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NON COMMUNICABLE DISEASES
NON COMMUNICABLE DISEASES
NON COMMUNICABLE DISEASES PRESENTED BY: DR RIPIKA SHARMA PG STUDENT DEPATMENT OF PUBLIC HEALTH DENTISTRY
NON COMMUNICABLE DISEASES PRESENTED BY: DR RIPIKA SHARMA PG STUDENT DEPATMENT OF PUBLIC HEALTH DENTISTRY

PRESENTED BY:

DR RIPIKA SHARMA

PG STUDENT

DEPATMENT OF PUBLIC HEALTH DENTISTRY

Contents:

INTRODUCTION

INDIAN SCENARIO

GLOBAL BURDEN OF CHRONIC DISEASES

DEFINATIONS

SURVILLANCE

GAPS IN NATURAL HISTORY OF NCDS

RESOLUTIONS ADOPTED BY WHA

ACTION PLAN FOR GLOBAL STRATEGY FOR PREVENTION AND CONTROL OF NON

COMMUNICABLE DISEASES

RISK FACTORS

COMMON RISK FACTOR APPROACH

GLOBAL STRATEGY FOR PREVENTION AND CONTROL OF NON COMMUNICABLE DISEASES  RISK FACTORS  COMMON RISK
GLOBAL STRATEGY FOR PREVENTION AND CONTROL OF NON COMMUNICABLE DISEASES  RISK FACTORS  COMMON RISK
GLOBAL STRATEGY FOR PREVENTION AND CONTROL OF NON COMMUNICABLE DISEASES  RISK FACTORS  COMMON RISK
GLOBAL STRATEGY FOR PREVENTION AND CONTROL OF NON COMMUNICABLE DISEASES  RISK FACTORS  COMMON RISK
 SOCIAL AND ECONOMIC IMPLICATIONS OF NON COMMUNICABLE DISEASES  PATHWAY ILLUSTRATING THE INCREASED PREVALENCE
 SOCIAL AND ECONOMIC IMPLICATIONS OF NON COMMUNICABLE DISEASES  PATHWAY ILLUSTRATING THE INCREASED PREVALENCE
 SOCIAL AND ECONOMIC IMPLICATIONS OF NON COMMUNICABLE DISEASES  PATHWAY ILLUSTRATING THE INCREASED PREVALENCE

SOCIAL AND ECONOMIC IMPLICATIONS OF NON COMMUNICABLE DISEASES

PATHWAY ILLUSTRATING THE INCREASED PREVALENCE OF NCDS HAS AN IMPACT

ON SES AND HEALTH OUTCOMES.

PREVALENCE OF NCDS HAS AN IMPACT ON SES AND HEALTH OUTCOMES.  Microeconomic, Health System and
PREVALENCE OF NCDS HAS AN IMPACT ON SES AND HEALTH OUTCOMES.  Microeconomic, Health System and

Microeconomic, Health System and Macroeconomic Impact of NCDs in India.

Financing for NCD

Financial impact of NCDs on households

Impact of ncds on health system and GDP

PREVENTION OF NON-COMMUNICABLE DISEASES

WHO BEST BUYS FOR CONTROL OF NON-COMMUNICABLE DISEASES

Cardiovascular diseases

CORONARY HEART DISEASES

STROKE

HYPERTENSION

 Cardiovascular diseases  CORONARY HEART DISEASES  STROKE  HYPERTENSION ORAL HEALTH IMPLICATION
 Cardiovascular diseases  CORONARY HEART DISEASES  STROKE  HYPERTENSION ORAL HEALTH IMPLICATION
 Cardiovascular diseases  CORONARY HEART DISEASES  STROKE  HYPERTENSION ORAL HEALTH IMPLICATION
 Cardiovascular diseases  CORONARY HEART DISEASES  STROKE  HYPERTENSION ORAL HEALTH IMPLICATION

ORAL HEALTH IMPLICATION

 Cardiovascular diseases  CORONARY HEART DISEASES  STROKE  HYPERTENSION ORAL HEALTH IMPLICATION
 Cardiovascular diseases  CORONARY HEART DISEASES  STROKE  HYPERTENSION ORAL HEALTH IMPLICATION
 Cardiovascular diseases  CORONARY HEART DISEASES  STROKE  HYPERTENSION ORAL HEALTH IMPLICATION

Why non communicable diseases are important:

Why non communicable diseases are important:  For most populations, the last century has witnessed the

For most populations, the last century has witnessed the most dramatic improvements in health in history.

Life expectancy at birth has increased from a global average of 46 years in 1950 to 66 years in 1998.

The health status and disease profile of human societies have historically been linked to the level of their economic development and social organization.

With industrialization, the major causes of death and disability, in the more advanced societies, have shifted from a predominance of nutritional deficiencies and infectious diseases, to those classified as degenerative [chronic diseases such as cardiovascular disease (CVD), cancer, and diabetes]. This shift has been termed “the epidemiologic transition.

as cardiovascular disease (CVD), cancer, and diabetes]. This shift has been termed “the epidemiologic transition. ”
as cardiovascular disease (CVD), cancer, and diabetes]. This shift has been termed “the epidemiologic transition. ”

Global burden of

communicable to noncommunicable diseases

(NCDs)

shifted

from

Global burden of communicable to noncommunicable diseases (NCDs) shifted from
Global burden of communicable to noncommunicable diseases (NCDs) shifted from
 NCDs caused an estimated 36 million deaths in 2008. This figure represents almost two
 NCDs caused an estimated 36 million deaths in 2008. This figure represents almost two
 NCDs caused an estimated 36 million deaths in 2008. This figure represents almost two
 NCDs caused an estimated 36 million deaths in 2008. This figure represents almost two
 NCDs caused an estimated 36 million deaths in 2008. This figure represents almost two

NCDs caused an estimated 36 million deaths in 2008. This figure represents

almost two thirds of all deaths globally, with nearly 80% of deaths due to

NCDs occurring in low- and middle-income countries, and approximately 29%

of deaths involving people less than 69 years of age .

The NCD burden is projected to increase disproportionately in lower income countries and populations over the next 10 years .

Current epidemiological evidence indicates that four major NCDs CVD, cancer, chronic respiratory disease and diabetes make the largest contribution to the NCD burden in low- and middle-income countries.

Indian scenario of NCDS  In India alone, rapid changes in the country’s society and
Indian scenario of NCDS  In India alone, rapid changes in the country’s society and
Indian scenario of NCDS  In India alone, rapid changes in the country’s society and
Indian scenario of NCDS  In India alone, rapid changes in the country’s society and

Indian scenario of NCDS

In India alone, rapid changes in the country’s society and lifestyles have

caused NCDs to become responsible for two-thirds of the total morbidity burden and about 53% of total deaths (up from 40.4% in 1990, and expected to increase to 59% by 2015) .

This change is an example of the widespread urbanization that has occurred during the last century.

to 59% by 2015) .  This change is an example of the widespread urbanization that
to 59% by 2015) .  This change is an example of the widespread urbanization that
to 59% by 2015) .  This change is an example of the widespread urbanization that
 In 2004, deaths due to non-communicable diseases in India were twice those from communicable
 In 2004, deaths due to non-communicable diseases in India were twice those from communicable
 In 2004, deaths due to non-communicable diseases in India were twice those from communicable
 In 2004, deaths due to non-communicable diseases in India were twice those from communicable
 In 2004, deaths due to non-communicable diseases in India were twice those from communicable

In 2004, deaths due to non-communicable diseases in India were twice those from communicable diseases.

In 2004, the people of India spent USD9.1 billion out-of pocket on tests, treatments and medical devices to manage their non communicable diseases (equal to 3.3% of India’s GDP for that year and 4 times the total spent by all governments on healthcare.)

As a low-middle income country it is not surprising that India’s expenditure on healthcare is also quite low. In 2007, India spent 4.1% of its Gross Domestic Product (GDP) on health services, only 26% of which was government funding.

 The major risk factors for non-communicable diseases are smoking, alcohol abuse, a sedentary lifestyle,
 The major risk factors for non-communicable diseases are smoking, alcohol abuse, a sedentary lifestyle,
 The major risk factors for non-communicable diseases are smoking, alcohol abuse, a sedentary lifestyle,
 The major risk factors for non-communicable diseases are smoking, alcohol abuse, a sedentary lifestyle,

The major risk factors for non-communicable diseases are smoking, alcohol

abuse, a sedentary lifestyle, and an unhealthy diet. As a result, 40-50% of non-communicable disease-related, premature deaths are preventable.

By 2020, heart disease and stroke will become the leading causes of death and disability worldwide, with the number of fatalities projected to increase to more than 24 million by 2030

The global burden of chronic diseases:

Approximately 58 million death occurred in the year 2005.

Projected main cause of death world wide

2% 10% 8% 33% 14% 33%
2% 10%
8%
33%
14%
33%

comunicable diseases, maternaland perinatal conditions, and nutritional deficiences. cardiovascular diseases cancer chronic respiratory diseases

and perinatal conditions, and

nutritional deficiences.

cardiovascular diseasesand perinatal conditions, and nutritional deficiences. cancer chronic respiratory diseases diabetes other chronic

cancerand nutritional deficiences. cardiovascular diseases chronic respiratory diseases diabetes other chronic diseases

chronic respiratory diseasesand perinatal conditions, and nutritional deficiences. cardiovascular diseases cancer diabetes other chronic diseases

diabetesand nutritional deficiences. cardiovascular diseases cancer chronic respiratory diseases other chronic diseases

other chronic diseasesperinatal conditions, and nutritional deficiences. cardiovascular diseases cancer chronic respiratory diseases diabetes

deficiences. cardiovascular diseases cancer chronic respiratory diseases diabetes other chronic diseases
deficiences. cardiovascular diseases cancer chronic respiratory diseases diabetes other chronic diseases
deficiences. cardiovascular diseases cancer chronic respiratory diseases diabetes other chronic diseases
deficiences. cardiovascular diseases cancer chronic respiratory diseases diabetes other chronic diseases
deficiences. cardiovascular diseases cancer chronic respiratory diseases diabetes other chronic diseases
TERMINOLOGIES
TERMINOLOGIES
TERMINOLOGIES
TERMINOLOGIES
TERMINOLOGIES
TERMINOLOGIES
TERMINOLOGIES
TERMINOLOGIES
TERMINOLOGIES
TERMINOLOGIES
TERMINOLOGIES
EPIDEMIOLOGY  The study of the distribution and determinants of health related states or events
EPIDEMIOLOGY  The study of the distribution and determinants of health related states or events
EPIDEMIOLOGY  The study of the distribution and determinants of health related states or events

EPIDEMIOLOGY

The study of the distribution and determinants of health related states or events in specified population, and the application of this

study to the control of health problems

related states or events in specified population, and the application of this study to the control
related states or events in specified population, and the application of this study to the control
related states or events in specified population, and the application of this study to the control

Definition of Chronic diseases

“An impairment of bodily structure and/or function that necessitates a modification of the patient’s normal life, and has persisted over an extended period of time.

(Euro Symposium 1957)

of the patient’s normal life, and has persisted over an extended period of time. ” (Euro
of the patient’s normal life, and has persisted over an extended period of time. ” (Euro
of the patient’s normal life, and has persisted over an extended period of time. ” (Euro
of the patient’s normal life, and has persisted over an extended period of time. ” (Euro
of the patient’s normal life, and has persisted over an extended period of time. ” (Euro

Definition of Chronic diseases

“comprising of all impairments or deviations from normal which have one or more of the following characteristics :

Are permanent

Leave residual disability

Are caused by non reversible pathological alteration

Require special training of the patient for rehabilitation

May be expected to require a long period of supervision, observation or care.

