Course title : Code and number: Credit hours: Prerequisite : Level

Non-Communicable Diseases PHS 434 434 4 (4 +0) CMD 225 7

 Distribution of course degrees:

1 - (10) degrees for first midterm examination.

2 - (10) degrees for second midterm examination. 3 - (20) the degree of a sudden and short tests and research assignments, and workshops to discuss and share. 4 - (60) degrees for the final test.

References:

1- S.L. Goel. Education of Communicable and Non-Communicable

Diseases (2009) Publisher: Deep & Deep Publications

2- Judith Carrier. Managing Long-term Conditions and Chronic Illness in

Primary Care: A Guide to Good Practice (2009) Publisher: Routledge; 1 edition

3- Patrick L., M.D. Remington, Ross C., Ph.D. Brownson, and Mark V.,

M.D. Wegner Chronic Disease Epidemiology and Control (2010) Publisher: American Public Health Association; 3 edition
4- State-based chronic disease control: the Rocky Mountain Tobacco-

Free Challenge.: An article from: Morbidity and Mortality Weekly Report (2005) Publication: Morbidity and Mortality Weekly Report

 Welcome to the contents

Diseases classification

diseases

communicable

non communicable

Is a disease which is not infectious. Such diseases may result from genetic or lifestyle factors. A non-communicable disease is an illness that is caused by something other than a pathogen. It might result from hereditary factors, improper diet, smoking, or other factors. Those resulting from lifestyle factors are sometimes called diseases of affluence. Examples include hypertension, diabetes, cardiovascular disease, cancer, and mental health problems, asthma, atherosclerosis, allergy etc. The non-communicable diseases are spread by: heredity, surroundings and behavior.

A non-communicable disease, or NCD, is a medical condition or disease, which by definition is non-infectious and nontransmissible among people. NCDs may be chronic diseases of long duration and slow progression

Noncommunicable diseases are not spread by pathogens May be present at birth In other cases, noncommunicable disease may develop as a result of a persons lifestyle behavior May develop from the effects of substances in the environment or the cause may be unknown.

Many noncommunicable diseases are chronic- diseases that are present either continuously or off and on over a long time. Examples: asthma

Some noncommunicable diseases cause the body cells and tissue to break down, or degenerate. Degenerative diseases are diseases that cause further breakdown in body cells, tissues, and organs as they progress. Example: multiple sclerosis

Some babies are born with physical or mental disabilities that are a result of genetics or birth defects The causes of many birth defects are unknown Some may result from harmful substances in environment (x-rays), lifestyle behaviors of the mother (alcohol), or a defect in genes ( down syndrome).

Some diseases there are certain risk factors. Risk factors are characteristics that increase a persons chances of developing a disease Risk factors over which people have no control are heredity, age, gender, and ethnic group.

Lifestyle behaviors are risk factors we have control of:

Eating habits Physical activity Sleep habits Healthful lifestyles can prevent, control, or reduce

the risk of certain diseases.

16

These substances can cause serious health problems or make existing health problems worse
Chemical waste buried in landfills creates fumes;

illness can occur years after initial exposure. Construction materials (asbestos) can cause lung disease long after exposure

 Household chemicals (paints, solvents) can

pollute the indoor air and cause health problems Secondhand smoke can be harmful to nonsmokers Improper waste disposal by manufacturers of household items like plastics/paint creates water and air pollution. Oil from cars old aerosol cans can pose health risks too.

 Radon a colorless, odorless gas released from soil and

rocks that contain tiny amounts of radium. Radon can seep into the air through foundations, basements, and pipes. Exposure over a long period of time increases the risk of lung cancer. Carbon monoxide is a colorless, odorless gas produced when fuel is burned. It is present in fumes from car exhaust and some furnaces and fireplaces. If fuel burning appliances do not work properly they can produce dangerous levels of carbon monoxide which can cause illness or death.

Allergies Alzheimers disease Arthritis Asthma Cancer Cardiovascular disease Cerebral palsy Cystic Fibrosis Multiple Sclerosis Muscular Dystrophy Sickle-Cell disease

 Approximately, 17 million people die prematurely each year as a

result of the global epidemic of chronic diseases The risks of high blood pressure and high blood cholesterol, tobacco and excessive alcohol consumption, obesity and physical inactivity were more commonly associated with affluent societies. becoming dominant in all middle and low income countries and not limited to the effluent countries NCDs, is responsible for almost 60% of world deaths (31.7 million deaths) and 43% of the global burden of diseases.

