Non-communicable diseases (NCDs)

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.

Approximately, 17 million people die prematurely each year as a result of the global epidemic of chronic diseases

The risks of high blood pressure and high blood cholesterol, tobacco and excessive alcohol consumption, obesity and physical inactivity were more commonly associated with affluent societies.

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.

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

In its 2003 annual report, MOH stated that it considers (NCDs), caused by unhealthy diets and habits, to be just as serious as those caused by under-nutrition

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, whole grain foods, and complex carbohydrates has lead to the increased prevalence of these illnesse.

Keeping in mind the current situation of health services and the increasing level of poverty, there should be a special concern of disability related to NCDs.

Health services today will not be able to meet the challenges of (NCDs) In Palestine

No or weak national data is available on the overall incidence and prevalence ofNCDs.

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 and DM in specific.

This lack of information leads to:- Inability to estimate the direct and indirect cost; resources required

e.g. drugs, policy; and decision making regarding prevention and treatment

Some Continuing Challenges Lack of national policies for NCD prevention and control

Low resources - only 1/3 of countries have a budget line for NCD prevention & control.

Lack of NCD surveillance systems

Fragmented and uncoordinated care

PHC capacity to deal with NCDs is poor

…

NCD CHALLENGES

Cost PressuresDisease burden, interventions, drugsQuality of CareCare teams, medical records, QIP & financial incentivesPreventionFragmentation, lack of protocols, lack of financial incentives/supportPoverty

CHANGES NEEDED

Comprehensiveness With policy/legislation

support Coordination

Information flows Continuity

Organized Care Communication

Orient. on self management

Community linkages

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)

Obesity

Obesity is a condition in which people have an excess of body fat.

According to (CDC), the prevalence of obesity in the U.S more than doubled between the years 1960 and 2000, with the greatest increase from 1980 forward.

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

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.

ClassificationObesity, in absolute terms, is an increase of body adipose tissue (fat

tissue) mass .BMIBody mass index or BMI is a simple and widely used method for estimating body fat mass. BMI was developed in the 19th century by the Belgian statistician

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

BMIClassification

Less than 18.5underweight

18.5–24.9normal weight

25.0–29.9 isoverweight

30.0–34.9 isclass I obesity

35.0–39.9class II obesity

Questions?? Questions??

The surgical 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 Gabriel I Uwaifo (June 19, 2006). "Obesity". Retrieved on

2008-09-29.

Cancer

Cancermedical 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).

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.

2006 Estimated US Cancer Deaths*

ONS=Other nervous system.Source: American Cancer Society, 2006.

Men291,270

Women273,560

26%Lung & bronchus

15%Breast

10%Colon & rectum

6% Pancreas

6%Ovary

4%Leukemia

3%Non-Hodgkin lymphoma

3%Uterine corpus

2%Multiple myeloma

2%Brain/ONS

All other sites 23%

Lung & bronchus 31%

Colon & rectum 10%

Prostate 9%

Pancreas 6%

Leukemia 4%

Liver & intrahepatic 4%bile duct

Esophagus 4%

Non-Hodgkin 3% lymphoma

Urinary bladder 3%

Kidney 3%

All other sites 23%

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Hypertension

The Silent killer

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DefinitionHypertension is high blood pressure. Blood pressure is the force of blood pushing against the walls of arteries as it flows through

them .

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Classification of hypertension :Essential ( primary ) Hypertension : It indicates that no specific medical cause can be found to explain a patient's condition, from the patients diagnosed with hypertension, 95% fall in the category of essential (or idiopathic) hypertension. Secondary Hypertension : Indicates that the high blood pressure is a result of (i.e. secondary to) another condition, such as kidney disease or tumors, 5% will fall in the category of secondary hypertension.

Risk factors for hypertension include:

ModifiableBody weightSodium chloride intakeAlcohol intakePhysical activityPsychosocial factorsSocio-economic statusHormonal contraceptives

Non-modifiableAgeSex/genderHeredityEthnicity/race

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Global burden of hypertension

The biggest increase in prevalence was expected to be in developing (increase of 24%) and third world countries (increase of 80%) as the rapidly take on the more western lifestyle.Scientists are now claiming that 1 in 3 adults in the world will have high blood pressure in 2025. By 2025, the number will increase by about 60% to a total of 1.56 billion as the

proportion of elderly people will increase significantly .

