RISK FACTORS AND DETERMINANTS OF NCD SRI LANKAN PERSPECTIVE DR.THILAK SIRIWARDANA DIRECTOR NON-COMMUNICABLE DISEASES MINISTRY OF HEALTH,NUTRITION & INDIGENOUS MEDICINE SRI LANKA
SRI LANKA POPULATION 21,446,000 AREA sq km 65,610 PROVINCES 09 DISTRICTS 26 ADMINISTRATIVE CAPITAL SRI JAYAWARDANAPURA COMMERCIAL CAPITAL COLOMBO PER CAPITA INCOME US$ 3631 URBAN POPULATION 18% Source http://data.un.org/countryprofile
DEFINITIONS A risk factor is any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury (NCD) http://www.who.int/topics/risk_factors/en/ The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system shaped by the distribution of money, power and resources - influenced by policy choices http://www.who.int/topics/social_determinants/en/
NCD are considered as a Health and Development Challenge in Sri Lanka Greater exposure to the four main risk behaviours Differences in exposures to risk behaviours and access to health services can be traced to inequities and further traced to underlying social, economic, political, environmental and cultural factors (and policy choices) NCDs are not simply a matter of personal responsibility.
The four main NCDs and their shared risk behaviours
Version of CSDH (Commission on Social Determinants of Health) frame work Source: Addressing the Social Determinants of Non-communicable Diseases UNDP
Tobacco use Harmful use of Alcohol Unhealthy Diet Physical Inactivity Income & Income distribution X X X X Education X X X X Unemployment X X X X Housing X X X X Social exclusion X X X X Social support X X X X Social gradients X X X X Transport X X X X
Tobacco production in Sri Lanka 20000 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 Metric Tones http://faostat3.fao.org/home/index.html#download
Tobacco Use http://www.adicsrilanka.org/wp-content/uploads/2013/02/sri-lanka-country-facts
Prevalence of Smoking in Sri Lanka higher among males than females 22.8% vs <1% (Sri Lanka STEPs survey 2008) Smoking was much higher in males than in females - 38.0% vs 0.1% Health May 10, 2010) (Katulanda et.al. Asia Pac J Public Prevalence of current smoking (smoking) in Sri Lanka was 18.3%, 17.2%, and 18.5% in overall, urban and rural respectively (Katulanda et.al. Asia Pac J Public Health May 10, 2010) Sri Lanka STEPs survey 2014/15 - awaiting results???
Import Quantities of Undenatured ethyl alcohol > 80% by volume to Sri Lanka 30000000 25000000 alcohol in litres 20000000 15000000 10000000 5000000 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 http://data.un.org/data.aspx?q=ethyl+alcohol+sri+lanka
Liquor production 2005-2014 140 120 100 80 60 40 20 Hard liquor Quantity by Proof Litres. - Millions Malt liquor(beer) Quantity by Bulk Litres Millions 0 Performance Report 2014- Sri Lanka Excise Department
Alcohol per Capita (15+) consumption (in litres of pure alcohol) (world Health Organization 2014) Average 2003-2005 Recorded 1.8 2.2 Average 2008-2010 Unrecorded 0.4 1.5 Total 2.2 3.7 WHO South Asia Region 2.9 3.5
Prevalence of Alcohol drinking higher among males than females 26% vs 1.2% (Sri Lanka STEPs survey 2008) The prevalence of current drinking and past drinking among males and females were 46.9% vs. 1% (Karunaratne, KGNS et.al. Sri Lanka Medical Association - 121st Annual Scientific Sessions ; 2008_.27pp) Prevalence of current drinkers were 39.6% among males and 2.4% among females (L C Somatunga et.al. Journal of the Postgraduate Institute of Medicine 2014;1(1):E7:1-12) Sri Lanka STEPs survey 2014/15 - awaiting results???
Physical activity Physical Inactivity STEPs survey 2007, NCD unit, Ministry of Health Low levels of Activity, Defined as <600 MET minutes per week Both Sexes Sri Lanka STEPs survey 2014/15 - awaiting results??? Male Female 25 17.9 31.9
Physical Inactivity Sri Lanka Diabetes and Cardiovascular Study. Katulanda et.al. 2013 Sep Males had a significantly higher weekly total MET minutes than females Rural adults were significantly more active than urban adults Tamils had the highest mean weekly total MET minutes Those with tertiary education had lowest mean weekly total MET minutes Female gender, older age, urban living, Muslim ethnicity and tertiary education significant predictors Associated with obesity, diabetes, hypertension and metabolic syndromes.