 This increase is clearly related to changes in global dietary

patterns and increased consumption of industrially processed fatty, salty and sugary foods
In its 2003 annual report, MOH stated that it considers (NCDs),

caused by unhealthy diets and habits, to be just as serious as those caused by under-nutrition

Some Continuing Challenges

Lack of national policies for NCD prevention and control
Low resources - only 1/3 of countries have a budget line for NCD prevention & control. Lack of NCD surveillance systems Fragmented and uncoordinated care PHC capacity to deal with NCDs is poor

NCD CHALLENGES
Cost Pressures Disease burden, interventions, drugs Quality of Care Care teams, medical records, financial incentives Prevention Fragmentation, lack of protocols, lack of financial incentives/support Poverty

CHANGES NEEDED

Comprehensiveness

With policy/legislation support Information flows Organized Care Orient. on self management

Coordination

Continuity

Communication Community linkages

How to strengthen health systems for NCDs?

Financing (increased, better and sustained Regulation (assured quality and affordability) Service Delivery (ensured access and availability) Governance (improved performance)

26

Epidemiology of NonCommunicable Diseases

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

Gaps in the natural history of NCD

1. 2.

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

Gaps in the natural history of NCD

Web of causation
Changes in life style stress

Abundance of food

lack of physical activity

smoking

emotional disturbance
aging

Obesity Hyperlipidemia thrombotic tendency

hypertension

changes artery walls Coronary arthrosclerosis coronary occlusion

Myocardial infarction

Gaps in the natural history of NCD

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.
3.

Prevention of NCD
To lessen the impact of NCDs on individuals and

society, a comprehensive approach is needed that requires all sectors, including health, finance, foreign affairs, education, agriculture, planning and others, to work together to reduce the risks associated with NCDs, as well as promote the interventions to prevent and control them.

32

 Other way is via a primary health-care approach to

strengthen early detection and timely treatment. Evidence shows that such interventions are excellent economic investments because, if applied to patients early, can reduce the need for more expensive treatment.

33

Prevention of NCD
Levels of prevention 1. Primordial For healthy people 2. Primary
3. 4. 1.

Secondary

For unhealthy people

Tertiary Primordial prevention- Prevention of the emergence or development of risk factors in countries or population groups 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. Can be divided into population & high risk strategy.

2.

Causation in epidemiology
Cause :is an event, circumstance, condition, risk factor, exposure, characteristic or a combination of these factors, which results in producing the disease. Necessary cause: Vibrio cholerae is necessary for Cholera. Sufficient cause : are factors and conditions ,which are other than the etiological cause of disease. In sanitary conditions, water conditions, adequate dose of vibrio cholerae,host immunity.

Association and causation :

Association may be defined as
ASSOCIATION

the concurrence of two variables more often than would be expected by chance. It does not necessarily imply a causal relationship.
SPURIOUS DIRECT (CAUSAL) INDIRECT

Correlation indicates the degree

of association between two characteristics. The correlation coefficients range from -1.0 to +1.0

ONE TO ONE CAUSAL

MULTI FACTORIAL

1. Spurious association: When an observed association between a disease and suspected factor is not real.
Direct (causal): One to one relationship Germ theory of disease Necessary cause Sufficient cause Multifactorial causation
2.

3.Indirect association : It is statistical association between a variable and a disease due to presence of another factor known or unknown, that is common to both the variable and disease. This common factor is confounding factor.
altitude

Iodine deficiency

endemic goiter

Criteria for causality

temporal

coherence

strength

association

biological

specificity

consistency

1. Temporal association: the cause must precede the effect. 2. Strength of association:

Larger the relative risk greater the likely hood of causal relation Dose response and duration response relationship 3. Specificity of association: one to one relationship between cause and effect. It is difficult in chronic diseases. lung cancer ca cervix Cigarette smoking

Consistency of association: .4 When results are replicated when studied in different settings and by different methods. Biological plausibility : .5 Association agrees with current understanding of the response of cells, tissues, organs and system to stimuli. Food intake and cancer are correlated. The positive association of intestine and rectal carcinoma is logical whereas positive association of food and Ca. skin makes no biological sense. Coherence of association: .6 Rising consumption of tobacco in form of cigarettes and rising incidence of lung Ca. Fall in RR of lung Ca when smoking is stopped.