(Commission on Chronic Illness USA )

May be expected to require a long period of supervision, observation or care. ” (Commission on
May be expected to require a long period of supervision, observation or care. ” (Commission on
May be expected to require a long period of supervision, observation or care. ” (Commission on
May be expected to require a long period of supervision, observation or care. ” (Commission on
 No international definition of what duration should be “long term”  Duration of at
 No international definition of what duration should be “long term”  Duration of at
 No international definition of what duration should be “long term”  Duration of at

No international definition of what duration should be

“long term”

Duration of at least 3 months

 No international definition of what duration should be “long term”  Duration of at least
 No international definition of what duration should be “long term”  Duration of at least
 No international definition of what duration should be “long term”  Duration of at least
NON- COMMUNICABLE DISEASES INCLUDE  Cardiovascular ( hypertension, coronary artery disease, stroke )  Renal
NON- COMMUNICABLE DISEASES INCLUDE  Cardiovascular ( hypertension, coronary artery disease, stroke )  Renal

NON- COMMUNICABLE DISEASES INCLUDE

Cardiovascular ( hypertension, coronary artery disease, stroke )

Renal (nephritis, nephrotic syndrome)

Nervous and mental ( mania, depression)

Musculoskeletal ( arthritis)

Respiratory (asthma, emphysema, bronchitis)

Cancer

Diabetes

Obesity

Blindness

Degenerative disorders

Accidents

emphysema, bronchitis)  Cancer  Diabetes  Obesity  Blindness  Degenerative disorders  Accidents
emphysema, bronchitis)  Cancer  Diabetes  Obesity  Blindness  Degenerative disorders  Accidents
emphysema, bronchitis)  Cancer  Diabetes  Obesity  Blindness  Degenerative disorders  Accidents

DALY

The most widely used measure of burden of diseases is DALY.

Combines number of years of healthy life lost to premature death with time spent in less than full health.

One DALY can be thought of, under a number of conditions, as one lost healthy year of life(Murray and Lopez 1996).

SURVEILLANCE

SURVEILLANCE
SURVEILLANCE
SURVEILLANCE
SURVEILLANCE
SURVEILLANCE
SURVEILLANCE
SURVEILLANCE
SURVEILLANCE
SURVEILLANCE
SURVEILLANCE

Public health surveillance

The term “surveillance” is derived from the French word meaning “to watch over”

In 1968 the 21st World Health Assembly described surveillance as the “systematic collection and use of epidemiologic information for the planning, implementation, and assessment of disease control”; in this sense, surveillance implies “information for action

The distinction between monitoring and surveillance of NCDs is blurred and the terms are often used interchangeably.

Surveillance implies an integrated approach connecting the data to development and evaluation of programmes whereas monitoring is

not always associated with programmes of action.

data to development and evaluation of programmes whereas monitoring is not always associated with programmes of
data to development and evaluation of programmes whereas monitoring is not always associated with programmes of
data to development and evaluation of programmes whereas monitoring is not always associated with programmes of
data to development and evaluation of programmes whereas monitoring is not always associated with programmes of

Surveillance systems are often considered information loops or cycles involving health care providers, public health agencies, and the public

care providers, public health agencies, and the public The cycle is not completed until information about

The cycle is not completed until information about these cases is relayed to those responsible for disease prevention and control and others “who need to know.”

The role of public health surveillance  To detect sudden changes in disease occurrence and
The role of public health surveillance  To detect sudden changes in disease occurrence and
The role of public health surveillance  To detect sudden changes in disease occurrence and

The role of public health surveillance

To detect sudden changes in disease occurrence and distribution

To follow secular (long - term) trends and patterns of

 To follow secular (long - term) trends and patterns of disease  To identify changes
 To follow secular (long - term) trends and patterns of disease  To identify changes

disease

To identify changes in agents and host factors

To detect changes in health care practices

Surveillance is based on a public health agenda, not a research agenda. Data need to be collected in a timely

way and should be of direct relevance to the health needs

of a population.

Active surveillance: a system employing staff members to regularly contact heath care providers or the population to seek information about health

conditions. Active surveillance provides the most accurate and timely information, but it is also expensive.

Passive surveillance: a system by which a health jurisdiction receives reports

submitted from hospitals, clinics, public health units, or other sources. Passive surveillance is a relatively inexpensive strategy to cover large areas, and it provides critical information for monitoring a community’s health. However,

because passive surveillance depends on people in different institutions to

provide data, data quality and timeliness are difficult to control.

 Categorical surveillance: an active or passive system that focuses on one or more diseases
 Categorical surveillance: an active or passive system that focuses on one or more diseases

Categorical surveillance: an active or passive system that focuses on one or more

diseases or behaviors of interest to an intervention program. These systems are useful for program managers.

Integrated surveillance: a combination of active and passive systems using a single infrastructure that gathers information about multiple diseases or

behaviors of interest to several intervention programs (for example, a health facilitybased system may gather information on multiple infectious diseases and injuries).

Behavioral risk factor surveillance system (BRFSS): an active system of repeated surveys that measure behaviors that are known to cause disease or injury (for example, tobacco or alcohol use, unprotected sex, or lack of physical

exercise). Because the aim of many intervention program strategies is to prevent disease by preventing unhealthy behavior, these surveys provide a direct measure of their effect in the population.It is useful for providing timely measures of program effectiveness for both communicable and

noncommunicable disease interventions.

Text book of Disease Control Priorities in Developing Countries ; Peter Nsubuga, Mark E. White, Stephen B. Thacker, and others

 The potential usefulness of surveillance as a public health tool to address problems beyond
 The potential usefulness of surveillance as a public health tool to address problems beyond
 The potential usefulness of surveillance as a public health tool to address problems beyond
 The potential usefulness of surveillance as a public health tool to address problems beyond

The potential usefulness of surveillance as a public health tool to address problems beyond infectious disease was emphasized in

1968 when the 21st World Health Assembly recommended the application of surveillance principles to a wider scope of

problems, including cancer, atherosclerosis, and social problems

such as drug addiction .

From health surveys to surveillance of risk factors  Properly conducted, surveillance ensures that countries
From health surveys to surveillance of risk factors  Properly conducted, surveillance ensures that countries
From health surveys to surveillance of risk factors  Properly conducted, surveillance ensures that countries
From health surveys to surveillance of risk factors  Properly conducted, surveillance ensures that countries

From health surveys to surveillance of risk factors

Properly conducted, surveillance ensures that countries have the information they need to control disease immediately or to plan strategies to prevent

disease and adverse health events in the future.

The distribution of the major common risk factors for chronic diseases within the population is the key item of information required by countries for planning health promotion and primary prevention programmes.

Because of the relatively long time that elapses between exposure to a causal

agent and manifestation of disease, monitoring and surveillance of chronic

diseases can be a costly exercise involving disease registers and legislation to ensure disease reporting.

For this reason most of the focus for surveillance of chronic disease, including oral diseases, involves surveillance of modifiable risk factors. As emphasized by the World oral health report, 2003.

WHO has developed major new tools for chronic disease surveillance:

WHO has developed major new tools for chronic disease surveillance:
WHO has developed major new tools for chronic disease surveillance:
WHO has developed major new tools for chronic disease surveillance:
The WHO Global InfoBase  To predict the future burden of chronic disease, including oral
The WHO Global InfoBase  To predict the future burden of chronic disease, including oral
The WHO Global InfoBase  To predict the future burden of chronic disease, including oral
The WHO Global InfoBase  To predict the future burden of chronic disease, including oral

The WHO Global InfoBase

To predict the future burden of chronic disease, including oral disease,data collection and reporting standards are needed to ensure that the data can be

used effectively to inform policy, prevention and control activities for health.

The WHO Global InfoBase stores the country data being collected as part of the STEPS approach.

The data entered may also derive from a range of sources such as reports published in the literature or ministry of health reports.

The database brings together existing country-level data stratified by age and sex, with complete source and survey information.

The InfoBase makes use of the compiled data to produce comparable country estimates for risk factors and selected diseases.

The WHO Global Oral Health Data Bank was recently updated on the basis of the available national reports (ministry of health and other), dental scientific literature (obtained through PubMed), information available in the Country/Area Profile Programme (CAPP) and data provided by WHO Collaborating Centres and the International Agency of Cancer Research.

The updated information on dentate status, dental caries, periodontal disease and incidence of oral cancer has now been entered into the WHO Global InfoBase and the databank will allow for cross-analysis of oral health status with general health (chronic disease) and common risk factors.

Such analysis will provide valuable information for integrated prevention of chronic disease and for the integration of oral health promotion into national and community health programmes.

Systematic surveillance data also allow for time series analysis of oral disease, chronic disease and common risk factors, and the health information system may also provide a means for systematic evaluation of the effect of public health intervention programmes.

system may also provide a means for systematic evaluation of the effect of public health intervention
system may also provide a means for systematic evaluation of the effect of public health intervention
system may also provide a means for systematic evaluation of the effect of public health intervention
system may also provide a means for systematic evaluation of the effect of public health intervention
 Most of these noncommunicable diseases share common preventable risk factors.  To anticipate the
 Most of these noncommunicable diseases share common preventable risk factors.  To anticipate the
 Most of these noncommunicable diseases share common preventable risk factors.  To anticipate the

Most of these noncommunicable diseases share common preventable risk factors.

To anticipate the epidemic in non communicable diseases, WHO has initiated the worldwide surveillance of risk factors using the WHO STEPwise approach to Surveillance (STEPS) of risk factors for noncommunicable diseases.

of risk factors using the WHO STEPwise approach to Surveillance (STEPS) of risk factors for noncommunicable
of risk factors using the WHO STEPwise approach to Surveillance (STEPS) of risk factors for noncommunicable
of risk factors using the WHO STEPwise approach to Surveillance (STEPS) of risk factors for noncommunicable
The WHO STEPwise approach to Surveillance of noncommunicable diseases (STEPS)  Is the WHO recommended
The WHO STEPwise approach to Surveillance of noncommunicable diseases (STEPS)  Is the WHO recommended
The WHO STEPwise approach to Surveillance of noncommunicable diseases (STEPS)  Is the WHO recommended
The WHO STEPwise approach to Surveillance of noncommunicable diseases (STEPS)  Is the WHO recommended

The WHO STEPwise approach to Surveillance of noncommunicable diseases (STEPS)

Is the WHO recommended NCD surveillance tool.

This framework unifies all WHO approaches to defining core variables for population-based surveys, surveillance and monitoring instruments.

The goal is to achieve data comparability over time and between countries.

STEPS offers an entry point for low and middle income countries to get started in NCD activities.

STEPS for NCD risk factors is based on the concept that surveillance systems require standardised data collection as well as sufficient flexibility to be appropriate in a variety of country situations and settings.

 The STEPwise approach, therefore, allows for the development of an increasingly comprehensive and complex
 The STEPwise approach, therefore, allows for the development of an increasingly comprehensive and complex
 The STEPwise approach, therefore, allows for the development of an increasingly comprehensive and complex
 The STEPwise approach, therefore, allows for the development of an increasingly comprehensive and complex

The STEPwise approach, therefore, allows for the development of an

increasingly comprehensive and complex surveillance system depending on

local needs and resources.

