1 By Hatim Jaber MD MPH JBCM PhD 17 -7-2017Faculty of Medicine Epidemiology and Biostatistics ( ) الوبائيات والإحصاء الحيوي Lecture Chronic Non-Communicable Diseases Epidemiology, Risk factors of NCD By Hatim Jaber MD MPH JBCM PhD

2 Chronic Non-communicable Diseases Epidemiology Risk factors of NCDBasic epidemiological concepts/ Epidemiological study types Association and causation  Bias and confounding Screening tests and result interpretation Communicable diseases Epidemiology Transmission of infectious diseases  Chronic Non-communicable Diseases Epidemiology Risk factors of NCD    Workplace Hazards – Radiation and Noise at workplace Current global environmental problems, their causes, effects, and prevention measures.(1) Current global environmental problems, their causes, effects, and prevention measures.(2) Food contamination and food borne diseases(1)  Food contamination and food borne diseases (2)

3 Presentation outline Introduction to NCD 11:00 to 11:10Time Introduction to NCD 11:00 to 11:10 Comparison of non-communicable diseases and communicable diseases 11:10 to 11:20 Risk Factor for NCD: types 11: 20 to 11:40 Risk factors for selected NCD: Cancer 11:40 to 12:00 Risk factors for selected NCD: Respiratory diseases 12:00 to 12:15

4 Non-Communicable Disease (NCD): Definition (cont.)Chronic conditions are characterized by the following: Do not result from an (acute) infectious process???????????????????? Are “not communicable” Cause premature morbidity, dysfunction, and reduced quality of life Usually develop and progress over long periods Often initially insidious Once manifested there is usually a protracted period of impaired health 4

5 Non-Communicable Disease (NCD): Extended DefinitionIn some definitions, NCDs also include: Chronic mental illness Injuries, which have an acute onset, but may be followed by prolonged convalescence and impaired function 5

6 Types of NCDs Cardiovascular disease (Coronary heart disease, Stroke)Cancer Chronic lung disease Diabetes Chronic neurologic disorders (Alzheimer’s, dementias) Arthritis/Musculoskeletal diseases 6

7 Classifying deaths and diseases (WHO)Communicable diseases [Group I] Those where death is directly due to the action of a communicable agent Non-communicable diseases Diseases [Group II] Cancer, diseases of various organ systems (eg respiratory, cardiovascular etc.), diabetes, mental health etc. External causes (injuries, poisonings and violence) [Group III]

8 Leading Causes of Attributable Global Mortality and Burden of Disease, 2004Attributable Mortality Attributable DALYs Leading Causes of Attributable Global Mortality and Burden of Disease, 2004

9 Source: W.H.O. Statistics

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

12 Characteristics of NCDsComplex etiology (causes) Multiple risk factors Long latency period Non-contagious origin (non-communicable) Prolonged course of illness Functional impairment or disability Incurability Insidious onset

13 RISK FACTORS

14 Risk Factor “An aspect of personal behavior or lifestyle, an environmental exposure, or a hereditary characteristic that is associated with an increase in the occurrence of a particular disease, injury, or other health condition.” (Principles of Epidemiology, CDC, 2006)

15 Why Risk Factors? Surveillance for non-communicable disease can be difficult because of: Lag time between exposure and health condition, More than one exposure for a health condition, and Exposure linked to more than one health condition. Interventions that target risk factors are needed to prevent disease.

16 Modifiable Risk FactorA risk factor that can be reduced or controlled by intervention, thereby reducing the probability of disease. The WHO has prioritized the following four: Physical inactivity Tobacco use Alcohol use Unhealthy diets

17 Non-Modifiable Risk FactorA risk factor that cannot be reduced or controlled by intervention, for example: Age Gender Race Family history (genetics)

18 Common Risk Factors

19 Non-Communicable Diseases vs. Communicable DiseasesHow do they differ regarding: Infectiousness? Risk of Disease?

20 Epidemiology “The study of the distribution and determinants of health-related states in specified populations, and the application of this study to control health problems.” Distribution Determinants Health-related States specified Population Application (Last, 2001)

21 Epidemiology: Who is Involved?Approaches in Medicine vs. Epidemiology: Who is Involved? Approach/ Consideration Clinical Medicine Epidemiology Focus Individuals Populations Main Goal Diagnosis and treatment Prevention and control Questions What is wrong with this patient? What are the leading causes of death or disability in this population? Risk factors? Treatment What treatment is appropriate? What can be done to reduce or prevent disease or risk factors? Who is involved? Physician, laboratorian, nurse, and others Epidemiologists, statisticians, and others from diverse disciplines Introduction to NCD Epidemiology