The next will be

Examples of chronic non - communicable diseases

41

Diabetes Mellitus

Definition of DM
Diabetes is a chronic disease that occurs when the pancreas does not produce enough insulin, or alternatively, when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar

Glucose Tolerance Categories

FPG mg/dL
126 100 and <126
Diabetes Mellitus

2-hr PG on OGTT mg/dL

200 140 and <200 Diabetes Mellitus

Prediabetes Glucose
Normal

Prediabetes Tolerance
Normal

<100

<140

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

Etiologic Classification of Diabetes Mellitus

Type1 Type2 b-cell destruction with lack of insulin Insulin resistance with insulin deficiency

Other specific types

exocrine Genetic defects in b-cell pancreas diseases drug- or chemical induced, and other rare forms
Insulin resistance with b-cell dysfunction

Gestational

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

Complications of Diabetes
Macrovascular
Brain Cerebrovascular disease Transient ischemic attack Cerebrovascular accident Cognitive impairment Heart Coronary artery disease Coronary syndrome Myocardial infarction Congestive heart failure Extremities Peripheral vascular disease Ulceration Gangrene Amputation

Microvascular
Eye Retinopathy Cataracts Glaucoma

Kidney Nephropathy Microalbuminuria Gross albuminuria Kidney failure

Nerves Neuropathy Peripheral Autonomic

 "Diabetes is a major threat to global public health that

is rapidly getting worse, and the biggest impact is on adults of working age in developing countries. At least 171 million people worldwide have diabetes. This figure is likely to more than double by 2030 to reach 366 million."

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

World 2003 = 194 million 2030 = 366 million Increase 75%

Epidemiology
In 2000, according to the World Health Organization, at least 171

million people worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is estimated that by the year 2030, this number will double.
Prevalence of Diabetes mellitus among population above 20 years

in 2005 was 11%.(WHO,)2006

Diabetes is in the top 10, and perhaps the top 5, of the most

significant diseases in the developed world. (Wikipedia)

 According to the American Diabetes Association,

approximately 18.3% (8.6 million) of Americans age 60 and older have diabetes. Diabetes mellitus prevalence increases with age. (ADA, .)2004
The National Diabetes Information Clearinghouse

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

Diabetes frequency is dramatically rising all over the world

The World Health Organization (WHO) estimates

that more than 180 million people worldwide have diabetes. This number is likely to more than double by 2030. In 2005, an estimated 1.1 million people died from diabetes. Almost 80% of diabetes deaths occur in low and middle-income countries.

 The global increase in diabetes will occur because of

population ageing and growth, and because of increasing trends towards obesity, unhealthy diets and sedentary lifestyles. Worldwide, 3.2 million deaths are attributable to diabetes every year. One in 20 deaths is attributable to diabetes; 8,700 deaths every day; six deaths every minute.

 At least one in ten deaths among adults between 35 and 64 years

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

Almost half of diabetes deaths occur in people under

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

 In developed countries most people with diabetes are

above the age of retirement, whereas in developing countries those most frequently affected are aged between 35 and 64. WHO projects that diabetes deaths will increase by more than 50% in the next 10 years without urgent action. Most notably, diabetes deaths are projected to increase by over 80% in upper-middle income countries between 2006 and 2015.

 In the developed world, diabetes is the most significant cause of adult blindness in the nonelderly, the leading cause of non-traumatic

amputation in adults, and diabetic nephropathy is the main illness requiring renal dialysis in the United States .

Estimated number of adults with diabetes by agegroup in the world

Estimated number of adults with diabetes by agegroup in developed courtiers

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

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

New cases of Diabetes mellitus in West Bank clinics

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

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

0.5 0.4 0.3 0.2 0.1 0 less than 34

6.30%

41.00% 28.20%

24.40%

35-54

55-64

65 and more

Distribution of diabetic (type II) cases by management in the West Bank health clinic:
1. About 28.6% of diabetics cases were managed by

insulin treatment. 2. About 5.0% were treated with a combined therapy (insulin and OHA). 3. About 64.7% of diabetics' cases were managed by tablets. 4. Diet control (exclusively managed by lifestyle modification) was 1.7%

Major risk factors

Family history Obesity Age (older than 45) History of gestational diabetes High cholesterol Hypertension

Prevention of effects combination approach

Increased exercise

Decreases need for insulin

Reduce calorie intake

Improves insulin sensitivity

Weight reduction

Improves insulin action

Triad of Treatment
Diet Medication Oral hypoglycemics Insulins Exercise

Diet
Lower calorie
Fewer foods of high glycemic index Spread meals evenly

Diabetic Meal Plan Using the Food Guide Pyramid

Anti-Diabetic medications
Oral hypoglycemic agents

Sulfonylureas Thiazolidinediones Biguanides Alpha-glucosidase inhibitors D-phenylalinine derivatives

Insulins

Obesity

 Obesity is a condition in which people have an excess of

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

one-third of Americans are obese.