For surveillance to be sustainable, the STEPwise approach advocates that small amounts of good quality data are more valuable than large amounts of poor quality data.

A strong argument can also be made for the benefits of monitoring a few modifiable NCD risk factors since they reflect both a large part of future NCD burden as well as indicating the success of interventions considered to be beneficial to a wide range of NCDs.

The key feature of the STEPS framework is the distinction between the different levels of risk- factor assessment:

self report information by QUESTIONNAIRE (Step 1),

objective information by PHYSICAL MEASUREMENTS (Step 2), or

objective information by blood samples for BIOCHEMICAL ANALYSES (Step 3);

the three modules involved in describing each risk factor:

CORE

EXPANDED CORE

OPTIONAL

The STEPS approach moves along a sequential process.

The key premise is that, by using the same standardized questions and protocols, all countries can use the information not only for informing within-country trends, but also for between- country comparisons.

In India the survey was conducted from april 2003 to march 2005 in 6 sites and again in 2007 in 7 states.

Steps 1 and 2 are desirable and appropriate for most countries. An important feature of

Steps 1 and 2 are desirable and appropriate

for most countries. An important feature of the STEPwise approach is that it allows expansion of the key variables by the addition of optional modules if there is strong (local) interest in

them. WHO does not recommend such advanced measurements for countries with limited resources.

Oral health indicators within the frame of STEPS  WHO Oral Health Programme designed a
Oral health indicators within the frame of STEPS  WHO Oral Health Programme designed a
Oral health indicators within the frame of STEPS  WHO Oral Health Programme designed a

Oral health indicators within the frame of STEPS

WHO Oral Health Programme designed a risk factor model which provided the conceptual framework for inclusion of oral health modules within STEPS.

designed a risk factor model which provided the conceptual framework for inclusion of oral health modules
designed a risk factor model which provided the conceptual framework for inclusion of oral health modules
designed a risk factor model which provided the conceptual framework for inclusion of oral health modules
 The indicators comprise both determinants of health and common modifiable risk factors such as
 The indicators comprise both determinants of health and common modifiable risk factors such as
 The indicators comprise both determinants of health and common modifiable risk factors such as
 The indicators comprise both determinants of health and common modifiable risk factors such as

The indicators comprise both determinants of health and common modifiable risk factors such as diet/nutrition, tobacco use and excessive alcohol

consumption.

In addition, oral hygiene practices and use of available oral health services are considered. Most of the risk indicators are Step 1 variables (i.e. ascertained by questionnaire), but oral health also lends itself to Step 2 (physical

measurements made during clinical examination).

Step 3 measurements in oral health may imply laboratory tests such as microbial assessment (e.g. Streptococcus mutans ) or buffer capacity of saliva.

The WHO Oral Health Programme has developed standardized questions for obtaining Step 1 data.

 The WHO Oral Health Programme has developed standardized questions for obtaining Step 1 data.

These oral health modules are currently being field-tested in several developing and developed countries. The results may help to identify

variables to form part of the core, expanded core and optional modules for

countries. An additional simplified questionnaire for assessment of the oral health system has been prepared to examine systems orientation (i.e. emergency or curative care only, prevention and health promotion).

has been prepared to examine systems orientation (i.e. emergency or curative care only, prevention and health
has been prepared to examine systems orientation (i.e. emergency or curative care only, prevention and health
has been prepared to examine systems orientation (i.e. emergency or curative care only, prevention and health
has been prepared to examine systems orientation (i.e. emergency or curative care only, prevention and health
has been prepared to examine systems orientation (i.e. emergency or curative care only, prevention and health
in  Surveillance systems have been in operation for several years in certain developing countries

in

in  Surveillance systems have been in operation for several years in certain developing countries such

Surveillance systems have been in operation for several years in certain developing

countries such as Madagascar and Thailand, where data from the evaluation of

child populations are used for targeting school-based oral health activities towards

those most in need.

Improved quality of oral health information systems worldwide may help to

strengthen

health

systems

and

operational

research

may

assist

translating sound knowledge about prevention programmes and health promotion

for the benefit of the poor and disadvantaged population groups

STRATEGIES AND APPROACHES IN ORAL DISEASE PREVENTION AND HEALTH PROMOTION

The threat posed by noncommunicable diseases and the need to provide

urgent and effective public health responses led to the formulation of a

global strategy for prevention and control of these diseases, endorsed in 2000

by the 53 rd World Health Assembly (resolution WHA 53.17). Priority is given to

diseases linked by common, preventable and lifestyle related risk factors

(e.g. unhealthy diet, tobacco use), including oral health.

by common, preventable and lifestyle related risk factors (e.g. unhealthy diet, tobacco use), including oral health.

The risk factor approach in promotion of oral health

The risk factor approach in promotion of oral health
The risk factor approach in promotion of oral health

Gaps in the natural history of NCD

1. Absence of known agent: in most of NCD the cause is not known.

2. Multifactorial causation: in absence of causative agents, risk factors are studied

An attribute or exposure that is significantly associated with development of disease.

If determinant is modified by intervention, it reduces possibility of

occurrence of disease.

Risk factors can be causative, contributory or predictive. They can be modifiable or non-modifiable

They can be individual or community risk factors

Epidemiological studies are needed to identify risk factors At-risk approach, at-risk groups, risk factors with diseases

studies are needed to identify risk factors  At -risk approach, at-risk groups, risk factors with

Gaps in the natural history of NCD

Web of causation

Changes in life style

stress

history of NCD Web of causation Changes in life style stress Abundance of food lack of
history of NCD Web of causation Changes in life style stress Abundance of food lack of
Abundance of food lack of physical activity disturbance smoking emotional Obesity hypertension Hyperlipidemia
Abundance of food
lack of physical activity
disturbance
smoking
emotional
Obesity
hypertension
Hyperlipidemia
thrombotic tendency
changes
artery
walls
Coronary arthrosclerosis
coronary occlusion

Myocardial

infarction

aging

thrombotic tendency changes artery walls Coronary arthrosclerosis coronary occlusion Myocardial infarction aging

Gaps in the natural history of NCD………

3.

Long latent period: it is the period between the first exposure to suspected cause and the eventual development of disease. This makes it difficult to link suspected causes with outcomes.

4.

Indefinite onset : Most (NCD) are slow in onset and development.

Distinction between diseased and non diseased may be difficult to establish.

Most (NCD) are slow in onset and development. Distinction between diseased and non diseased may be
Most (NCD) are slow in onset and development. Distinction between diseased and non diseased may be
Most (NCD) are slow in onset and development. Distinction between diseased and non diseased may be
In response to the rising burden of chronic diseases, the world health assembly has adopted

In response to the rising burden of chronic diseases, the world

health assembly has adopted many resolution's:

First in 1956- calling for increased action to be taken to prevent and control the growing burden of chronic diseases.

WHA has adopted a series of related resolutions which amplify WHO’s mandate

in the area of chronic diseases:

Resolution WHA 56.1: on the WHO framework of tobacco control.

Resolution WHA 57.16: on health promotion and healthy lifestyles.

Resolution WHA 57.17: on the global strategy on diet, physical activity and health

Resolution WHA 58.22: on cancer prevention and control,

Resolution WHA 58.26: on public health problem caused by harmful use of alcohol;

Resolution WHA 60.23: on prevention and control of non communicable diseases.

problem caused by harmful use of alcohol; Resolution WHA 60.23: on prevention and control of non
problem caused by harmful use of alcohol; Resolution WHA 60.23: on prevention and control of non
 On May 27, 2013 , ministers from 194 WHO member states adopted the Global
 On May 27, 2013 , ministers from 194 WHO member states adopted the Global
 On May 27, 2013 , ministers from 194 WHO member states adopted the Global

On May 27, 2013, ministers from 194 WHO member states adopted the Global

Action Plan for the Prevention and Control of NCDs 2013 to 2020 at the 66th

World Health Assembly.

of NCDs 2013 to 2020 at the 66th World Health Assembly.  Two months later, the
of NCDs 2013 to 2020 at the 66th World Health Assembly.  Two months later, the

Two months later, the United Nations (U.N.) Economic and Social Council adopted a resolution requesting that the U.N. secretary general establish an interagency task force on the prevention and control of NCDs.

Fuster V,Global Burden of Cardiovascular Disease JACC VOL. 64, NO. 5, 2014 AUGUST 5, 2014:520 2

2013-2020 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases
2013-2020 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases
2013-2020 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases

2013-2020 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases

Working in partnership to prevent and control the 4 noncommunicable diseases cardiovascular diseases, diabetes, cancers and chronic respiratory diseases and the 4 shared risk factors tobacco use,

physical inactivity, unhealthy diets and the harmful use of alcohol.

and the 4 shared risk factors — tobacco use, physical inactivity, unhealthy diets and the harmful
and the 4 shared risk factors — tobacco use, physical inactivity, unhealthy diets and the harmful
and the 4 shared risk factors — tobacco use, physical inactivity, unhealthy diets and the harmful
The six objectives of the 2013-2020 Action Plan are: . To raise the priority accorded

The six objectives of the 2013-2020 Action

Plan are:

.

To raise the priority accorded to the prevention and control of noncommunicable diseases in global,
To raise the priority accorded to
the prevention and control of
noncommunicable diseases in
global, regional and national
agendas and internationally
agreed development goals,
through strengthened
international cooperation and
advocacy.

To strengthen national capacity, leadership, governance, multisectoral action and partnerships to

accelerate country response for the prevention and control

of noncommunicable diseases.

the prevention and control of noncommunicable diseases. To reduce modifiable risk factors for noncommunicable
the prevention and control of noncommunicable diseases. To reduce modifiable risk factors for noncommunicable

To reduce modifiable risk factors for noncommunicable

diseases and underlying social

determinants through creation of health-promoting environments.

To strengthen and orient health systems to address the prevention and control of noncommunicable diseases
To strengthen and orient health systems to address the prevention and control of noncommunicable diseases
To strengthen and orient health
systems to address the
prevention and control of
noncommunicable diseases and
the underlying social
determinants through people-
centred primary health care
and universal health coverage.
To promote and support national capacity for high-quality research and development for the prevention and
To promote and support national
capacity for high-quality
research and development for
the prevention and control of
noncommunicable diseases.
the prevention and control of noncommunicable diseases. To monitor the trends and determinants of noncommunicable
the prevention and control of noncommunicable diseases. To monitor the trends and determinants of noncommunicable
the prevention and control of noncommunicable diseases. To monitor the trends and determinants of noncommunicable
To monitor the trends and determinants of noncommunicable diseases and evaluate progress in their prevention
To monitor the trends and
determinants of
noncommunicable diseases and
evaluate progress in their
prevention and control.
VOLUNTARY GLOBAL TARGETS
VOLUNTARY GLOBAL TARGETS
VOLUNTARY GLOBAL TARGETS
VOLUNTARY GLOBAL TARGETS
VOLUNTARY GLOBAL TARGETS

VOLUNTARY GLOBAL TARGETS

VOLUNTARY GLOBAL TARGETS
 INTEGRATION OF ORAL HEALTH IN CONTEXT TO NON COMMUNICABLE DISEASES
 INTEGRATION OF ORAL HEALTH IN CONTEXT TO NON COMMUNICABLE DISEASES
 INTEGRATION OF ORAL HEALTH IN CONTEXT TO NON COMMUNICABLE DISEASES

INTEGRATION OF ORAL HEALTH IN CONTEXT TO NON COMMUNICABLE DISEASES

 INTEGRATION OF ORAL HEALTH IN CONTEXT TO NON COMMUNICABLE DISEASES
 INTEGRATION OF ORAL HEALTH IN CONTEXT TO NON COMMUNICABLE DISEASES
 INTEGRATION OF ORAL HEALTH IN CONTEXT TO NON COMMUNICABLE DISEASES
Oral health  The theme for World Health Day (April 7, 1994), “Oral Health for
Oral health  The theme for World Health Day (April 7, 1994), “Oral Health for
Oral health  The theme for World Health Day (April 7, 1994), “Oral Health for
Oral health  The theme for World Health Day (April 7, 1994), “Oral Health for

Oral health

The theme for World Health Day (April 7, 1994), “Oral Health for a Healthy Life,”

The UN assembly in 1995 recognized the fact that oral disease burden is high globally and share common risk factors with other NCDS.

