMI), anxiety, acute depression
Some infectious diseases are chronic: e.g. T.B., HIV / AIDS
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6. NCD Examples (I) Congenital anomalies
Malnutrition (pediatric, geriatric)
Endocrinal / metabolic disorders (e.g. diabetes, gout)
Cardiovascular diseases (e.g. hypertension; atherosclerosis; ischemic heart disease [IHD]: angina, myocardial infarction) .
Locomotor system problems: e.g. arthritis (acute, chronic)
Chronic respiratory conditions (e.g. bronchial asthma)
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7. NCD Examples (II)
Occupational-related conditions (e.g. pneumoconiosis)
Neoplasms (benign / malignant; childhood / adult)
Injuries (intentional / non-intentional)
Sensory loss (e.g. deafness, blindness)
Diseases of senescence (degenerative diseases)
Psychiatric disorders (neuroses, psychoses)
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8. misconceptions
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9. Reality: chronic diseases are concentrated among the poor
8. Reality: In all but the least developed countries of the world, the poor are much more likely than the wealthy to develop chronic diseases, and everywhere are more likely to die as a result. Moreover, chronic diseases cause substantial financial burden, and can push individuals and households into poverty.
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10. Reality: almost half in people under age 70
7.Reality: Almost half of chronic diseases occur prematurely, in people under 70 years of age. One quarter of all chronic disease deaths occur in people under 60 years of age.
In low and middle income counties, middle-aged adults are especially vulnerable to chronic diseases. People in these countries tend to develop disease at younger ages, suffer longer – often with preventable complications – and die sooner than those in high income countries.
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11. Reality: chronic diseases affect men and women almost equally
6. Reality: Chronic diseases, including heart disease, affect women and men almost equally.
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12. Reality: 80% of premature heart disease, stroke and type 2 diabetes is preventable, 40% of cancer is preventable
4. Reality: the major causes of chronic diseases are known, and if these risk factors were eliminated, at least 80% of all heart disease, stroke and type 2 diabetes would be prevented; over 40% of cancer would be prevented.
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13. Reality: inexpensive and cost-effective interventions exist
3. Reality: a full range of chronic disease interventions are very cost-effective for all regions of the world, including sub-Saharan Africa. Many of these solutions are also inexpensive to implement.
The ideal components of a medication to prevent complications in people with heart disease, for example, are no longer covered by patent restrictions and could be produced for little more than one dollar a month.
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14. Magnitude of the problem
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15. Magnitude of the Problem (I)
NCD are considered the leading causes of death and disability on a global scale, (for at least the last two decades of the 20th century).
Disease rates (morbidity and mortality) from these conditions are accelerating globally, advancing across regions and social classes
Special burden in less developed nations.
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16. Magnitude of the Problem (II)
Among the many NCDs that contribute importantly to the global burden of disease, disability and death, cardiovascular disease (CVD), cancer, diabetes and chronic respiratory diseases are four of the most prominent. These four conditions are linked by common lifestyle determinants such as imbalanced diet, physical inactivity and tobacco consumption. They together contribute to 50% of global mortality. NCD are expected to account for an increasing share of disease burden, rising globally from 43% in 1998 to 73% by The expected increase is likely to be particularly rapid in less developed nations.
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17. The Regional Situation
The WHO Region for the Eastern Mediterranean, NCD - 52% of all deaths and 47% of the disease burden in EMR during the year 2005
This burden is likely to rise to 60% in the year 2020
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18. Chronic Diseases result in
percent of deaths 4 52
EMR Adult Population
Cardiovascular
Chronic Respiratory
Disease
Type 2 Diabetes
Cancer
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19. Risk factors
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20. NCD Causal Pathway
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21. Risk Factors (I) Aging of the population
Use of motor vehicles (automobiles)
Life-style changes
Poor / unbalanced / unhealthy nutrition
Tobacco consumption / addiction
Physical inactivity
Harmful use of alcohol consumption
Obesity
Other social and behavioral factors.