Obesity is growing problem across the globe. Worldwide, more than 300 million adults are obese,

according to (WHO). obesity is the second-leading cause of preventable death in the U.S, surpassed only by smoking. At least 300,000 Americans die each year as a result of factors attributed to obesity, American Obesity Association

Obesity is a major risk factor for a number of serious health conditions, including:

Coronary heart disease. Cancer. Diabetes. Fatty liver disease. Gallbladder disease. High blood pressure.. Osteoarthritis. Stroke. Sleep apnea and other breathing problems.

Classification
Obesity, in absolute terms, is an increase of body adipose tissue (fat tissue) mass. BMI Body mass index or BMI is a simple and widely used method for estimating body fat mass. BMI was developed in the 19th century by the Belgian statistician

 BMI is an accurate reflection of body fat percentage in the majority of the adult

population. It is less accurate in people such as body builders and pregnant women in whom body composition is affected.
BMI is calculated by dividing the subject's weight by the square of his or her height:

BMI = kg / m2

BMI

Classification

Less than 18.5 18.524.9 25.029.9 is 30.034.9 is

underweight

normal weight overweight class I obesity

35.039.9

class II obesity

Questions ??

 The surgical literature breaks down "class III" obesity into further

categories.
Any BMI > 40 is severe obesity A BMI of 40.049.9 is morbid obesity A BMI of >50 is super obese

Gabriel I Uwaifo (June 19, 2006). "Obesity". Retrieved on 2008-09-29.

Cancer

Cancer
medical term: (malignant neoplasm) is

a class of diseases in which a group of cells display uncontrolled growth, invasion and sometimes metastasis (spread to other locations in the body via lymph or blood) .

 Cancer may affect people at all ages, even fetuses, but

the risk for most varieties increases with age. Cancer causes about 13% of all deaths. According to the American Cancer Society, 7.6 million people died from cancer in the world during 2007.

2006 Estimated US Cancer Deaths*

Lung & bronchus 31%

Colon & rectum

Prostate Pancreas Leukemia Liver & intrahepatic bile duct Esophagus Non-Hodgkin lymphoma Urinary bladder Kidney All other sites

10%
9% 6% 4% 4% 4% 3% 3% 3% 23%

Men 291,270

Women Lung & bronchus 26% 273,560

Breast
Colon & rectum Pancreas Ovary Leukemia Non3% Hodgkin lymphoma Uterine corpus 3% Multiple myeloma 2% 10% 6% 6% 4%

15%

Brain/ONS
All other sites

2%
23%

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

Hypertension The Silent killer

88

Definition

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

89

Classification of hypertension : Essential ( primary ) Hypertension : It indicates that no specific medical cause can be found to explain a patient's condition, from the patients diagnosed with hypertension, 95% fall in the category of essential (or idiopathic) hypertension.
Secondary Hypertension : Indicates that the high blood pressure is a result of (i.e. secondary to) another condition, such as kidney disease or tumors, 5% will fall in the category of secondary hypertension.
90

Risk factors for hypertension include:

Modifiable
Body weight
Sodium chloride intake Alcohol intake Physical activity Psychosocial factors Socio-economic status Hormonal contraceptives Non-modifiable Age Sex/gender Heredity Ethnicity/race

91

Global burden of hypertension

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

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

92

Prevalence of hypertension can differ according to gender and age.

Men are at increased risk for high blood pressure as compared to women until the age of 55. After 55, there is a higher percentage of women at risk for high blood pressure. High blood pressure is 2 to 3 times more

common in women taking oral contraceptives, especially in obese and older women, than in women not taking them. 64% of men over 75 years old have hypertension.
93

 77% of women over 75 years old have hypertension. Older females have a significant risk of developing high blood pressure. More than 50% of women over age 60 have high blood pressure.