Kearney PM et al. Lancet 2005; 365:217-223.

Prevalence of hypertension can differ according to gender and age.

Men are at increased risk for high blood pressure as compared to women until the age of 55. After 55, there is a higher percentage of women at risk for high blood pressure.

High blood pressure is 2 to 3 times more common in women taking oral contraceptives, especially in obese and older women, than in women not taking them.

64% of men over 75 years old have hypertension.

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77% of women over 75 years old have hypertension.

Older females have a significant risk of developing high blood pressure. More than 50% of women over age 60 have high blood pressure. 

African-Americans who live in the United States have the highest prevalence of hypertension in the world. ( WHO )

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Hypertension affects 65 million adults in the United States. The prevalence of hypertension is higher at the older ages.

In USA

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In PalestineIn Palestine, no or weak national data are available on the overall incidence and prevalence of cardiovascular diseases (CVD), hypertension diseases, Diabetes Mellitus (DM) and accidents.In general we depend on mortality data to estimate the impacts of these diseases. The current system counts mainly the visits of the patients to PHC, which does not reflect the real prevalence or incidence. Besides, there is no classification by age or gender mainly because of no computerized system.

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Population pyramid for 2004

•Total population: 3,638,000 (WB 2,300,000/ GS 1,338,000)

( Demographic Indicators, 2004 ,MOH)

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Hypertension disease Mortality in 2005:

•Hypertension disease is the fifth-leading cause of cardiovascular diseases deaths; 12.9% of the total cardiovascular mortality, with a rate of 13.0 per 100,000.

•Hypertension disease is the eight-leading cause of deaths in total population (4.8%), while it was the ninth leading deaths in males and females (2.7% and 3.8%) of males and females deaths respectively.

Cardiovascular Disease

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.

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 conquered and life expectancy improves.

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).

Definition

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

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.

Risk factors, cont. Environment, your chances can increase because of areas with a

lot of smog or other form of air pollution, including passive smoking.

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.

Risk factors for CVD in Palestine There is little published information on the cardiovascular

disease risk factors of Palestinian population. The study was aim 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

This study shown 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%

Other study conducted by Heart Institute and Epidemiology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, evaluated the coronary risk characteristics of Palestinian and Israeli women with coronary artery disease in Jerusalem. The study finding reflect that Palestinian Arab women in Jerusalem appear to have more diabetes and exhibit lifestyle factors (lower socioeconomic status, suffered more passive smoking and were less physically active) that generally increase the risk for CHD than Jewish women.

The result of previous studies 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.

Risk factors conclusion & recommendation

According to these result greater attention to primary prevention is needed.

These result suggests the need investigate determinants of the metabolic syndrome and the possible role of passive smoking in Arab women as well as modes of intervention via health promotion and risk factor management in this population.

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 2005, representing 30 % of all global deaths.

Of these deaths, 7.6 million were due to heart attacks and 5.7 million were due to stroke.

Statistics, cont Around 80% of these deaths occurred in low and

middle income countries (LMIC). If appropriate action is not taken, by 2015, an

estimated 20 million people will die from cardiovascular disease every year, mainly from heart attacks and strokes. (WHO, 2005)

Percentage breakdown of deaths from cardiovascular diseases

Statistics, cont American Heart Association, 2006.

Estimates for the year 2005 are that 80,700,000 people in the United States have one or more forms of cardiovascular disease (CVD).

• High blood pressure — 73,000,000. • Coronary heart disease — 16,000,000. Myocardial infarction (acute heart attack) — 8,100,000.

Statistics, cont

Angina pectoris (chest pain or discomfort caused by reduced blood supply to the heart muscle) — 9,100,000.

• Stroke — 5,800,000. • Heart Failure — 5,300,000

Over 142,000 Americans killed by CVD in 2004 are under age 65

Statistics, cont

2004 death rates from CVD were 335.1 for white males and 454.0 for black males; for white females 238.0 and for black females 333.6 (Death rates are per 100,000 population.

From 1993 to 2003 death rates from CVD declined 24.7 percent.

Despite this decline in the death rate, in the same 10-year period the actual number of deaths declined only 8 percent.

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. This involves males and females with a proportion of 18.7% and 19.9% respectively of the total number of death in Palestine.

Cardiovascular diseases and stroke are major cause of illness, disability and death in Palestine, which causes an increase in personal, community and health care costs. This really requires a competent plan to address this important and serious issue.