Hence oral health was recommended to be included in NCDS for its prevention

and control.

The 8 th world congress of preventive dentistry in September 2005 in Liverpool jointly organized by WHO , IADR and European association for dental public health with 43 countries participation emphasized oral health an integral part

of general health and wellbeing as a basic human right.

Their impact on individuals and communities is considerable in terms of pain and suffering, impairment of function and reduced quality of life and cost of treatment. The extent of inequalities in oral health outcomes is unacceptable.

Strategies and management of oral diseases in the context of NCDs

A 2007 WHO resolution called for oral health to be integrated with chronic disease prevention programs. Commonly used approaches to prevention and control of oral diseases have been relatively ineffective. However, methods exist to prevent a very large proportion of oral diseases.

Therefore, FDI will encourage:

 

1.

Reducing

the

“knowledge-

implementation

gap”

by

recommending

promotion approaches.

guidelines

for

evidence

based

health

2. Applying the principles outlined in the Ottawa Charter for Health Promotion, which recommends a shift from a vertical

to a more horizontal approach and involves more integration with others involved in tackling NCDs.

a shift from a vertical to a more horizontal approach and involves more integration with others
a shift from a vertical to a more horizontal approach and involves more integration with others
a shift from a vertical to a more horizontal approach and involves more integration with others
a shift from a vertical to a more horizontal approach and involves more integration with others

UN High level meeting on Non Communicable Diseases (19-20 September 2011 in New York)

Political declaration on the prevention and control of non-communicable diseases (ncds) was adopted by 193 member states

In particular the declaration called for interventions affecting upstream social determinants of health and illness.

The increasing global burden of NCDs is a major barrier to development and achievement of the Millennium Development Goals.

NCDs are a contributing factor to poverty and hunger.

and achievement of the Millennium Development Goals.  NCDs are a contributing factor to poverty and
and achievement of the Millennium Development Goals.  NCDs are a contributing factor to poverty and
and achievement of the Millennium Development Goals.  NCDs are a contributing factor to poverty and
and achievement of the Millennium Development Goals.  NCDs are a contributing factor to poverty and
Implications for oral health  NCDs are largely caused by a cluster of risk factors:
Implications for oral health  NCDs are largely caused by a cluster of risk factors:
Implications for oral health  NCDs are largely caused by a cluster of risk factors:
Implications for oral health  NCDs are largely caused by a cluster of risk factors:
Implications for oral health  NCDs are largely caused by a cluster of risk factors:

Implications for oral health

NCDs are largely caused by a cluster of risk factors: tobacco, unhealthy diet, particularly sugars, physical inactivity and harmful use of alcohol.

Those risk factors also cause oral diseases. Indeed, the UN Political Declaration recognized in Paragraph 19, "that renal, oral and eye diseases pose a major health burden for many countries and that these diseases share common risk factors and can benefit from common responses to non- communicable diseases".

Oral Disease Added to United Nations Declaration on Non communicable Diseases, Oral Disease Added to United Nations Declaration on Non communicable Diseases | JCDA | Essential Dental Knowledge

 World Oral Health Day (WOHD) is celebrated every year on the 20 t h
 World Oral Health Day (WOHD) is celebrated every year on the 20 t h
 World Oral Health Day (WOHD) is celebrated every year on the 20 t h
 World Oral Health Day (WOHD) is celebrated every year on the 20 t h
 World Oral Health Day (WOHD) is celebrated every year on the 20 t h

World Oral Health Day (WOHD) is celebrated every year on the 20 th March. It is an international day to celebrate the benefits of a healthy mouth and to

promote worldwide awareness of the issues around oral health and the

importance of looking after oral hygiene to everyone old and young.

Because 90% of the world’s population will suffer from oral diseases in their lifetime and many of them can be avoided with increased governmental, health association and society support and funding for prevention, detection

and treatment programmes.

Recently WHO, jointly with the FDI and the International Association for Dental Research (IADR), formulated goals for oral health to be achieved by the year 2020

Global Goals for Oral Health  Rationale  The FDI and the WHO established the
Global Goals for Oral Health  Rationale  The FDI and the WHO established the
Global Goals for Oral Health  Rationale  The FDI and the WHO established the

Global Goals for Oral Health

Rationale

The FDI and the WHO established the first Global Oral Health Goals jointly in

1981 to be achieved by the year 2000.

They had been useful and, for many populations, had been achieved or exceeded.

1981 to be achieved by the year 2000.  They had been useful and, for many
1981 to be achieved by the year 2000.  They had been useful and, for many
 Global Oral Health Goals, Objectives and Targets for the Year 2020 Goals  To
 Global Oral Health Goals, Objectives and Targets for the Year 2020 Goals  To
 Global Oral Health Goals, Objectives and Targets for the Year 2020 Goals  To
 Global Oral Health Goals, Objectives and Targets for the Year 2020 Goals  To

Global Oral Health Goals, Objectives and Targets for the Year 2020 Goals

To promote oral health and to minimise the impact of diseases of oral and craniofacial origin on general health and psychosocial development, giving emphasis to promoting oral health in populations

with the greatest burden of such conditions and diseases;

To minimise the impact of oral and craniofacial manifestations of general diseases on individuals and society, and to use these manifestations for early diagnosis, prevention and effective management of systemic diseases.

 Targets  The targets should be selected to match predetermined oral health priorities at
 Targets  The targets should be selected to match predetermined oral health priorities at
 Targets  The targets should be selected to match predetermined oral health priorities at

Targets

The targets should be selected to match predetermined oral health priorities

at a national or local level. Consideration should be given to the following areas when selecting targets, based on local priorities:

Pain, functional disorders, infectious diseases, oro-pharyngeal cancer, oral manifestations of HIV-infection, noma, trauma, cranio-facial anomalies,

of HIV-infection, noma, trauma, cranio-facial anomalies, dental caries, developmental anomalies of teeth, periodontal
of HIV-infection, noma, trauma, cranio-facial anomalies, dental caries, developmental anomalies of teeth, periodontal

dental caries, developmental anomalies of teeth, periodontal diseases, oral

mucosal diseases, salivary gland disorders, tooth loss, health care services, health care information systems.

 The Common Risk Factor Approach (CRFA) addresses risk factors common to many chronic conditions
 The Common Risk Factor Approach (CRFA) addresses risk factors common to many chronic conditions
 The Common Risk Factor Approach (CRFA) addresses risk factors common to many chronic conditions
 The Common Risk Factor Approach (CRFA) addresses risk factors common to many chronic conditions

The Common Risk Factor Approach (CRFA) addresses risk factors common to many chronic conditions and prevention of

oral disease needs to be integrated with preventing other NCDs

The CRFA will be a guiding principle for FDI when giving advice to NDAs on prevention, tobacco cessation and caries and

periodontal disease management and should start early in the life

course .

IADRS GROUP RECOMMENDATIONS  A shift from the current downstream approaches by integrating oral health
IADRS GROUP RECOMMENDATIONS  A shift from the current downstream approaches by integrating oral health
IADRS GROUP RECOMMENDATIONS  A shift from the current downstream approaches by integrating oral health

IADRS GROUP RECOMMENDATIONS

A shift from the current downstream approaches by integrating oral health strategies with those directed at

the major NCDS ( “best buys” are midstream and upstream approaches)

oral health strategies with those directed at the major NCDS ( “best buys” are midstream and
oral health strategies with those directed at the major NCDS ( “best buys” are midstream and
 Oral diseases burden is increasing and majority of dental decay remains untreated across all
 Oral diseases burden is increasing and majority of dental decay remains untreated across all
 Oral diseases burden is increasing and majority of dental decay remains untreated across all
 Oral diseases burden is increasing and majority of dental decay remains untreated across all

Oral diseases burden is increasing and majority of dental decay remains untreated across all countries, evidence of

failure of vertical approach.

Evidence shows population wide prevention strategies

that are no longer vertical , but horizontal can tackle

common risk factors effectively.

 Oral disease burden is increasing and a majority of dental decay is untreated across
 Oral disease burden is increasing and a majority of dental decay is untreated across
 Oral disease burden is increasing and a majority of dental decay is untreated across

Oral disease burden is increasing and a majority of dental decay is untreated across all the countries , evidence of

the failure of vertical approach

and a majority of dental decay is untreated across all the countries , evidence of the
and a majority of dental decay is untreated across all the countries , evidence of the
and a majority of dental decay is untreated across all the countries , evidence of the

RISK FACTOR SUEVILLANCE

RISK FACTOR SUEVILLANCE
RISK FACTOR SUEVILLANCE
RISK FACTOR SUEVILLANCE
RISK FACTOR SUEVILLANCE
RISK FACTOR SUEVILLANCE
RISK FACTOR SUEVILLANCE
RISK FACTOR SUEVILLANCE

Risk factors for NCD

RISK FACTORS

The risk factors for NCDs are classified in terms of their amenability to interventions as :

MODIFIABLE

RISK FACTORS,

NON-

MODIFIABLE RISK FACTORS

AND

INTERMEDIATE

RISK FACTORS.

83

to interventions as : MODIFIABLE RISK FACTORS, NON- MODIFIABLE RISK FACTORS AND INTERMEDIATE RISK FACTORS. 83
Modifiable Risk Factors
Modifiable Risk Factors
Modifiable Risk Factors
Modifiable Risk Factors
Modifiable Risk Factors
Modifiable Risk Factors
Modifiable Risk Factors

Modifiable Risk Factors

Modifiable Risk Factors
Modifiable Risk Factors
Tobacco Use  Tobacco consumed in any form, whether smoked or chewed and second-hand tobacco
Tobacco Use  Tobacco consumed in any form, whether smoked or chewed and second-hand tobacco
Tobacco Use  Tobacco consumed in any form, whether smoked or chewed and second-hand tobacco

Tobacco Use

Tobacco consumed in any form, whether smoked or chewed and second-hand tobacco smoke exposures are associated with adverse health effects. It is

associated with cardiovascular diseases, cancers, chronic respiratory disease,

and other communicable and non communicable diseases.

Tobacco kills up to half of its users.

•Tobacco kills nearly 6 million people each year.

•Annual death toll could rise to more than 8 million by 2030.

•Nearly 80% of the world’s 1 billion smokers live in low- and middle-income countries.

than 8 million by 2030.  •Nearly 80% of the world’s 1 billion smokers live in
than 8 million by 2030.  •Nearly 80% of the world’s 1 billion smokers live in

Global Adult Tobacco Survey

Global Adult Tobacco Survey
Global Adult Tobacco Survey
Global Adult Tobacco Survey

Tobacco Use: Health Effects

Tobacco Use: Health Effects Mathers CD, Loncar D. Projections of global mortality and burden of disease

Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine, 2006, 3(11): e442.

Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine,
Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine,
Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine,
Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine,

Tobacco Use: Health Effects (cont.)

Among smokers

Cancer

Coronary heart disease

Diseases of the lungs

Peripheral vascular disease

Stroke

Fetal complications and stillbirth

Second-hand smoke causes

Heart disease, including heart attack

•Lung cancer

Fetal complications and stillbirth Second-hand smoke causes  Heart disease, including heart attack  •Lung cancer
Fetal complications and stillbirth Second-hand smoke causes  Heart disease, including heart attack  •Lung cancer
Fetal complications and stillbirth Second-hand smoke causes  Heart disease, including heart attack  •Lung cancer
Fetal complications and stillbirth Second-hand smoke causes  Heart disease, including heart attack  •Lung cancer
Fetal complications and stillbirth Second-hand smoke causes  Heart disease, including heart attack  •Lung cancer
Fetal complications and stillbirth Second-hand smoke causes  Heart disease, including heart attack  •Lung cancer
 Alcohol Consumption  There is a direct relationship between higher levels of alcohol consumption
 Alcohol Consumption  There is a direct relationship between higher levels of alcohol consumption
 Alcohol Consumption  There is a direct relationship between higher levels of alcohol consumption

Alcohol Consumption

There is a direct relationship between higher levels of alcohol consumption

and rising risk of cardiovascular diseases and some liver diseases. Heavy episodic drinking (binge drinking) is especially associated with cardiovascular diseases.

and some liver diseases. Heavy episodic drinking (binge drinking) is especially associated with cardiovascular diseases.
and some liver diseases. Heavy episodic drinking (binge drinking) is especially associated with cardiovascular diseases.
and some liver diseases. Heavy episodic drinking (binge drinking) is especially associated with cardiovascular diseases.

Global Alcohol Consumption

11.5% of all global drinkers are episodic, heavy users.

2.5 million people die from alcohol consumption per year

The majority of adults consume at low-risk levels.

Estimated worldwide consumption of alcohol has remained relatively stable.

http://www.who.int/substance_abuse/publications/global_alcohol_report/m

sbgsruprofiles.pdf

relatively stable.  http://www.who.int/substance_abuse/publications/global_alcohol_report/m sbgsruprofiles.pdf
relatively stable.  http://www.who.int/substance_abuse/publications/global_alcohol_report/m sbgsruprofiles.pdf
relatively stable.  http://www.who.int/substance_abuse/publications/global_alcohol_report/m sbgsruprofiles.pdf
relatively stable.  http://www.who.int/substance_abuse/publications/global_alcohol_report/m sbgsruprofiles.pdf

Global Alcohol Consumption

Global Alcohol Consumption
Global Alcohol Consumption
Global Alcohol Consumption
Total adult per capita consumption, unrecorded APC and proportion of unrecorded APC of total APC,
Total adult per capita consumption, unrecorded APC and proportion of unrecorded APC of total APC,
Total adult per capita consumption, unrecorded APC and proportion of unrecorded APC of total APC,
Total adult per capita consumption, unrecorded APC and proportion of unrecorded APC of total APC,

Total adult per capita consumption, unrecorded APC and proportion of unrecorded APC of total APC, in litres of pure alcohol, by WHO region, 2005

consumption, unrecorded APC and proportion of unrecorded APC of total APC, in litres of pure alcohol,
Five-year change in recorded adult per capita consumption, 2001 – 2005
Five-year change in recorded adult per capita consumption, 2001 – 2005

Five-year change in recorded adult per capita consumption, 20012005

Five-year change in recorded adult per capita consumption, 2001 – 2005

Harmful Use of Alcohol: Effects

Immediate effects:

Diminished brain function

Loss of body heat

Fetal damage

Risk for unintentional injuries

Risk for violence

Coma and death

Long-term effects:

Liver diseases

Cancers

Hypertension

Gastrointestinal disorders

Neurological issues

Psychiatric issues

diseases  Cancers  Hypertension  Gastrointestinal disorders  Neurological issues  Psychiatric issues
diseases  Cancers  Hypertension  Gastrointestinal disorders  Neurological issues  Psychiatric issues
diseases  Cancers  Hypertension  Gastrointestinal disorders  Neurological issues  Psychiatric issues
diseases  Cancers  Hypertension  Gastrointestinal disorders  Neurological issues  Psychiatric issues
diseases  Cancers  Hypertension  Gastrointestinal disorders  Neurological issues  Psychiatric issues

Metabolic Risk Factors

the four metabolic risk factors

1.

Raised Blood Pressure (Hypertension)

2.

Raised Cholesterol

3.

Raised Blood Glucose

4.

Overweight and Obesity

Blood Pressure (Hypertension) 2. Raised Cholesterol 3. Raised Blood Glucose 4. Overweight and Obesity
Blood Pressure (Hypertension) 2. Raised Cholesterol 3. Raised Blood Glucose 4. Overweight and Obesity
Blood Pressure (Hypertension) 2. Raised Cholesterol 3. Raised Blood Glucose 4. Overweight and Obesity
Blood Pressure (Hypertension) 2. Raised Cholesterol 3. Raised Blood Glucose 4. Overweight and Obesity
Blood Pressure (Hypertension) 2. Raised Cholesterol 3. Raised Blood Glucose 4. Overweight and Obesity
Blood Pressure (Hypertension) 2. Raised Cholesterol 3. Raised Blood Glucose 4. Overweight and Obesity
Blood Pressure (Hypertension) 2. Raised Cholesterol 3. Raised Blood Glucose 4. Overweight and Obesity
Blood Pressure (Hypertension) 2. Raised Cholesterol 3. Raised Blood Glucose 4. Overweight and Obesity
Blood Pressure (Hypertension) 2. Raised Cholesterol 3. Raised Blood Glucose 4. Overweight and Obesity
 Consumption of Fruits, Vegetables and Processed Food  Inadequate consumption of fruits and vegetables
 Consumption of Fruits, Vegetables and Processed Food  Inadequate consumption of fruits and vegetables
 Consumption of Fruits, Vegetables and Processed Food  Inadequate consumption of fruits and vegetables

Consumption of Fruits, Vegetables and Processed Food

Inadequate consumption of fruits and vegetables (less than five servings /day) increases the risk for cardiovascular diseases, stomach cancer and colorectal cancer.

The consumption of high levels of high-energy foods, such as processed foods that

are high in fats and sugars, promotes obesity.

Consumption of > 5 gram of dietary salt/ day predisposes to higher blood pressure levels and increased risk of cardiovascular diseases.

Consumption of high amounts of saturated fats and transfat increases the risk of

 Consumption of high amounts of saturated fats and transfat increases the risk of coronary heart

coronary heart disease and diabetes.

 Consumption of high amounts of saturated fats and transfat increases the risk of coronary heart
 Consumption of high amounts of saturated fats and transfat increases the risk of coronary heart
 Consumption of high amounts of saturated fats and transfat increases the risk of coronary heart
Global Changes in Diet  Most countries have increased overall daily consumption of: Daily calories,
Global Changes in Diet  Most countries have increased overall daily consumption of: Daily calories,
Global Changes in Diet  Most countries have increased overall daily consumption of: Daily calories,

Global Changes in Diet

Most countries have increased overall daily consumption of: Daily calories,

Fat and meats, and

consumption of: Daily calories,  Fat and meats, and  Energy dense and nutrient-poor foods such

Energy dense and nutrient-poor foods such as: Starches

Refined sugars

Trans-fats

foods such as: Starches  Refined sugars  Trans-fats  http://www.pitt.edu/~super4/41011-42001/41171.pdf
foods such as: Starches  Refined sugars  Trans-fats  http://www.pitt.edu/~super4/41011-42001/41171.pdf

http://www.pitt.edu/~super4/41011-42001/41171.pdf

Physical Inactivity  Low physical activity is an important cause of overweight and obesity. 
Physical Inactivity  Low physical activity is an important cause of overweight and obesity. 
Physical Inactivity  Low physical activity is an important cause of overweight and obesity. 
Physical Inactivity  Low physical activity is an important cause of overweight and obesity. 

Physical Inactivity

Low physical activity is an important cause of overweight and obesity.

Participation in 150 minutes of moderate physical activity for every week or

equivalent activity is estimated to reduce the risk of cardiovascular disease, diabetes, breast and colon cancer, and depression.

activity is estimated to reduce the risk of cardiovascular disease, diabetes, breast and colon cancer, and
activity is estimated to reduce the risk of cardiovascular disease, diabetes, breast and colon cancer, and
activity is estimated to reduce the risk of cardiovascular disease, diabetes, breast and colon cancer, and
Global Changes in Physical Activity  31 % of the world’s population does not get
Global Changes in Physical Activity  31 % of the world’s population does not get
Global Changes in Physical Activity  31 % of the world’s population does not get
Global Changes in Physical Activity  31 % of the world’s population does not get

Global Changes in Physical Activity

31% of the world’s population does not get enough physical activity.

Many social and economic changes contribute to this trend:

Aging populations,

Transportation, and

Communication technology.

 Transportation, and  Communication technology. 
 Transportation, and  Communication technology. 

http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html

http://www.sciencedirect.com/science/article/pii/S0140673612608988

Global Changes in Physical Activity (cont.)

6-10 % OF MAJOR NCDS IS ATTRIBUTABLE TO PHYISCAL INACTIVITY

Global Changes in Physical Activity (cont.)  6-10 % OF MAJOR NCDS IS ATTRIBUTABLE TO PHYISCAL
Global Changes in Physical Activity (cont.)  6-10 % OF MAJOR NCDS IS ATTRIBUTABLE TO PHYISCAL
Physical Activity: Health Effects REDUCES THE RISK OF:  High blood pressure  Type 2
Physical Activity: Health Effects REDUCES THE RISK OF:  High blood pressure  Type 2
Physical Activity: Health Effects REDUCES THE RISK OF:  High blood pressure  Type 2

Physical Activity: Health Effects

REDUCES THE RISK OF:

Physical Activity: Health Effects REDUCES THE RISK OF:  High blood pressure  Type 2 diabetes
Physical Activity: Health Effects REDUCES THE RISK OF:  High blood pressure  Type 2 diabetes
Physical Activity: Health Effects REDUCES THE RISK OF:  High blood pressure  Type 2 diabetes

High blood pressure

Type 2 diabetes

•Certain cancers

•Heart attacks

•Stroke

•Falls

•Early death

•Stroke  •Falls  •Early death  Adverse lipid profile  Arthritis pain 

Adverse lipid profile

Arthritis pain

Psychiatric issues

Poverty

Poverty Poverty means that there is less purchasing power in the homes This low purchasing power

Poverty means that there is less purchasing power in the homes

means that there is less purchasing power in the homes This low purchasing power results in

This low purchasing power results in compromising on the

choices that is made

at the household level.

on the choices that is made at the household level. This results in major health-damaging behaviors
on the choices that is made at the household level. This results in major health-damaging behaviors
on the choices that is made at the household level. This results in major health-damaging behaviors
on the choices that is made at the household level. This results in major health-damaging behaviors
on the choices that is made at the household level. This results in major health-damaging behaviors

This results in major health-damaging behaviors such as tobacco use, harmful use of alcohol,

inadequate

consumption of fruits and vegetables and preferential use of less expensive and unhealthy foods among the vulnerable

and marginalized

groups of people.

