Global overview of Non- Communicable Diseases (NCDs)

Faculty of Medicine الصحة العامة (31505291) Health Public Lecture 15 Global overview of Non- Communicable Diseases (NCDs) By Hatim Jaber MD MPH JBCM PhD 25-7-2018 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 09:15 to 09:25 Current trends an occurrence of global NCDs 09:25 to 09:35 Current trends an occurrence of global NCDs 09: 35 to 09:40 Risk factors associated with NC global diseases. 09:40 to 09:50 Aging populations and chronic illness 09:50 to 10:15 Basic principles and policies for prevention and control at global level

Trends in Global Deaths 2002-30 Source: World Health Statistics 2007

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] 5

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.

Distribution of deaths in the world by sex, 2004 12 GBD report 2004 update, 2008

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. 13

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.

Global status report on noncommunicable diseases (April 2011 the World Health Organization (WHO) ) 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. Behavioral risk factors, including tobacco use, physical inactivity, and unhealthy diet, are responsible for about 80% of coronary heart disease and cerebrovascular disease. 15

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 noncommunicable disease will account for 73% of all deaths GBD 2004 Update, 2008 16

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% 17

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. 18

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

Mortality rates among men and women aged 15 59 years, region and cause-of-death group, 2004 GBD report 2004 update, 2008 22

Projected global deaths for selected causes, 2004 2030 23 GBD report 2004 update, 2008

Noncommunicable diseases: country income 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 highincome countries reporting the proportion of NCD deaths to total deaths to be more than 70%. 24

Noncommunicable diseases: Current status and trends in risk factors 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%). 25

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 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. 28

Noncommunicable diseases: parameters for estimation of behavioral and metabolic risk factors 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. 29

Noncommunicable diseases: parameters for estimation of behavioral and metabolic risk factors 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). 30

PREVENTION OF NONCOMMUNICABLE DISEASES: A GLOBAL PERSPECTIVE

Noncommunicable diseases: Prevention and Control of NCDs 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. 32

Noncommunicable diseases: The six objectives of the 2008-2013 Action Plan are: 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 33

Noncommunicable diseases: The six objectives of the 2008-2013 Action Plan are: 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 34

First global ministerial conference on healthy lifestyles and noncommunicable disease control 28-29 April 2011, Moscow, the Russian Federation 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 35

What are the main noncommunicable diseases? Heart disease and stroke Cancer Diabetes Chronic respiratory disease

NCDs and risk factors Lifestyle diseases caused by behaviors

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

NCD deaths as a proportion of all deaths, 2012 Source: WHO Global Health Estimates 2014 (Year: 2012), Deaths by age group 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 NCDs and nutritional conditions Infectious and parasitic diseases, respiratory infections Maternal and neonatal conditions Injuries

NCDs are not a "rich country" problem The proportion of people who die prematurely from NCDs is highest in poorest countries Low-income Lower middle-income Upper middle-income High-income 0 10 20 30 40 50 60 70 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

NCDs included in the 2030 Agenda for Sustainable Development

Why are NCDs relevant to SDGs? Rio+20: The SDGs can only be achieved in the absence of NCDs 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)

percentage Why are NCDs relevant to development? NCDs lead to impoverishment from long-term treatment and care costs Cancer 60 50 40 30 20 10 0 No cancer Catastrophic expenditures Impoverishment NCDs lead to high burden of disease, low quality of life and lost human potential

NCDs in SDG 3 Ensure healthy lives and promote well-being for all at all ages Target 3.3 By 2030, end the epidemics of HIV, TB and malaria3 Target 3.4 By 2030, reduce by one third premature mortality from NCDs and promote mental health and well-being Target 3.5 Strengthen the prevention and treatment of substance abuse, including harmful use of alcohol Target 3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents Target 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all Target 3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination Target 3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate Target 3.b Support the research and development of vaccines and medicines for the NCDs that primarily affect developing countries

2030 Agenda for Sustainable Development By 2030: Target 3.4: Reduce by one third premature mortality from NCDs by prevention, treatment and promoting mental health and wellbeing Target 3.a: Implement the WHO tobacco treaty Target 3.5: Reduce the harmful use of alcohol

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

WHO Global NCD Action Plan 2013-2020 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

10 Progress Monitoring Indicators 1 Adoption of national NCD targets and indicators 2 Mortality data 3 Risk factor surveys 4 National integrated NCD strategy/action plan 5 Tobacco demand-reduction measures taxation smoke-free policies health warnings advertising bans

10 Progress Monitoring Indicators 6 8 7 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 9 Guidelines for the management of major NCDs 10 Drug therapy/counselling for high-risk persons

Global Strategy on Diet, Physical Activity and Health 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/

WHO Toolkit on Salt Reduction

WHO Commission on Ending Childhood Obesity who.int/end-childhood-obesity/final-report

WHO brings diabetes into the public eye World Health Day - 22 March 2016 http://www.who.int/campaigns/world-health-day/2016/en

Evidence on alcohol and health 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)) Properties of ethanol : Psychoactive and intoxicating Toxic with high mortality in overdoses Carcinogenic Dependence-producing

% 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/ 56

Odds Ratio of Myocardial Infarction Risk of myocardial infarction increases with every single cigarette smoked per day INTERHEART study 52 countries 12 461 cases, 14 637 controls Never 1-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16 17-18 19-20 >=21 Number of cigarettes smoked per day 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. 57

Pseudo science "medical science" "a longer, healthier life thank your doctor for that" "Doctors" "three outstanding independent research organisations" "nationwide survey" "T-zone test"

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

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 60

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 63

Age standardised mortality per 100,000 Trends in stomach cancer mortality Source : WHO HFA database 64

Helicobacter pylori bacterium - a causal factor for stomach cancer 65

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 66