Non-communicable diseases

(NCDs)
Non-communicable diseases (NCDs)
Is a disease which is not infectious. Such diseases may result from
genetic or lifestyle factors.
A non-communicable disease is an illness that is caused by something
other than a pathogen.
It might result from hereditary factors, improper diet, smoking, or
other factors. Those resulting from lifestyle factors are sometimes
called diseases of affluence.
Examples include hypertension, diabetes, cardiovascular disease,
cancer, and mental health problems, asthma, atherosclerosis, allergy
etc.
The non-communicable diseases are spread by: heredity, surroundings
and behavior.
Approximately, 17 million people die prematurely each year as a
result of the global epidemic of chronic diseases
The risks of high blood pressure and high blood cholesterol,
tobacco and excessive alcohol consumption, obesity and physical
inactivity were more commonly associated with affluent societies.
becoming dominant in all middle and low income countries and not
limited to the effluent countries
NCDs, is responsible for almost 60% of world deaths (31.7 million
deaths) and 43% of the global burden of diseases.
This increase is clearly related to changes in global dietary
patterns and increased consumption of industrially processed
fatty, salty and sugary foods

In its 2003 annual report, MOH stated that it considers (NCDs),
caused by unhealthy diets and habits, to be just as serious as
those caused by under-nutrition
NCDs Situation in Palestine:
NCDs are the leading cause of death among adult population in the
Palestinian society, contribute to more than 50% of causes of death
among adults
common Risk factors to NCDs in Palestinian population.
Tobacco consumption is among the highest in the world.
Diet rich in saturated fat, and in simple sugars, with the decreased
consumption of fibers, whole grain foods, and complex carbohydrates
has lead to the increased prevalence of these illnesse.
Keeping in mind the current situation of health services and the
increasing level of poverty, there should be a special concern of
disability related to NCDs.

Health services today will not be able to
meet the challenges of (NCDs) In Palestine
No or weak national data is available on the overall incidence and prevalence
ofNCDs.
In general we depend on mortality data to estimate the impacts of these diseases.
No classification by age or gender. No any information on disabilities resulting
from any of the chronic diseases
The current system counts mainly the visits of the patients to PHC centers, which
does not reflect the real prevalence and incidence.
Fragmentation in reporting and managing system regarding NCDs in general and
DM in specific.

This lack of information leads to:
- Inability to estimate the direct and indirect cost; resources required e.g. drugs, policy;
and decision making regarding prevention and treatment


Some Continuing Challenges

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

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




CHANGES NEEDED
Comprehensiveness
With policy/legislation
support
Coordination
Information flows
Continuity
Organized Care
Communication
Orient. on self management
Community linkages
How to strengthen health
systems for NCDs?
Financing (increased, better and sustained
Regulation (assured quality and affordability)
Service Delivery (ensured access and
availability)
Governance (improved performance)

Obesity


Obesity is a condition in which people have an excess of
body fat.
According to (CDC), the prevalence of obesity in the U.S
more than doubled between the years 1960 and 2000, with
the greatest increase from 1980 forward.

According to the National Institutes of Health, almost
one-third of Americans are obese.

Obesity is growing problem across the globe.
Worldwide, more than 300 million adults are obese,
according to (WHO).
obesity is the second-leading cause of preventable death
in the U.S, surpassed only by smoking. At least 300,000
Americans die each year as a result of factors attributed to
obesity, American Obesity Association
Obesity is a major risk factor for a number
of serious health conditions, including:
Coronary heart disease.
Cancer.
Diabetes.
Fatty liver disease.
Gallbladder disease.
High blood pressure..
Osteoarthritis.
Stroke.
Sleep apnea and other breathing problems.



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


Classification BMI
underweight Less than 18.5
normal weight 18.524.9
overweight 25.029.9 is
class I obesity 30.034.9 is
class II obesity 35.039.9
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*
ONS=Other nervous system.
Source: American Cancer Society, 2006.
Men
291,270
Women
273,560
26% Lung & bronchus
15% Breast
10% Colon & rectum
6% Pancreas
6% Ovary
4% Leukemia
3% Non-
Hodgkin
lymphoma
3% Uterine corpus
2% Multiple myeloma
2% Brain/ONS
All other sites 23%
Lung & bronchus 31%
Colon & rectum 10%
Prostate 9%
Pancreas 6%
Leukemia 4%
Liver & intrahepatic 4%
bile duct
Esophagus 4%
Non-Hodgkin 3%
lymphoma
Urinary bladder 3%
Kidney 3%
All other sites 23%

28
29
Definition
Hypertension is high blood
pressure. Blood pressure is the
force of blood pushing against the
walls of arteries as it flows through
them.

30
Classification of hypertension :
Essential ( primary ) Hypertension :
It indicates that no specific medical cause can be found to
explain a patient's condition, from the patients diagnosed
with hypertension, 95% fall in the category of essential (or
idiopathic) hypertension.

Secondary Hypertension :
Indicates that the high blood pressure is a result of (i.e.
secondary to) another condition, such as kidney disease or
tumors, 5% will fall in the category of secondary
hypertension.