ENVIRONMENT

Environmental risk factors are contributing to the NCD’s’ like as Air Pollution,

water Pollution, Occupational Hazards and Exposure to Radiation.

INADEQUATE HEALTH SERVICES

Failure and inability to obtain preventive health services such as screening,

regular follow up are major predisposing factors to the NCDs. Also, some late diagnosis of disease conditions, untreated infections may lead to carcinomas.

STRESS FACTORS

Acute and chronic stresses such as Homelessness, Stressful work conditions and Situations as in Natural and Manmade Disasters are major causes for many physiological and psychological disorders.

and Situations as in Natural and Manmade Disasters are major causes for many physiological and psychological
and Situations as in Natural and Manmade Disasters are major causes for many physiological and psychological
NON MODIFIABLE RISK FACTORS
NON MODIFIABLE RISK FACTORS
NON MODIFIABLE RISK FACTORS
NON MODIFIABLE RISK FACTORS
NON MODIFIABLE RISK FACTORS

NON MODIFIABLE RISK FACTORS

NON MODIFIABLE RISK FACTORS

Non modifiable risk factors

The Risk factors, which cannot be modified:

Age: Elderly and children are the vulnerable group to get the diseases basically.

Sex: There will be some difference between the disease ratios among the gender.

Family History of Genetic Factors: Genetic factors are major risk factors

which cannot be modified.

Personality: Individual personality may contribute in development of the non communicable diseases.

be modified.  Personality: Individual personality may contribute in development of the non communicable diseases.
be modified.  Personality: Individual personality may contribute in development of the non communicable diseases.
be modified.  Personality: Individual personality may contribute in development of the non communicable diseases.
be modified.  Personality: Individual personality may contribute in development of the non communicable diseases.
INTERMEDIATE RISK FACTORS
INTERMEDIATE RISK FACTORS
INTERMEDIATE RISK FACTORS
INTERMEDIATE RISK FACTORS
INTERMEDIATE RISK FACTORS
INTERMEDIATE RISK FACTORS

INTERMEDIATE RISK FACTORS

INTERMEDIATE RISK FACTORS
INTERMEDIATE RISK FACTORS
INTERMEDIATE RISK FACTORS
Intermediate Risk Factors  Obesity and Overweight (overweight (BMI>=25) or Obese (BMI>=30))  Physical
Intermediate Risk Factors  Obesity and Overweight (overweight (BMI>=25) or Obese (BMI>=30))  Physical
Intermediate Risk Factors  Obesity and Overweight (overweight (BMI>=25) or Obese (BMI>=30))  Physical
Intermediate Risk Factors  Obesity and Overweight (overweight (BMI>=25) or Obese (BMI>=30))  Physical
Intermediate Risk Factors  Obesity and Overweight (overweight (BMI>=25) or Obese (BMI>=30))  Physical

Intermediate Risk Factors

Obesity and Overweight (overweight (BMI>=25) or Obese (BMI>=30))

Physical inactivity and inappropriate nutrition are directly reflected in the growing burden of overweight in the Indian population predominantly in the urban areas.

Central obesity is an important risk factor for diabetes and appears to better predict the risk of diabetes among Indians in Asian region.

Hyperlipidemias(>200 mg/dl) Serum Cholesterol A high blood cholesterol level is called hyperlipidaemia. Cholesterol

Hyperlipidemias(>200 mg/dl)

Serum Cholesterol

A high blood cholesterol level is called hyperlipidaemia.

Cholesterol can be measured as the level of Total Cholesterol in the blood. National guidelines suggest a challenging target of total cholesterol of less than 4.0mmol/l for individuals with established cardiovascular disease, diabetes, or at high risk of developing cardiovascular disease

Total cholesterol has two components;

1.High density lipoproteins; often called “good cholesterol”.it is the fraction of cholesterol that removes cholesterol (via the liver) from the blood.

Guidelines on HDL-C recommend treatment for those with concentrations below 1.0mmol/l.

2. Low density lipoproteins; often called “bad cholesterol” .High levels of (LDL-C) is positively correlated with CHD mortality

High saturated fat dietary intake can raise cholesterol levels

108

Risk Factors…

CHD risk prediction based on serum lipid levels a total “cholesterol/HDL ratio” has been

developed.

A ratio less than 3.5 has been recommended as a clinical goal for CHD prevention.

With newer technique HDL and LDL are further subdivided into sub fractions.

Recent evidences indicates that Plasma Apolipoprotein A1 (the major HDL protein) and

apolipoprotein B (the major LDL protein) are better predictors. Therefore measurements of

Apolipoprotein may replace lipoprotein cholesterol determinations in assessing the risk.

109

Therefore measurements of Apolipoprotein may replace lipoprotein cholesterol determinations in assessing the risk. 109
Global Burden of Raised Total Cholesterol  In 2008, global prevalence of raised total cholesterol
Global Burden of Raised Total Cholesterol  In 2008, global prevalence of raised total cholesterol
Global Burden of Raised Total Cholesterol  In 2008, global prevalence of raised total cholesterol

Global Burden of Raised Total Cholesterol

In 2008, global prevalence of raised total cholesterol among adults (≥ 5.0 mmol/l) was 39% (37% for males and 40% for females).

Estimated to cause 2.6 million deaths.

The Framingham Heart Study demonstrated the lower the HDL-C and higher LDL-C levels, the greater is the likelihood of developing coronary artery disease. The level of risk increases 3 fold when LDL-C is 220mg/dL and HDL-C is 25mg/dL (or 12.2mmol/l and 1.4mmol/l).

disease. The level of risk increases 3 fold when LDL-C is 220mg/dL and HDL-C is 25mg/dL
disease. The level of risk increases 3 fold when LDL-C is 220mg/dL and HDL-C is 25mg/dL
disease. The level of risk increases 3 fold when LDL-C is 220mg/dL and HDL-C is 25mg/dL

Raised Total Cholesterol: Health Effects

Increases risks of heart disease and stroke Globally, 1/3 of ischaemic heart disease

is attributable to high cholesterol

A 10% reduction in serum cholesterol in men aged 40 has been reported to result in a 50% reduction in heart disease within 5 years

A 10% reduction in serum cholesterol in men aged 70 years can result in an average 20% reduction in heart disease occurrence in the next 5 years

http://www.who.int/gho/ncd/risk_factors/cholesterol_text/en/

reduction in heart disease occurrence in the next 5 years  http://www.who.int/gho/ncd/risk_factors/cholesterol_text/en/
reduction in heart disease occurrence in the next 5 years  http://www.who.int/gho/ncd/risk_factors/cholesterol_text/en/
reduction in heart disease occurrence in the next 5 years  http://www.who.int/gho/ncd/risk_factors/cholesterol_text/en/
reduction in heart disease occurrence in the next 5 years  http://www.who.int/gho/ncd/risk_factors/cholesterol_text/en/

Raised blood Pressure (>120/80 mmhg)

 Raised blood Pressure (>120/80 mmhg)  Raised blood pressure is considered as modern life style

Raised blood pressure is considered as modern life style disorder in the present scenario. It is a major risk factor for cardiovascular diseases.

Hypertension and Excessive Sodium Intake

Sodium, through hypertension, is a major cause of cardiovascular disease deaths and

disability.

About 10% of cardiovascular disease is caused by excess sodium intake.

of cardiovascular disease is caused by excess sodium intake.  8.5 million deaths could be prevented

8.5 million deaths could be prevented over 10 years if sodium intake were reduced by 15%.

Sources of Sodium

People are unaware of how much dietary sodium they are eating.

In the U.S. 75% of sodium consumed comes from processed and restaurant foods.

In China and Japan, 75% of sodium consumed comes from cooking with high sodium products.

and restaurant foods.  In China and Japan, 75% of sodium consumed comes from cooking with
and restaurant foods.  In China and Japan, 75% of sodium consumed comes from cooking with
and restaurant foods.  In China and Japan, 75% of sodium consumed comes from cooking with
and restaurant foods.  In China and Japan, 75% of sodium consumed comes from cooking with
and restaurant foods.  In China and Japan, 75% of sodium consumed comes from cooking with

Recommendations and Actual Intakes WHO

Recommendations A population salt intake of less than 5 grams or approximately 2,000 milligrams of sodium, per person per day is recommended to reach national targets or in their absence. This level was recommended for the prevention of cardiovascular diseases.

Actual Intake Latest global estimates show that average sodium intake varies

from 2,000 to 7,200 milligrams of sodium per person per day.

global estimates show that average sodium intake varies from 2,000 to 7,200 milligrams of sodium per
global estimates show that average sodium intake varies from 2,000 to 7,200 milligrams of sodium per
global estimates show that average sodium intake varies from 2,000 to 7,200 milligrams of sodium per
global estimates show that average sodium intake varies from 2,000 to 7,200 milligrams of sodium per
global estimates show that average sodium intake varies from 2,000 to 7,200 milligrams of sodium per

Raised Blood Glucose(>120 mg/dl)

Global Burden of Elevated Glucose

In 2004, it was estimated that elevated glucose resulted in 3.4 million deaths (5.8% of all deaths).

Globally, approximately 9% of adults aged 25 and over had elevated blood glucose in 2008.

(5.8% of all deaths).  Globally, approximately 9% of adults aged 25 and over had elevated
(5.8% of all deaths).  Globally, approximately 9% of adults aged 25 and over had elevated
(5.8% of all deaths).  Globally, approximately 9% of adults aged 25 and over had elevated
(5.8% of all deaths).  Globally, approximately 9% of adults aged 25 and over had elevated

Elevated Glucose: Health Effects

Elevated glucose levels can lead to type 2 diabetes. Diabetes: leading cause of renal failure

Lower limb amputations are at least 10 times more common in people with diabetes than in non-diabetic people

•Raised glucose is a major cause of heart disease and renal disease.

with diabetes than in non-diabetic people  •Raised glucose is a major cause of heart disease
with diabetes than in non-diabetic people  •Raised glucose is a major cause of heart disease
with diabetes than in non-diabetic people  •Raised glucose is a major cause of heart disease
with diabetes than in non-diabetic people  •Raised glucose is a major cause of heart disease
with diabetes than in non-diabetic people  •Raised glucose is a major cause of heart disease
 WHO also identifies the six leading risk factors that are associated with non- communicable
 WHO also identifies the six leading risk factors that are associated with non- communicable
 WHO also identifies the six leading risk factors that are associated with non- communicable

WHO also identifies the six leading risk factors that are associated with non- communicable diseases as being the leading global risk factors for death

today:

Tobacco use

High blood pressure

Physical inactivity

High cholesterol levels

Overweight/obesity

High blood glucose levels

Tobacco use High blood pressure Physical inactivity High cholesterol levels Overweight/obesity High blood glucose levels
Tobacco use High blood pressure Physical inactivity High cholesterol levels Overweight/obesity High blood glucose levels

2012 WHO Global Targets: Reducing Risk Factors

2012 WHO Global Targets: Reducing Risk Factors http://www.who.int/nmh/events/2012/4November2012_PPT_RevPaper_TA.pdf

http://www.who.int/nmh/events/2012/4November2012_PPT_RevPaper_TA.pdf

2012 WHO Global Targets: Reducing Risk Factors http://www.who.int/nmh/events/2012/4November2012_PPT_RevPaper_TA.pdf
2012 WHO Global Targets: Reducing Risk Factors http://www.who.int/nmh/events/2012/4November2012_PPT_RevPaper_TA.pdf
COMPARATIVE HEALTH CARE SPENDING:
COMPARATIVE HEALTH CARE SPENDING:
COMPARATIVE HEALTH CARE SPENDING:
COMPARATIVE HEALTH CARE SPENDING:

COMPARATIVE HEALTH CARE SPENDING:

COMPARATIVE HEALTH CARE SPENDING:

Social and economic implications of non

communicable diseases…

economics of NCD

Thakur, et al.: Socio-

The multi-dimensional effect at individual, household, health system, and

macroeconomic level, NCDs are being labeled as a global ‘chronic

emergency.