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22. Risk factors (II) Modifiable Non-Modifiable Cigarette smoking
High Blood pressure
Elevated serum Cholesterol
Diabetes
Life style changes (dietary patterns, physical activity)
Stress factors
Alcohol abuse
Non-Modifiable
Age
Sex
Family Hx
Genetic factors
Personality?
Race
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23. Risk factors (III): EMR
Tobacco use %
Hypertension %
Diabetes %
Overweight-obesity 40-70%
Dyslipidemia %
Physical Inactivity %
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24. Sources of NCD Data Mortality statistics
Hospital records (especially discharge)
Disease registries (e.g. cancer / diabetes / hypertension registries)
Interview surveys
Occupational medical records
Sickness and disability insurance statistics
Drugs' dispensing statistics (prescribed, over-the-counter)
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25. Prevention & control
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26. NCD Prevention and control (I)
Goals:
To reduce disease incidence
To prevent / delay onset of disability
To alleviate severity of disease
To prolong the individuals’ life
(Inshaa-Allah)
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27. NCD Prevention and control (II)
Important issues:
One of the most important objectives of NCD control is the change of the public's perception of NCD from one of "inevitability" to that of "preventability".
NCD control is based on avoidance of the most important risk factors (e.g. tobacco addiction, physical inactivity, poor nutrition), all of which are behavioral factors, often difficult to change.
Healthy behaviors should be promoted early on in life through comprehensive school health education and efforts to change behavior in children and young people.
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28. NCD Prevention and control (III)
Primary prevention
Population Strategy
High Risk strategy
Secondary prevention
Tertiary prevention
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29. Population strategy Health promotion & education
Behavioral changes: balanced healthy diet, tobacco control, physical activity, weight reduction, especially children & adolescents
Blood pressure control
Self care
Stress management
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30. High Risk approach
Identify high risk people and families, e.g. those with family history with an NCD (e.g. DM, hypertension); high serum cholesterol, etc
Providing specific advice: helping them to exercise, reduce weight, diet control, etc
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31. NCD Prevention and control: (III) Primary prevention
Directed at susceptible persons, before they develop a certain NCD, thus aims at reducing incidence.
Needs establishment of risk factors, before-hand (community-specific).
Examples: tobacco prevention programs, promotion of physical activity, dietary recommendations (for balanced diets suitable for age, gender, physical activities, growth & development, weather, community).
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32. NCD Prevention and control: (IV): Secondary prevention
Directed at asymptomatic individuals, but have developed biological changes resulting from the disease, thus aims at reducing prevalence.
Goal: early detection, management, avoiding / reducing undesirable consequences / complications.
Examples: screening programs (e.g. for diabetes, hypertension, cancer), recommended when: natural history permits early detection, available screening tests for early detection, acceptable to the population at risk; effective management regimens
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33. NCD Prevention and control: (V): Tertiary prevention
Directed at preventing disability in people who have symptomatic disease, thus aims at trying to improve quality of life.
Goal: prevention of progression of a disease and its complications; provision of rehabilitation.
Examples: screening for / management of diabetic complications (e.g. retinopathy); orthopedic prosthesis (e.g. for fracture-hip); physiotherapy (e.g. for cardiovascular stroke / paralysis / sports injuries’ victims)
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34. References 1
Last J. A dictionary of epidemiology. 5th Edition. Oxford, New York, Toronto: Oxford University Press, 2008.
Remington PL, Brownson RC, Wegner MV. Chronic disease epidemiology and control. 3rd Edition. Washington, D.C.: American Public Health Association, 2010.
WHO Action Plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases. Geneva: WHO, 2008
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35. References 2
Fadhil I. Diabetes and other non-communicable diseases: An Eastern Mediterranean Perspective. WHO, 2009
Kuh D, Ben Shlomo Y. A life course approach to chronic disease epidemiology. Oxford, New York, Toronto: Oxford University Press, 1997.
Newcomer RJ, Benjamin AE. Indicators of chronic health conditions. Baltimore, London: The Johns Hopkins University Press, 1997.
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