Risk factors for hypertension include:
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

31
32
Global burden of hypertension

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

Kearney PM et al. Lancet 2005; 365:217-223.
Prevalence of hypertension can differ
according to gender and age.

Men are at increased risk for high blood
pressure as compared to women until the age of
55. After 55, there is a higher percentage of
women at risk for high blood pressure.
High blood pressure is 2 to 3 times more
common in women taking oral contraceptives,
especially in obese and older women, than in
women not taking them.
64% of men over 75 years old have
hypertension.
33
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 )


35
Hypertension affects 65 million adults in the United States.
The prevalence of hypertension is higher at the older ages.

In USA
36
In Palestine
In Palestine, no or weak national data are available
on the overall incidence and prevalence of
cardiovascular diseases (CVD), hypertension
diseases, Diabetes Mellitus (DM) and accidents.
In general we depend on mortality data to estimate
the impacts of these diseases. The current system
counts mainly the visits of the patients to PHC,
which does not reflect the real prevalence or
incidence. Besides, there is no classification by age
or gender mainly because of no computerized
system.

37
Population pyramid for 2004
Total population: 3,638,000 (WB 2,300,000/ GS 1,338,000)

( Demographic Indicators, 2004 ,MOH)
38
Hypertension disease Mortality in 2005 :

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

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



Cardiovascular Disease
Introduction
Non communicable disease account for a
large and increasing burden of disease
worldwide. It is currently estimated that
non communicable disease accounts for
approximately 59% of global deaths and
43% of global disease burden. This is
projected to increase to 73% of deaths and
60% of disease burden by 2020.
Introduction, cont.
The worldwide burden of cardiovascular disease is
substantial. In most industrialized countries,
cardiovascular disease are the leading cause of
disability and death. Developing countries, with
previous low rate are now seeing increased rates as
economic develop, infectious disease are conquered
and life expectancy improves.

Cardiovascular disease refers to the class of
diseases that involve the heart or blood
vessels (arteries and veins). While the term
technically refers to any disease that affects
the cardiovascular system, it is usually used
to refer to those related to atherosclerosis
(arterial disease).
Definition
CVD are present in many forms and have
different categories and include:-
Hypertension (high blood pressure)
Coronary heart disease (heart attack)
Cerebrovascular disease (stroke)
Peripheral vascular disease
Heart failure
Rheumatic heart disease
Congenital heart disease
Cardiomyopathies
Risk factors for cardiovascular
disease
Non-modifiable Risk Factors

Age
Gender, men under the age 64 are much more likely to die of
coronary heart disease than women, although anyone can die
from it.
Genetic factors/Family history of cardiovascular disease.
Race (or ethnicity), Studies show that blacks are twice as likely
to develop high blood pressure as Caucasians.
Risk factors, cont.
Environment, your chances can increase because of areas with a lot
of smog or other form of air pollution, including passive smoking.

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



Risk factors for CVD in Palestine
There is little published information on the cardiovascular
disease risk factors of Palestinian population.
The study was aim to identify the most common coronary
heart disease risk factors among adult population in Gaza
Strip to develop preventive health education and health
promotion programs

This study shown that the most common
identified CHD risk factors were physical
inactivity 53%, hypertension and obesity 43%
for each, family history 38%, diabetes mellitus
34%, high LDL 34%, elevated cholesterol level
33%, smoking 29%, low HDL 27%,
hyperuricemia 25%, and elevated triglycerides
level 14%
Other study conducted by Heart Institute and
Epidemiology Unit, Hadassah-Hebrew University
Medical Center, Jerusalem, evaluated the coronary
risk characteristics of Palestinian and Israeli women
with coronary artery disease in Jerusalem. The study
finding reflect that Palestinian Arab women in
Jerusalem appear to have more diabetes and exhibit
lifestyle factors (lower socioeconomic status, suffered
more passive smoking and were less physically active)
that generally increase the risk for CHD than Jewish
women.

The result of previous studies seems to be that
most of the identified CHD risk factors could be
preventable.
These results may highlight the problem as a
public in nature that need community-based
intervention programs integrated to health
education programs.
Risk factors conclusion & recommendation

According to these result greater attention to
primary prevention is needed.
These result suggests the need investigate
determinants of the metabolic syndrome and
the possible role of passive smoking in Arab
women as well as modes of intervention via
health promotion and risk factor management
in this population.

Global Burden of Cardiovascular
Disease




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

An estimated 17.5 million people died from
cardiovascular disease in 2005, representing 30 % of all
global deaths.

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

Statistics, cont

Around 80% of these deaths occurred in low and
middle income countries (LMIC).

If appropriate action is not taken, by 2015, an
estimated 20 million people will die from
cardiovascular disease every year, mainly from heart
attacks and strokes. (WHO, 2005)

Percentage breakdown of deaths
from cardiovascular diseases

Statistics, cont
American Heart Association, 2006.

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

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


Statistics, cont
Angina pectoris (chest pain or discomfort caused
by reduced blood supply to the heart muscle)
9,100,000.
Stroke 5,800,000.
Heart Failure 5,300,000
Over 142,000 Americans killed by CVD in 2004 are
under age 65
Statistics, cont
2004 death rates from CVD were 335.1 for white males and 454.0
for black males; for white females 238.0 and for black females
333.6 (Death rates are per 100,000 population.