Burden and Social Determinants of NCD in India.

A recent report by the World Bank for South-East Asia Region estimated NCDs to account for 62% of DALY losses in India in 2004.

While most of the developed countries witnessed a rise in NCD at a time when the communicable diseases had reached significantly lower levels; India is one of the developing countries which has witnessed a ‘double burden’ epidemiological transition with high rates of NCD morbidity and mortality at a time when the communicable diseases have yet not been controlled.

with high rates of NCD morbidity and mortality at a time when the communicable diseases have
with high rates of NCD morbidity and mortality at a time when the communicable diseases have
with high rates of NCD morbidity and mortality at a time when the communicable diseases have
with high rates of NCD morbidity and mortality at a time when the communicable diseases have

Indians contribute to 2.7 million CVD cases, 62.4 million diabetes, 1.5 million stroke, more than 30 million chronic respiratory diseases and 0.95 million

incident cancer cases.

As per latest projections, the number of diabetics in India are estimated to 62.4 million, which is the second largest in the world after China.

The prevalence of CVD has increased by nearly two times in rural areas, it has increased by six times in urban areas during the past four decades. This rate of increase has been estimated to be twice the rate at which CVDs increased in the developed countries.

. This rate of increase has been estimated to be twice the rate at which CVDs
. This rate of increase has been estimated to be twice the rate at which CVDs
. This rate of increase has been estimated to be twice the rate at which CVDs
. This rate of increase has been estimated to be twice the rate at which CVDs
 CVD was initially regarded as a disease of the affluent classes in INDIA. 
 CVD was initially regarded as a disease of the affluent classes in INDIA. 
 CVD was initially regarded as a disease of the affluent classes in INDIA. 
 CVD was initially regarded as a disease of the affluent classes in INDIA. 

CVD was initially regarded as a disease of the affluent classes in INDIA.

As the epidemic is maturing, a graded reversal of social gradient, with socio-

economically disadvantaged groups becoming increasingly vulnerable.

CVD risk is increasing among poor in slum and rural areas.

In selected urban, rural and slum communities of north India, prevalence of

hypertension was found to be statistically similar after controlling for age,

gender and education (P>0.05).

Prevalence of physical inactivity, central obesity, overweight and hypertension were found to be statistically similar among illiterate and literate population after controlling the effect of age, sex and place of residence (P>0.05).

As per Million Death Study (2001-03) in India, CVDs are already at the top among top 10 causes of adult deaths (2569 years) in urban and rural India

contributing to 32.8% and 23% of deaths, respectively.

Such numbers are compounded by the barriers to care for the rural poor with NCDs. In addition, technology for NCD care is usually concentrated in hospitals, making it harder to reach for rural dwellers.

Few study found that use of key treatments also differed by socioeconomic status.

harder to reach for rural dwellers.  Few study found that use of key treatments also
harder to reach for rural dwellers.  Few study found that use of key treatments also
harder to reach for rural dwellers.  Few study found that use of key treatments also
harder to reach for rural dwellers.  Few study found that use of key treatments also
Pathway illustrating the increased prevalence of NCDs has an impact on SES and health outcomes.

Pathway illustrating the increased prevalence of NCDs has an impact on SES and health outcomes.

Pathway illustrating the increased prevalence of NCDs has an impact on SES and health outcomes.
Pathway illustrating the increased prevalence of NCDs has an impact on SES and health outcomes.
Pathway illustrating the increased prevalence of NCDs has an impact on SES and health outcomes.
Pathway illustrating the increased prevalence of NCDs has an impact on SES and health outcomes.
 Socioeconomic inequalities affect health through more than one mechanism and involve material, psychosocial and
 Socioeconomic inequalities affect health through more than one mechanism and involve material, psychosocial and
 Socioeconomic inequalities affect health through more than one mechanism and involve material, psychosocial and
 Socioeconomic inequalities affect health through more than one mechanism and involve material, psychosocial and

Socioeconomic inequalities affect health through more than one mechanism and involve material, psychosocial and behavioral factors. Low income may affect

health directly.

A study which estimated causes of premature mortality in US found that 40% of

premature mortality in the US is the result of behavioral factors, compared

social and

environmental factors and 10% from healthcare deficiencies.

with

30%

arising

from

genetic

predisposition,

20%

from

Marmot et al have shown that the role of social determinants in the causation of NCDs seems to be more important than even the role of major behavioral risk factors.

social determinants play a role by altering the way people make their choices about personal behaviors, which exacerbates NCD prevalence, and hence it makes an even important case for the Governments to act on these social determinants

Microeconomic, Health System and Macroeconomic Impact of NCDs in India  Health care in India
Microeconomic, Health System and Macroeconomic Impact of NCDs in India  Health care in India
Microeconomic, Health System and Macroeconomic Impact of NCDs in India  Health care in India

Microeconomic, Health System and

Macroeconomic Impact of

NCDs

in

India

Health care in India is highly privatized, both in terms of financing and delivery. More than 80% of outpatient and 40% of inpatient care is sourced from private sector.

India spends about 4.2% of its GDP on health care, with about 30% of this total

health expenditure (THE) is contributed by the public sector. With only about 10% of the total population under cover of any form of health insurance, nearly 90% of the total private health expenditure is borne out-of-pocket by the households in 2000, which has reduced to 86.4% in 2009 and is still very high.

expenditure is borne out-of-pocket by the households in 2000, which has reduced to 86.4% in 2009
expenditure is borne out-of-pocket by the households in 2000, which has reduced to 86.4% in 2009
Financing for NCD  Mahal et al 2010 found that between two study periods (1995
Financing for NCD  Mahal et al 2010 found that between two study periods (1995
Financing for NCD  Mahal et al 2010 found that between two study periods (1995
Financing for NCD  Mahal et al 2010 found that between two study periods (1995

Financing for NCD

Mahal et al 2010 found that between two study periods (199596 and 2004), the share of NCDs in total out-of-pocket health expenditures in India increased from 31.6% to 47.3%, (or over 9 billion USD) of total OOP

expenditures, suggesting a growing importance of NCDs in terms of their

financial impact on households.

The average out-of-pocket expense per stay for inpatient treatment for NCDs is almost two times than for non-NCDs whether the treatment is in public or private facilities.

It is possible that early detection and treatment of NCDs at outpatient centers can substantially reduce the visits for inpatient care and reduce the cost of treatment for NCDs.

Financial households impact of NCDs on  Study in India showed that about 25% of
Financial households impact of NCDs on  Study in India showed that about 25% of
Financial households impact of NCDs on  Study in India showed that about 25% of
Financial households impact of NCDs on  Study in India showed that about 25% of

Financial

households

impact

of

NCDs

on

Study in India showed that about 25% of families with a member with CVD and 50% with cancer experience catastrophic expenditure and 10% and

25%, respectively, are driven to poverty.

The odds of incurring catastrophic hospitalization expenditure were nearly 160% higher with cancer than the odds of incurring catastrophic spending when hospitalization was due to a communicable disease.

Overall, NCDs are linked closely with MDG 2, 4, 5, 6 and 8e, so managing NCDs

is of central importance to progress toward achievement of these goals. By taking away a significant portion of household’s capacity to pay, NCDs leave little to be spent on education especially female education.

Impact of NCDs on health system  Increased prevalence of NCDs has also led to
Impact of NCDs on health system  Increased prevalence of NCDs has also led to

Impact of NCDs on health system

Increased prevalence of NCDs has also led to increased pressures on the health systems for providing treatment care and support.

The proportion of hospitalizations and outpatient consultations as a result of

NCDs rose from 32% to 40% and 22% to 35%, respectively, within a decade from

1995 to 2004. In macroeconomic term, most of the estimates suggest that the NCDs in India account for an economic burden in the range of 510% of GDP, which is significant and slowing down GDP thus hampering development.

Health and wealth reinforce each other and health systems are a catalyst for both, so strengthening health system is crucial to address the challenge of NCDs.

Impact of NCDs on gross domestic product  Mahal et al. 2010 concluded that in
Impact of NCDs on gross domestic product  Mahal et al. 2010 concluded that in
Impact of NCDs on gross domestic product  Mahal et al. 2010 concluded that in

Impact of NCDs on gross domestic product

Mahal et al. 2010 concluded that in the event of elimination of NCDs in 2004, India’s per capita GDP would be higher than its 2004 value (USD 562) by 5

10%.From 2005 to 2015, India is projected to lose international $237 billion

(1.5% of GDP) as a result of heart disease, stroke and diabetes

India is projected to lose international $237 billion (1.5% of GDP) as a result of heart
India is projected to lose international $237 billion (1.5% of GDP) as a result of heart
India is projected to lose international $237 billion (1.5% of GDP) as a result of heart

PREVENTION OF NON-COMMUNICABLE DISEASES

Prevention of NCDs can be done through following method 3,11

Primordial prevention: Through the prevention of emergence or development of risk factors in the population or in the countries in which they have not yet appeared. Efforts are directed towards discouraging children from adopting

harmful life styles.

Primary prevention: Action taken prior to the onset of disease which removes the possibility that the disease will ever occur. Effort will be done through health promotion and specific protection

the possibility that the disease will ever occur. Effort will be done through health promotion and

Secondary prevention: Action which halts the progress of the disease at its incipient stage and prevents complications.

Tertiary prevention: All measures available to reduce impairments and disabilities minimize suffering due to departure from good health and promote patient’s adjustment to irremediable conditions. Effort will be done through disability limitations and rehabilitation

patient’s adjustment to irremediable conditions. Effort will be done through disability limitations and rehabilitation
patient’s adjustment to irremediable conditions. Effort will be done through disability limitations and rehabilitation
patient’s adjustment to irremediable conditions. Effort will be done through disability limitations and rehabilitation
patient’s adjustment to irremediable conditions. Effort will be done through disability limitations and rehabilitation
WHO BEST BUYS FOR CONTROL OF NON- COMMUNICABLE DISEASES  World Health Organization has led
WHO BEST BUYS FOR CONTROL OF NON- COMMUNICABLE DISEASES  World Health Organization has led
WHO BEST BUYS FOR CONTROL OF NON- COMMUNICABLE DISEASES  World Health Organization has led

WHO BEST BUYS FOR CONTROL OF NON- COMMUNICABLE DISEASES

World Health Organization has led global efforts to address NCDs through development of different instruments. Those are Population level interventions and Individual Level Interventions.

Population level Interventions

NCDs can best be addressed by a combination of primary prevention, targeting whole population, by measures that targeting high-risk individuals and by improved access to essential health-care interventions for people with NCDs.

Enforcing bans on tobacco advertising, promotion and sponsorship.

Raising taxes on tobacco.