Fruit and Vegetable production (Ministry of Agriculture Sri Lanka) Fruit production 2011/2012 Maha session is 4,89,653 metric tons Vegetable production 2011/2012 Maha session is 3,91,545 metric tons
Fruit &Vegetable Consumption STEPs survey 2007, NCD unit, Ministry of Health Consumption Both Male Female Sexes Ate less than 5 of combined servings of fruits & vegetables /day 82.4 81.4 83.3
Sugar consumption in Sri Lanka http://www.statistics.gov.lk/agriculture/indices/percapita.html#sugar1 35 30 Per Capita availability Kg/Yr (Local production+import) 25 20 15 10 5 0 1998 1999 2000 2001 2002 2003 2004 2005 2006
Salt production and Consumption www.deephe.com Annual average Production Industrial purposes 150,000 Metric tons 30,000 Metric tons Per capita consumption (average) Per Capita consumption per day (average) Assumption : No salt imported or exported 5.6 Kg 15.5gm
Dietary Fat Consumption
Sri Lankan food Consumption (1980-2010) http://indi.ca/2011/10/how-sri-lankans-get-their-eat-on-food-consumptionexpenditure What Sri Lankans are eating Still mainly rice and coconut milk curries
Industrialization Industrial Estates
Gross National Product by Industrial Origin at Current Prizes Central Bank of Sri Lanka Annual Report 2014 3,500,000 3,000,000 Rupees in Millions 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 2010 2011 2012 2013(a) 2014(b)
Census years Urban Growth in Sri Lanka 1871-2012 Urban Population Annual Average Growth Rate of Urban Population % No of Towns Level of Urbanization 1871 260,376-19 10.8 1881 281,065 0.8 20 10.2 1891 321,413 1.2 20 10.7 1901 414,046 2.9 28 11.6 1911 537,666 3.1 37 13.1 1921 631,871 1.7 42 14.2 1931 737,273 3.4 42 15.0 1946 1,023,044 1.9 42 15.4 1953 1,239,133 2.1 43 15.3 1963 2,016,285 6.2 99 19.1 1971 2,848,116 4.1 135 22.4 1981 3,192,489 1.2 134 21.5 2001 2,467,171 1.0 45 13.1 2012 3,704,470 0.6 56 18.2 Department of Census and Statistics
Level of Urbanization by Province Department of Census and Statistics
Trade Liberalization & Foreign Investment Impact on consumers Impact on producers Impact on local food processors Impact on Food Culture
Mortality from Hypertension, IHD, Diabetes and Malignant Neoplasms by Socio Economical status in Sri Lanka 1999-2003, Ravi P. Rannan-Eliya et.al Institute of Health Policy
FOOD POLICY Free food programme Food stamp programme Public food grain distribution programme Janasaviya programme Samurdhi programme
INTELLECTUAL PROPERTY LAWS Effects on Drug prices as in India But not easy to control
Typology of multi-sectoral action on NCDs SOURCE Addressing the Social Determinants of Non-communicable Diseases - UNDP
Expanding delivery Platform HLC/Mobile/Workplace screening program Healthy Army Healthy Nation program and in navy and air force Health promotive villages, schools, institutions etc Inter ministerial/departmental program on NCD prevention Jogging tracks with low cost open space gyms Gymnasiums and physical activity programs in ministries, departments
NCD-specific actions on social determinants Ratifying FCTC, passing NATA act, School canteen policy & healthy canteen guidelines Placing alcohol outlets away from religious places and schools Ban smoking/drinking in public places and sale of tobacco to persons below 21 years Tobacco taxes 70% of value of the cigarettes, Tobacco warnings & pictorial messages on packaging Circulars on healthy eating/serving in health institutions, restaurants, canteens etc Healthy life style centres Islandwide Decisions on national BMI cut off points voluntary inclusion of traffic light signs
NCD-sensitive actions on social determinants Education for all free education Agra-Hara insurance program CSR programs of private sector organizations Cycling tracks in new roads Non-promotion of escalator use for energy conservation Samurdhi poverty reduction program National food production programme 2016/2018 Health in Other Policies