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.

Mortality rate per 100,000 of cardiovascular diseases was:

• All heart diseases 56.8 • Rheumatic HD 0.7

• Ischemic HD 36.4 • Pulmonary HD 1.6

• Other heart diseases 18.1 • CVA 29.8

• Essential hypertension 13

Cardiovascular Disease Mortality Indicator

Statistics

In 2005, 3,799 persons died from cardiovascular diseases (1,956 males and 1,843 females), with a proportion of 36.7% of total deaths, with a rate of101/100,000 population.

Mortality among males was higher than females (51.5% in males and 48.5% in females).

Statistics, cont

Cardiovascular mortalities are ranking as following:

1. All heart diseases (Ischaemic, Rheumatic, Pulmonary and Other Heart diseases), constitute 56.8% of cardiovascular diseases with a rate of 54.4 per 100,000 population

2. Ischaemic heart disease constitutes 37.5% of

cardiovascular diseases with a rate of 35.9 per 100,000 population;

3. Cerebrovascular disease constitutes 24.4% of CVDs with a rate of 23.4 per 100,000 population.

4. Hypertensive disease constitutes 17.4% of cardiovascular diseases with a rate of 16.6 per 100,000 population.

5. Other heart diseases constitutes 17.4% of cardiovascular diseases with a rate of 16.7 per 100,000 population.

Statistics, cont

Mortality rate of all CVD in Palestine,2005 (per 100,000)

Diabetes Mellitus

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

Glucose Tolerance Categories

The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2002;25(suppl):S5

FPG 2-hr PG on OGTT

126

100 and <126

<100

200

140 and <200

<140

GlucosePrediabetes

Normal

Diabetes Mellitus

TolerancePrediabetes

Diabetes Mellitus

Normal

mg/dL mg/dL

Etiologic Classification of Diabetes Mellitus

Type1-cell destruction with lack ofinsulin

Type2 Insulin resistance with insulin deficiency

Other specific typesGenetic defects in -cell exocrine pancreas diseases

drug- or chemicalinduced, and other rare forms

GestationalInsulin resistance with -cell dysfunction

Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197.

BrainCerebrovascular disease

• Transient ischemic attack

• Cerebrovascular accident

• Cognitive impairment

Complications of Diabetes

HeartCoronary artery disease

• Coronary syndrome• Myocardial infarction• Congestive heart

failure

ExtremitiesPeripheral vascular disease

• Ulceration• Gangrene• Amputation

Macrovascular Microvascular

EyeRetinopathyCataractsGlaucoma

KidneyNephropathy

• Microalbuminuria• Gross albuminuria• Kidney failure

NervesNeuropathy

• Peripheral• Autonomic

"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."

GLOBAL PROJECTIONS FOR THE GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC: 2003-2030 (millions)DIABETES EPIDEMIC: 2003-2030 (millions)

WorldWorld 2003 = 194 million2003 = 194 million 2030 = 366 million2030 = 366 million

Increase 75%Increase 75%

Epidemiology In 2000, according to the World Health Organization, at

least 171 million people worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is estimated that by the year 2030, this number will double.

Prevalence of Diabetes mellitus among population above 20 years in 2005 was 11%.(WHO,2006)

Diabetes is in the top 10, and perhaps the top 5, of the most significant diseases in the developed world. (Wikipedia)

According to the American Diabetes Association, approximately 18.3% (8.6 million) of Americans age 60 and older have diabetes. Diabetes mellitus prevalence increases with age. (ADA, 2004).

The National Diabetes Information Clearinghouse estimates that diabetes costs $132 billion in the United States alone every year (Eberhart, MS et al, 2004).

Diabetes frequency is dramatically rising all over the world

The World Health Organization (WHO) estimates that more than 180 million people worldwide have diabetes. This number is likely to more than double by 2030.

In 2005, an estimated 1.1 million people died from diabetes.

Almost 80% of diabetes deaths occur in low and middle-income countries.

The global increase in diabetes will occur because of population ageing and growth, and because of increasing trends towards obesity, unhealthy diets and sedentary lifestyles.

Worldwide, 3.2 million deaths are attributable to diabetes every year.

One in 20 deaths is attributable to diabetes; 8,700 deaths every day; six deaths every minute.

At least one in ten deaths among adults between 35 and 64 years old is attributable to diabetes.