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

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



Cardiovascular disease in
Palestine


Cardiovascular disease (CVDs), principally heart diseases
is the first leading cause of death among population in
Palestine in the year 2005 exactly as it is in the whole
world. This involves males and females with a proportion
of 18.7% and 19.9% respectively of the total number of
death in Palestine.


Cardiovascular diseases and stroke are major
cause of illness, disability and death in
Palestine, which causes an increase in personal,
community and health care costs. This really
requires a competent plan to address this
important and serious issue.
There are no available data to suggest the
overall prevalence or incidence of
cardiovascular disease and hypertension, we
depend on mortality data from the different
health centers to estimate the impact of theses
diseases on society.

Mortality rate per 100,000 of cardiovascular
diseases was:

All heart diseases 56.8
Rheumatic HD 0.7
Ischemic HD 36.4
Pulmonary HD 1.6
Other heart diseases 18.1
CVA 29.8
Essential hypertension 13





Cardiovascular Disease Mortality Indicator
Statistics
In 2005, 3,799 persons died from cardiovascular
diseases (1,956 males and 1,843 females), with a
proportion of 36.7% of total deaths, with a rate 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;


3. Cerebrovascular disease constitutes 24.4% of CVDs
with a rate of 23.4 per 100,000 population.
4. Hypertensive disease constitutes 17.4% of
cardiovascular diseases with a rate of 16.6 per
100,000 population.
5. Other heart diseases constitutes 17.4% of
cardiovascular diseases with a rate of 16.7 per
100,000 population.
Statistics, cont
Mortality rate of all CVD in
Palestine,2005 (per 100,000)

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

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

FPG 2-hr PG on OGTT
126
100 and <126
<100
200
140 and <200
<140
Glucose
Prediabetes
Normal
Diabetes Mellitus
Tolerance
Prediabetes
Diabetes Mellitus
Normal
mg/dL mg/dL
Etiologic Classification of
Diabetes Mellitus
b-cell destruction with lack of
insulin
Type1
Insulin resistance with insulin
deficiency

Type2
Genetic defects in b-cell exocrine
pancreas diseases drug- or chemical
induced, and other rare
forms
Other specific types
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.
Brain
Cerebrovascular disease
Transient ischemic
attack
Cerebrovascular
accident
Cognitive impairment
Complications of Diabetes
Heart
Coronary artery disease
Coronary syndrome
Myocardial infarction
Congestive heart
failure
Extremities
Peripheral vascular
disease
Ulceration
Gangrene
Amputation
Macrovascular 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 non-
elderly, the leading cause of non-traumatic
amputation in adults, and diabetic nephropathy
is the main illness requiring renal dialysis in the
United States.
Estimated number of adults with diabetes by age-
group in the world
Estimated number of adults with diabetes by age-
group in developed courtiers
Estimated number of adults with diabetes
by age-group in developing courtiers

Diabetes in Palestine

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

Prevalence of DM

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



The gap between the expected prevalence rates of DM
and cases under supervision reflects under registration
and underreporting and also requires special efforts to
accelerate early case finding activities in order to avoid
high cost of treating the complications and disability
consequences of the disease. Also this will give more
realistic estimation of the prevalence for appropriate
evaluation of the problem.(MOH, 2006)
Prevalence rates of diabetes and hypertension among registered
Population 40 years and above by Field, 2005
New cases of Diabetes mellitus in West Bank
clinics

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


6.30%
41.00%
28.20%
24.40%
0
0.1
0.2
0.3
0.4
0.5
less than 34 35-54 55-64 65 and more
New reported cases of D.M. in WB clinics by age 2005
Distribution of diabetic (type II) cases by
management in the West Bank health
clinic:

1. About 28.6% of diabetics cases were managed by
insulin treatment.
2. About 5.0% were treated with a combined therapy
(insulin and OHA).
3. About 64.7% of diabetics' cases were managed by
tablets.
4. Diet control (exclusively managed by lifestyle
modification) was 1.7%

Mortality among Palestinian refugee
A total of 2,721 deaths which accounted for 2 per cent of
all non communicable disease patients were reported
during 2005. 48.2 per cent of them have diabetes and
hypertension combined, 36.4 per cent have hypertension
and 15.4 per cent have diabetes (UNRWA Annual Report,
2005).
Disease-specific mortality rates among
reported deaths
Mortality of diabetes mellitus
In Palestine: DM did not report a one of the 10th
leading cause of death among Palestinians. It
constituted 3.6% of total population deaths. 372
persons died with mortality rate of 10.2 per 100,000
(176 males, with a rate of 9.5 per 100,000 males and
196 females, with mortality rate of 10.9 per 100,000).
The average annual mortality rate of DM was 12.4 per
100,000 population in the last five years.
In Gaza Strip: 215 persons died with mortality rate of
16.1 per 100,000 (98 males and 117 females). In West
Bank: 157 persons died with mortality rate of 6.8 per
100,000 (78 males and 79 females).
Major risk factors

Family 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
Thanks