Strong legislative effort for tobacco control: Government of India had ratified the National Anti-Tobacco Legislation in 2007, which bans smoking in public places throughout the country.

Restricting access to retailed alcohol.

Enforcing bans on alcohol advertising.

Raising taxes on alcohol.

Promoting salt reduction in the community through awareness generation and reducing salt content of processed foods.

 Promoting salt reduction in the community through awareness generation and reducing salt content of processed
 Promoting salt reduction in the community through awareness generation and reducing salt content of processed
 Regulatory mechanism for fruits and vegetable prices.  Promoting public awareness about diet (Replacing
 Regulatory mechanism for fruits and vegetable prices.  Promoting public awareness about diet (Replacing
 Regulatory mechanism for fruits and vegetable prices.  Promoting public awareness about diet (Replacing

Regulatory mechanism for fruits and vegetable prices.

Promoting public awareness about diet (Replacing trans-fat in food with

polyunsaturated fat) and physical activity, through mass media.

Comprehensive policies on food production, nutrition, marketing, and transport to promote primordial prevention of CVDs. (Cardio-vascular diseases)

Modifying the environment (building the play grounds & parks for

the environment (building the play grounds & parks for relaxation).  Promoting use of cleaner alternate
the environment (building the play grounds & parks for relaxation).  Promoting use of cleaner alternate

relaxation).

Promoting use of cleaner alternate fuels in kitchens.

Improved monitoring and strict enforcement of air quality norms in urban as well as rural areas.

Public education on air-quality and measures to reduce air pollution.

Developing alternative financing models that protect citizens from the catastrophic financial impact of chronic diseases including CVDs.(Cardio- vascular diseases)

A major initiative in CVD control has been the launch of the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke [NPCDCS) in 2010. This envisages early diagnosis, risk reduction, and appropriate management of these diseases at primary health care level.

Protection from occupational carcinogens

Protection against HBV( Hepatitis B virus) and HPV (Human papilloma virus) by vaccination

occupational carcinogens  Protection against HBV( Hepatitis B virus) and HPV (Human papilloma virus) by vaccination
occupational carcinogens  Protection against HBV( Hepatitis B virus) and HPV (Human papilloma virus) by vaccination
occupational carcinogens  Protection against HBV( Hepatitis B virus) and HPV (Human papilloma virus) by vaccination
 Individual Level Interventions  Screening and early diagnosis of disease in all health care
 Individual Level Interventions  Screening and early diagnosis of disease in all health care
 Individual Level Interventions  Screening and early diagnosis of disease in all health care

Individual Level Interventions

Screening and early diagnosis of disease in all health care settings

Individual health education towards prevention of diseases and promotion of

health.

Counselling, drug therapy, specific treatment and rehabilitations.

prevention of diseases and promotion of health.  Counselling, drug therapy, specific treatment and rehabilitations.
prevention of diseases and promotion of health.  Counselling, drug therapy, specific treatment and rehabilitations.
prevention of diseases and promotion of health.  Counselling, drug therapy, specific treatment and rehabilitations.

Cardiovascular disease has the same meaning for health care

today as the epidemics of centuries had for medicine in earlier

times: 50% of the population in developed countries die of

cardiovascular disease” (Pal Kertai)

Someone has a heart attack every two minutes

(British Heart Foundation)

die of cardiovascular disease” (Pal Kertai) Someone has a heart attack every two minutes (British Heart
die of cardiovascular disease” (Pal Kertai) Someone has a heart attack every two minutes (British Heart

142

Historical Perspectives of CVD Epidemiology

Concept of “risk factors”, coined by Framingham Heart Study, involved gaining understanding of factors predisposing to occurrence of CVD

Framingham Heart Study was the first large-scale epidemiologic study, begun in 1948

First demonstrated epidemiologic relations of cigarette smoking, blood pressure, and cholesterol levels to incidence of CHD.

143

demonstrated epidemiologic relations of cigarette smoking, blood pressure, and cholesterol levels to incidence of CHD. 143

Public Health Significance

Leading cause of mortality in developed countries and a rising tendency in developing countries (disease of civilization)

A major impact on life expectancy

Significantly contributes to morbidity and death rates in the middle aged population: potential life years lost, common cause of premature death, labor force (economic costs), family life

Morbidity: nearly 30% of all disability cases

Contributes to deterioration of the quality of life

144

life  Morbidity: nearly 30% of all disability cases  Contributes to deterioration of the quality

Cardiovascular diseases

CVD comprise of a group of diseases of the heart and the vascular system.

Major conditions are

Ischemic heart disease

Hypertension

Cerebrovascular disease

Congenital heart disease

Rheumatic heart disease

disease  Hypertension  Cerebrovascular disease  Congenital heart disease  Rheumatic heart disease 145
disease  Hypertension  Cerebrovascular disease  Congenital heart disease  Rheumatic heart disease 145
disease  Hypertension  Cerebrovascular disease  Congenital heart disease  Rheumatic heart disease 145
disease  Hypertension  Cerebrovascular disease  Congenital heart disease  Rheumatic heart disease 145

Cardiovascular diseases

Problem Statement

World

32 million deaths NCD

16.7 million CVD

> 1/3 of these deaths in middle aged adults.

Heart disease and stroke are the 1 st and 2 nd leading cause of death for adult men and women.

Cardiovascular diseases (CVDs) account for >17 million deaths globally each year (30% of all deaths), 80% of which occur in low-income and middle-income countries, and this figure is expected to grow to 23.6 million by 2030.

Ischaemic heart disease alone caused 7 million deaths worldwide in 2010, an

increase of 35% since 1990.

146

 The projected trends in CVD mortality and the expected shifts from infectious to chronic
 The projected trends in CVD mortality and the expected shifts from infectious to chronic
 The projected trends in CVD mortality and the expected shifts from infectious to chronic

The projected trends in CVD mortality and the expected shifts from infectious to chronic diseases over the next few decades are shown in Figure .

CVD mortality and the expected shifts from infectious to chronic diseases over the next few decades
CVD mortality and the expected shifts from infectious to chronic diseases over the next few decades
CVD mortality and the expected shifts from infectious to chronic diseases over the next few decades

Deaths caused by CVD at 4 different stages of epidemiologic transition

Deaths caused by CVD at 4 different stages of epidemiologic transition 149

149

Cardiovascular Diseases

Problem Statement

India

2.33 million people died due to CVD during 2008.

Projections of number of death due to IHD

- 1990 1.17 million

- 2000 1.59 million

- 2010 2.03 million

of number of death due to IHD - 1990  1.17 million - 2000  1.59
of number of death due to IHD - 1990  1.17 million - 2000  1.59
of number of death due to IHD - 1990  1.17 million - 2000  1.59
of number of death due to IHD - 1990  1.17 million - 2000  1.59

Hospital based data:

Thirty year trends of (1960 -1990) hospital admissions reveal that admissions due to coronary disease have increased from 5% of hospital admission to almost 30%.

Projections based on modeling:

In a response to a systematic review by Ghaffar et al, Gupta projected a more than two fold increase in CHD mortality by the year 2020 as compared to the

numbers in 1990 (the projected mortality in 2020 is 2584000 as compared to

1175000 deaths in 1990).

Murray and Lopez in their Global Burden of Disease study project 4.8 million CVD deaths by the year 2020 AD, with majority of deaths occurring in middle age (47.7% of all CVD deaths). India will have lost 43.5 million DALYs by the year 2020 due to CVD.

occurring in middle age (47.7% of all CVD deaths). India will have lost 43.5 million DALYs
occurring in middle age (47.7% of all CVD deaths). India will have lost 43.5 million DALYs
occurring in middle age (47.7% of all CVD deaths). India will have lost 43.5 million DALYs
occurring in middle age (47.7% of all CVD deaths). India will have lost 43.5 million DALYs

Characteristics of CVD in Indians

The risk of death due to CHD is substantially higher among Indians and this is evident from ‘migrant’ studies which report a 1.5-3.8 CHD mortality ratio

among migrant Indians when compared to the local populations.

MORTALITY FROM CHD IN SOUTH ASIANS OVERSEAS

ratio among migrant Indians when compared to the local populations.  MORTALITY FROM CHD IN SOUTH
ratio among migrant Indians when compared to the local populations.  MORTALITY FROM CHD IN SOUTH

The INTERHEART study, a large case-control study, involving 15152 patients of

incident AMI and 14820 age & sex matched controls from 52 countries across

the globe demonstrated that the risk imposed by conventional risk factors for AMI among South Asians is similar to the Western populations

. However, given the background high prevalence of diabetes, impaired

glucose tolerance, insulin resistance and metabolic syndrome, the population

attributable risk and the individual-absolute risk get magnified manifold.

Burden of CVD risk factors in South Asians:

attributable risk and the individual-absolute risk get magnified manifold. Burden of CVD risk factors in South
Burden of CVD risk factors in South Asians:  Several cross-sectional studies were initiated in
Burden of CVD risk factors in South Asians:  Several cross-sectional studies were initiated in
Burden of CVD risk factors in South Asians:  Several cross-sectional studies were initiated in

Burden of CVD risk factors in South Asians:

Several cross-sectional studies were initiated in the late 1980s to obtain CVD risk factor prevalence among Indians. Studies that were large and well

designed are summarized in table . The cross sectional studies that were

carried out are of three types:

Cross-sectional surveys within India;

Migrant studies comparing South Asian (mainly Indians) to other local population; and

Comparison of migrants and their relatives living within India.

Asian (mainly Indians) to other local population; and  Comparison of migrants and their relatives living
Asian (mainly Indians) to other local population; and  Comparison of migrants and their relatives living
Proven and putative risk markers for Cardiovascular diseases
Proven and putative risk markers for Cardiovascular diseases
Proven and putative risk markers for Cardiovascular diseases

Proven and putative risk markers for Cardiovascular diseases

Proven and putative risk markers for Cardiovascular diseases
Proven and putative risk markers for Cardiovascular diseases
Proven and putative risk markers for Cardiovascular diseases
Proven and putative risk markers for Cardiovascular diseases
Coronary Heart Disease  Defined as “impairment of heart function due to inadequate blood flow
Coronary Heart Disease  Defined as “impairment of heart function due to inadequate blood flow
Coronary Heart Disease  Defined as “impairment of heart function due to inadequate blood flow

Coronary Heart Disease

Defined as “impairment of heart function due to inadequate blood flow to the heart compared to its needs caused by obstructive changes in the coronary circulation in the heart.

Cause of 25-30% of the deaths in industrialized countries.

The WHO has drawn attention to the fact that CHD is our modern

“epidemic”, i.e., a disease that affects populations, not an unavoidable

attribute of ageing.

Coronary Heart Disease

CHD may manifest itself in many presentations :

Angina Pectoris of effort

Myocardial infarction

Irregularities of heart

Cardiac Failure

Sudden death

Pectoris of effort  Myocardial infarction  Irregularities of heart  Cardiac Failure  Sudden death
Pectoris of effort  Myocardial infarction  Irregularities of heart  Cardiac Failure  Sudden death
Pectoris of effort  Myocardial infarction  Irregularities of heart  Cardiac Failure  Sudden death
Pectoris of effort  Myocardial infarction  Irregularities of heart  Cardiac Failure  Sudden death

Epidemicity

Epidemics of CHD began at different times in different countries

US - epidemics began in 1920- now declining

Britain 1930

Developing countries are catching up.

Singapore Doubled in 20 yrs.

Countries where the epidemic began earlier are now showing a decline