Three-quarters of the deaths among people with diabetes aged under 35 years are due to their condition.

Almost half of diabetes deaths occur in people under the age of 70 years; 55% of In developing countries the number of people with diabetes will increase by 150% in the next 25 years.

In developed countries most people with diabetes are above the age of retirement, whereas in developing countries those most frequently affected are aged between 35 and 64.

WHO projects that diabetes deaths will increase by more than 50% in the next 10 years without urgent action. Most notably, diabetes deaths are projected to increase by over 80% in upper-middle income countries between 2006 and 2015.

In the developed world, diabetes is the most significant cause of adult blindness in the non-elderly, the leading cause of non-traumatic amputation in adults, and diabetic nephropathy is the main illness requiring renal dialysis in the United States.

Estimated number of adults with diabetes by age-group in the world

Estimated number of adults with diabetes by age-group in developed courtiers

Estimated number of adults with diabetes by age-group in developing courtiers

Diabetes in PalestineAccording to WHO global estimate and the epidemic nature of diabetes; prevalence of diabetes is expected to increase in Palestine and figures should be revised to have more realistic estimation which enables health providers to be aware of the size of the problem so more effective health strategies can be adopted.

Prevalence of DM

The prevalence of DM in Palestine was based on a study conducted in 2000 in cooperation with Al Quds University and MOH. The preliminary results indicated that the prevalence DM in Palestine is about 9% in 2000. It is around the reported prevalence rate in Egypt and Tunisia (9%) and less than in Saudi Arabia (12%) and Oman (13%).

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. Also this will give more realistic estimation of the prevalence for appropriate evaluation of the problem.(MOH, 2006)

Prevalence rates of diabetes and hypertension among registered Population 40 years and above by Field, 2005

New cases of Diabetes mellitus in West Bank clinics

In 2005, out of total 2,741 new reported cases of diabetes in the West Bank diabetic clinics, out of them 28.2% was among age group of (55-64), 41.0% among age group of 35-54 years, 6.3% among age less than 35 years, 24.4% among age 65 years and over.

6.30%

41.00%

28.20%24.40%

0

0.1

0.2

0.3

0.4

0.5

less than 34 35-54 55-64 65 and more

New reported cases of D.M. in WB clinics by age 2005

Distribution of diabetic (type II) cases by management in the West Bank health clinic:

1. About 28.6% of diabetics’ cases were managed by insulin treatment.

2. About 5.0% were treated with a combined therapy (insulin and OHA).

3. About 64.7% of diabetics' cases were managed by tablets.

4. Diet control (exclusively managed by lifestyle modification) was 1.7%

Mortality among Palestinian refugee

A total of 2,721 deaths which accounted for 2 per cent of all non communicable disease patients were reported during 2005. 48.2 per cent of them have diabetes and hypertension combined, 36.4 per cent have hypertension and 15.4 per cent have diabetes (UNRWA Annual

Report, 2005) .

Disease-specific mortality rates among reported deaths

Mortality of diabetes mellitusIn Palestine: DM did not report a one of the

10th leading cause of death among Palestinians. It constituted 3.6% of total population deaths. 372 persons died with mortality rate of 10.2 per 100,000 (176 males, with a rate of 9.5 per 100,000 males and 196 females, with mortality rate of 10.9 per 100,000). The average annual mortality rate of DM was 12.4 per 100,000 population in the last five years.

In Gaza Strip: 215 persons died with mortality rate of 16.1 per 100,000 (98 males and 117 females). In West Bank: 157 persons died with mortality rate of 6.8 per 100,000 (78 males and 79 females).

Major risk factors

Family historyObesityAge (older than 45)History of gestational diabetesHigh cholesterolHypertension

Prevention of effects combination approach

Increased exerciseDecreases need for insulin

Reduce calorie intakeImproves insulin sensitivity

Weight reductionImproves insulin action

Triad of Treatment Diet

Medication Oral hypoglycemics Insulins

Exercise

Diet

Lower calorie

Fewer foods of “high glycemic index”

Spread meals evenly

Diabetic Meal Plan Using the Food Guide Pyramid

Anti-Diabetic medicationsOral hypoglycemic agents

Sulfonylureas Thiazolidinediones Biguanides Alpha-glucosidase inhibitors D-phenylalinine derivatives

Insulins

Thanks…