22 Approaches to EpidemiologyDescriptive Epidemiology Analytic Epidemiology Introduction to NCD Epidemiology

23 Public Health Surveillance

24 Management and TeamworkPublic Health Officials Laboratory Technicians Clinical Staff Epidemiologist Sanitarians Community

25 Answers 1-2 Name at least four types of NCDs. cardiovascular disease, cancer, diabetes, chronic lung disease, chronic neurologic disorders, arthritis, musculoskeletal disorders Name at least four characteristics of NCDs: complex etiology, multiple risk factors, long latency period, non-contagious origin, prolonged course of illness, functional impairment or disability, incurability

26 Answers 3-4 What are at least three examples of modifiable risk factors? alcohol use, smoking, poor diet, physical inactivity, high blood pressure, high blood glucose What are at least three examples of non- modifiable risk factors? age, race, gender, family history

27 Answer 5 How do NCDs and communicable diseases differ?Communicable disease occurrence depends upon the presence / absence of disease already occurring in that population; For NCDs, all disease events. are generally independent of one another For NCDs, the risk of disease largely depends on population characteristics and other health behaviors; Communicable disease can also be influenced by these characteristics, but they have properties that contribute to whether an exposed individual will become infected.

28 Types of NCDs Cardiovascular disease (e.g., Coronary heart disease, Stroke) Cancer Chronic respiratory disease Diabetes Chronic neurologic disorders (e.g., Alzheimer’s, dementias) Arthritis/Musculoskeletal diseases Unintentional injuries (e.g., from traffic crashes) 28 28

29 Global Trends Causes of DeathsProjected Deaths in 2015 and 2030 30 Intentional injuries Other unintentional Road traffic accidents 25 Deaths (millions) Other NCDs 20 Cancers 15 CVDT 10 Mat//peri/nutritional Other infectious HIV, TB, malaria 5 High income Middle income Low income 2929

30 Metabolic Risk Factors“Metabolic" refers to the biochemical processes involved in the body's normal functioning Behaviors (modifiable risk factors) can lead to metabolic/physiologic changes. WHO has prioritized the following four metabolic risk factors: Raised blood pressure Raised total cholesterol Elevated glucose Overweight and obesity

31 Knowledge Check What are the 4 main NCDs that are the focus of WHO?Which NCD is projected to cause the most deaths by 2030? How would you describe the difference between modifiable and non-modifiable risk factors? What are the 4 modifiable shared risk factors? What are the 4 priority metabolic risk factors?

32 FOUR LEADING NCDS

33 Cardiovascular Disease: DefinitionCardiovascular disease (CVD) is a group of disorders of the heart and blood vessels, and may include: Coronary heart disease Disease of the blood vessels supplying the heart muscle Cerebrovascular disease (Stroke) Disease of the blood vessels supplying the brain Peripheral arterial disease Disease of blood vessels supplying the arms and legs Congenital heart disease Malformations of heart structure existing at birth

34 Cardiovascular Disease: Risk FactorsMajor modifiable risk factors High blood pressure Abnormal blood lipids Tobacco use Physical inactivity Obesity Unhealthy diet (salt) Diabetes Other modifiable risk factors Low socioeconomic status Mental ill health (depression) Psychosocial stress Heavy alcohol use Use of certain medication Lipoprotein(a) Non-modifiable risk factors Age Heredity or family history Gender Ethnicity or race “Novel” risk factors Excess homocysteine in blood Inflammatory markers (C- reactive protein) Abnormal blood coagulation (elevated blood levels of fibrinogen) Overview of NCD’s and Risk Factors

35 Diabetes: Risk FactorsMajor modifiable Risk Factors Unhealthy diets Physical Inactivity Obesity or Overweight High Blood Pressure High Cholesterol Other Modifiable Risk Factors Low socioeconomic status Heavy alcohol use Psychological stress High consumption of sugar- sweetened beverages Low consumption of fiber Non-modifiable Risk Factors Increased age Family history/genetics Race Distribution of fat Other Risk Factors Low birth weight Presence of autoantibodies

36 Cancer: Definition Generic term for a large group of diseases that can affect any part of the body. “Rapid creation of abnormal cells that grow beyond their usual boundaries, and which can then invade adjoining parts of the body and spread to other organs” (WHO, 2012) Benign tumors Malignant tumors

37 Global Burden of Cancer7.6 million people died from cancer in 2008. 70% of all cancer deaths occur in low- and middle- income countries. Deaths from cancer are estimated to reach million by 2030. About 30% of cancers are attributable to behavior risk factors.