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

Hypertension disease Mortality in 2005 :

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

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

95

Cardiovascular Disease

Introduction
Non communicable disease account for a large and increasing burden of disease worldwide. It is currently estimated that non communicable disease accounts for approximately 59% of global deaths and 43% of global disease burden. This is projected to increase to 73% of deaths and 60% of disease burden by 2020.

Introduction, cont.
The worldwide burden of cardiovascular disease is substantial. In most industrialized countries, cardiovascular disease are the leading cause of disability and death. Developing countries, with previous low rate are now seeing increased rates as economic develop, infectious disease are conquered and life expectancy improves.

Definition
Cardiovascular disease refers to the class of diseases that involve the heart or blood vessels (arteries and veins). While the term technically refers to any disease that affects the cardiovascular system, it is usually used to refer to those related to atherosclerosis (arterial disease).

CVD are present in many forms and have different categories and include: Hypertension (high blood pressure) Coronary heart disease (heart attack) Cerebrovascular disease (stroke) Peripheral vascular disease Heart failure Rheumatic heart disease Congenital heart disease Cardiomyopathies

Risk factors for cardiovascular disease

Non-modifiable Risk Factors

Age Gender, men under the age 64 are much more likely to die of

coronary heart disease than women, although anyone can die from it. Genetic factors/Family history of cardiovascular disease. Race (or ethnicity), Studies show that blacks are twice as likely to develop high blood pressure as Caucasians.

Risk factors, cont.

Environment, your chances can increase because of areas with a lot

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

Modifiable Risk Factors cigarette smoking, high cholesterol and high blood Pressure, lack of exercise, diabetes, obesity, alcohol, certain infections and inflammation, estrogens, androgens, and certain psychosocial factors.

Global Burden of Cardiovascular Disease

Cardiovascular disease is the number one cause of death globally and is projected to remain the leading cause of death.

An estimated 17.5 million people died from cardiovascular disease in 2005, representing 30 % of all global deaths. Of these deaths, 7.6 million were due to heart attacks and 5.7 million were due to stroke.

Statistics, cont
Around 80% of these deaths occurred in low and middle income countries (LMIC). If appropriate action is not taken, by 2015, an estimated 20 million people will die from cardiovascular disease every year, mainly from heart attacks and strokes. (WHO, 2005)

Percentage breakdown of deaths from cardiovascular diseases

Statistics, cont
American Heart Association, 2006. Estimates for the year 2005 are that 80,700,000 people in the United States have one or more forms of cardiovascular disease (CVD).
High blood pressure 73,000,000.

Coronary heart disease 16,000,000.

Myocardial infarction (acute heart attack) 8,100,000.

Statistics, cont
Angina pectoris (chest pain or discomfort caused

by reduced blood supply to the heart muscle) 9,100,000. Stroke 5,800,000. Heart Failure 5,300,000 Over 142,000 Americans killed by CVD in 2004 are under age 65

Statistics, cont
2004 death rates from CVD were 335.1 for white males and 454.0 for black males; for white females 238.0 and for black females 333.6 (Death rates are per 100,000 population. From 1993 to 2003 death rates from CVD declined 24.7 percent. Despite this decline in the death rate, in the same 10-year period the actual number of deaths declined only 8 percent.

Cardiovascular Disease Mortality Indicator

Mortality rate per 100,000 of cardiovascular diseases was: All heart diseases 56.8 Rheumatic HD 0.7 Ischemic HD 36.4 Pulmonary HD 1.6 Other heart diseases 18.1 CVA 29.8 Essential hypertension 13

Statistics
In 2005, 3,799 persons died from cardiovascular diseases (1,956 males and 1,843 females), with a proportion of 36.7% of total deaths, with a rate of 101/100,000 population. Mortality among males was higher than females (51.5% in males and 48.5% in females).

Statistics, cont
Cardiovascular mortalities are ranking as following: 1. All heart diseases (Ischaemic, Rheumatic, Pulmonary and Other Heart diseases), constitute 56.8% of cardiovascular diseases with a rate of 54.4 per 100,000 population 2. Ischaemic heart disease constitutes 37.5% of cardiovascular diseases with a rate of 35.9 per 100,000 population;

Statistics, cont
3. Cerebrovascular disease constitutes 24.4% of CVDs

with a rate of 23.4 per 100,000 population. 4. Hypertensive disease constitutes 17.4% of cardiovascular diseases with a rate of 16.6 per 100,000 population. 5. Other heart diseases constitutes 17.4% of cardiovascular diseases with a rate of 16.7 per 100,000 population.

Thanks