38 Estimated age-standardised incidence and mortality rates: total populationCancer Epidemiology

39 Cervical Cancer: DefinitionCancer of the female reproductive system: Two cell types present (squamous and glandular) Tend to occur where the two cell types meet 99% of cases linked to genital infection with human papillomavirus (HPV) TAP Pharmaceuticals, “Female Reproductive Systems 28

40 Cervical Cancer Estimated age-standardised rates (World) per 100,000

41 Cervical Cancer: Risk FactorsHuman papilloma virus infection (HPV) Smoking Immune Deficiencies Poverty No access to PAP screening Family history of cervical cancer

42 Lung Cancer: DefinitionCancer that forms in tissues of the lung, usually in the cells lining air passages Leading cause of cancer death globally,1.37 million deaths in 2008 Affects more men than women Two main types: Small cell lung cancer Non-small cell lung cancer

43 Lung Cancer Incidence and Mortality in 2008: Both SexesSource:

44 Lung Cancer: Risk FactorsSmoking cigarettes, pipes, or cigars - now or in the past Being exposed to second-hand smoke Being treated with radiation therapy to the breast or chest Being exposed to asbestos, radon, chromium, nickel, arsenic, soot, or tar Living where there is air pollution

45 Breast Cancer: DefinitionCancer that forms in the tissues of the breast, usually in the ducts or in the lobules Occurs commonly in women, rarely occurs in men 1 of 8 women will be diagnosed with breast cancer in her lifetime.

46 Breast Cancer Incidence and Mortality in 2008: Both Sexes

47 Breast Cancer: Risk FactorsHormone therapies Weight and physical activity Race Genetics or family history BRCA1 and BRCA2 genes Age is the most reliable risk factor! Risk increases with age

48 Prostate Cancer 2nd most common cancer among menThe cancer develops inside of the prostate gland. Risk factors: age, race, obesity, weight gain Mortality Rate Year

49 Prostate Cancer Incidence and Mortality in 2008: Total Population

50 Colorectal Cancer 3rd most common type of cancerForms in the lower part of the digestive system (large intestine) Risk Factors include: Aging Black race Unhealthy diet and low exercise Diabetes Family history of colorectal cancer

51 Colorectal Cancer Incidence and Mortality in 2008: Both Sexes 51

52 CHRONIC RESPIRATORY DISEASES

53 Global Burden of Chronic Respiratory DiseaseA leading cause of death High under-diagnoses rates 90% of deaths occur in low-income countries 42

54 Chronic Respiratory Diseases: Shared Risk FactorsGenes Infections Socio-economic status Aging Populations

55 COPD: Definition Chronic obstructive pulmonary diseaseCOPD – term used for lung diseases that prevent proper lung airflow Chronic bronchitis, emphysema More than just “smoker’s cough”

56 COPD: Burden Accurate epidemiologic data on COPD prevalence, morbidity, and mortality are difficult and expensive to collect. 65 million people worldwide have moderate to severe COPD. More than 3 million people died of COPD in (3% of all deaths globally). Almost 90% of COPD deaths occur in low- and middle-income countries.

57 Chronic Respiratory Diseases: AsthmaRecurrent attacks of “breathlessness and wheezing” (WHO, 2012) A gradient of severity Can cause sleepiness, fatigue Low fatality rates, but often underdiagnosed 235 million people affected 46

58 Tobacco Use 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.

59 Global Adult Tobacco Survey 54

60 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

61 Overview of NCD’s and Risk FactorsDIET Overview of NCD’s and Risk Factors

62 Global Changes in Diet Most countries have increased overall daily consumption of: Daily calories, Fat and meats, and Energy dense and nutrient-poor foods such as: Starches Refined sugars Trans-fats

63 Unhealthy Diet: Health EffectsCoronary heart disease Stroke Cancer Type 2 diabetes Hypertension Diseases of the liver and gallbladder Obesity

64 PHYSICAL INACTIVITY

65 Global Changes in Physical Activity31% 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.

66 Global Changes in Physical Activity (cont.)Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet Jul 21;380(9838):219-29 62

67 Physical Activity: Health EffectsReduces risk of: Type 2 diabetes Certain cancers Heart attacks Stroke Falls Early death Reduces: High blood pressure Adverse lipid profile Arthritis pain Psychiatric issues

68 HARMFUL USE OF ALCOHOL

69 Global Alcohol Consumption11.5% 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.

70 Global Alcohol Consumption (cont.)

71 Harmful Use of Alcohol: DefinitionExcessive drinking, per day Heavy drinking – on average > > Binge drinking – single occasion ≥ ≥

72 Harmful Use of Alcohol: EffectsImmediate effects: Long-term effects: Liver diseases Cancers Hypertension Gastrointestinal disorders Neurological issues Psychiatric issues Diminished brain function Loss of body heat Fetal damage Risk for unintentional injuries Risk for violence Coma and death

73 Metabolic Risk FactorsWhat are the four metabolic risk factors? Raised Blood Pressure (Hypertension) Raised Cholesterol Raised Blood Glucose Overweight and Obesity

74 Raised Blood Pressure Hypertension(Systolic)/(Diastolic) in mm of Hg (mercury) Systolic = amount of force your arteries use when the heart pumps Diastolic = amount of force your arteries use when the heart relaxes Measurement Normal Pre-Hypertensive Hypertensive Systolic mmHg <120 140+ Diastolic <80 80-89 90+

75 High Blood Pressure US Department of Health & Human Services, National Heart, Lung, and Blood

76 Raised Blood Pressure: Health EffectsLeading risk factor for stroke Major risk factor for coronary heart disease In some age groups, the risk of CVD doubles for each increment of 20/10 mmHg of blood pressure Other complications of raised blood pressure: Heart failure Peripheral vascular disease Renal impairment Retinal hemorrhage Visual impairment

77 Hypertension and Excessive Sodium IntakeSodium, through hypertension, is a major cause of cardiovascular disease deaths and disability. About 10% of cardiovascular disease is caused by excess sodium intake. 8.5 million deaths could be prevented over 10 years if sodium intake were reduced by 15%.

78 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.

79 Recommendations and Actual Intakes WHO/PAHOA 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.

80 Raised Total CholesterolHDL: High density lipoproteins; often called “good cholesterol” LDL: Low density lipoproteins; often called “bad cholesterol” VLDL: Very low density lipoproteins; has highest amount of triglycerides Triglycerides: Type of fat found in your blood (stored in fat cells)

81 Global Burden of Raised Total CholesterolIn 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. What is the prevalence of raised total cholesterol in your country? Search the WHO Global Health Observatory website:

82 Raised Total Cholesterol: Health EffectsIncreases 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

83 Elevated Glucose Sugar produces fuel and energy for our cellsInsulin helps control the amount of glucose in our bodies

84 Global Burden of Elevated GlucoseIn 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. Overview of NCD’s and Risk Factors

85 Elevated Glucose: Health EffectsElevated 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.

86 Overweight and ObesityOverweight and obesity are defined as ''abnormal or excessive fat accumulation that presents a risk to health.” (1) BMI - the Body Mass Index BMI = (weight in kg)/(height in meters, squared) - Between 25 and 29.9 indicates overweight - 30 or higher indicates obesity Skinfold Thickness Test Waist-to-Hip Circumference Ratio Men > 102 cm are considered high risk Women > 88 cm are considered high risk 1.

87 Overweight and Obesity: Global BurdenWorldwide, obesity has more than doubled since 1980. In 2008, more than 1.4 billion adults, 20 and older, were overweight. Of these, 200 million men and nearly 300 million women were obese. 65% of the world’s population live in countries where the mortality associated with overweight and obesity is higher than the mortality associated with underweight. Globally, in 2010 the number of overweight children under the age of five was estimated to be over 42 million. Close to 35 million of these are living in developing countries.

88 10 Progress Monitoring IndicatorsAdoption of national NCD targets and indicators 2 Mortality data 3 Risk factor surveys 4 National integrated NCD strategy/action plan 5 Tobacco demand-reduction measures taxation  smoke-free policies  health warnings  advertising bans

89 10 Progress Monitoring Indicators6 Harmful use of alcohol reduction measures availability regulations  advertising and promotion bans  pricing policies 7 Unhealthy diet reduction measures salt/sodium policies  saturated fatty acids and trans-fats policies  marketing to children restrictions  marketing of breast-milk substitutes restrictions 8 Public awareness on diet/physical activity 9 Guidelines for the management of major NCDs 10 Drug therapy/counselling for high-risk persons