Chapter 14- Noncommunicable diseases

November 21, 2023

Only 2.5 weeks of class left

Learning Objectives

- Describe the burden of noncommunicable diseases and mental disorders

- Discuss the most important risk factors for the burden of these conditions
- Outline the costs and consequences of selected noncommunicable diseases and mental
disorders
- Outline the costs and consequences of selected noncommunicable diseases and mental
disorders
- Review measures that can be taken to address the burden of these conditions in cost-effective
and fair ways
- Describe some successful causes of dealing with noncommunicable diseases and mental disorser
in low and middle income countries (research is lacking)

The importance of noncommunicable diseases

- Burden of noncommunicable diseases (NCDs) is greater than burden of communicable diseases

in low and middle income countries
o Excluding SSA
- Burden of NCD will continue to increase as countries develop economically
- Risk factors relate to lifestyle, which is within people’s control
- Often prevented at low cost (lifestyle change), but expensive to treat

Key terms and Definitions

- Noncommunicable disease (opposite of communicable diseases): cannot be spread by an

infectious agent, they last a long time, and they are often disabling and lead to death if not
treated appropriately
o Also, referred to as chronic diseases
- Cardiovascular disease: diseases of the heart or blood vessels. Encompasses both ischemic
health disease (heart attack/myocardial infraction) and stroke
- Cholesterol: a fatlike substance that is made by the body and found in animal-based foods such
as meat, fish, poultry, and eggs
- Diabetes: an illness caused by poor control by the body of blood sugar
o Pancreas stops working proper by not producing enough insulin, which is a hormone
that regulates blood sugar
- Hypertension: high blood pressure with a reading of 140/90 mmHg or greater. Blood pressure is
the amount of pressure exerted on walls of blood vessels
o Systolic (140): amount of pressure when heart contracts
o Diastolic (90): amount of pressure when the heart rests
- Ischemic heart disease: disturbance of the heart function due to inadequate supply of oxygen to
the heart muscle
- Stroke: sudden loss of function of the brain due to clotting or hemorrhaging
The burden of noncommunicable disease

Cardiovascular diseases

- Ischemic heart disease (IHD)and stroke referred to as cardiovascular disease and makes up 27%
of all global deaths
- Ischemic heart disease caused about 10mil deaths in 2016 and is the leading specific cause of
deaths in 2016 globally for all age groups.
- IHD second leading cause of DALYs globally among all age groups and both sexes in 2016. Stroke
was third leading cause of DALYs
- Risk factors: sex, ethnicity, hypertension, tobacco use, high cholesterol, lack of physical activity,
and excessive alcohol consumption

Table 14-3 deaths and DALYS from select noncommunicable causes by world bank region, 2016, as
percentage of total deaths and DALYs

o East Asia and Pacific- stroke caused 18% of deaths

o Middle East and North America- Ischemic heart disease caused 26% of deaths

Table 14-4 Deaths and DALYs from select noncommunicable and communicable causes, by world bank
country income level, 2016, as percentage of total deaths and DALYs

o Low-income countries: 7% of deaths from cancer, and 7% of deaths from malaria

o Lower middle-income countries: 16% of deaths from ischemic heart disease
o Upper middle-income countries: 18% of deaths from ischemic heart disease
o High income countries: 17% of deaths from ischemic heart disease

Diabetes

- 425 mil people and 8.8% of adults had diabetes in 2017

- About 80% of all deaths from diabetes are in low and middle income countries
- ** costly complications: blindness, kidney failure, amputation of lower extremities, and stroke
- Family history is a risk factor for both types
- Diet and obesity are also risk factors for type 2
- Figure 14-1 prevalence of diabetes in people 20-79 years old by IDF region, 2017
o Africa least, north America and Caribbean most
- Figure 14-2 number of people 20-79 years old with diabetes by IDF region, in milliona, 2017 and
2045
o All areas increase for diabetes in 2045, with South-east Asia and western pacific having
the most.

Chronic Obstructive Pulmonary Disease (COPD)

- Chronic lung disease that causes limitation in lung airflow

- Main risk factors: tobacco smoking, household air pollution, ambient particulate matter
pollution, occupational exposure to dust, chemical fumes and other irritants
- In 2016, 250 mil cases of COPD globally
 - COPD was associated with 5.6% of all deaths in 2016 and 90% of those deaths were in low-and
middle-income countries

Cancer

- Many forms of cancer = unique challenge

- All forms of cancer make up about 16% of all deaths and 9.2% of DALYS for all age groups and
both sexes in 2016
- Brest cancer is the leading cause of cancer death in low- and middle-income countries and for
women globally
- Lung cancer is most common and leading cause of cancer deaths worldwide
- Different types of cancers are more prevalent in different regions of the world (pie charts)
- Tabel 14-5 Leading risk factors by cancer type
o Lung: tobacco use, asbestos exposure, air pollution

Mental disorders

- Table 14-6 key mental health terms and definitions

o Bipolar disorder: mood disorder characterized by swing of mania and depression
o Depression: mental state characterized by feelings for sadness, loneliness, despair, low
self-esteem, and self-reproach
o Panic disorder: an anxiety disorder characterized by attacks of acute intense anxiety
(same physical symptoms as heart attack)
o Schizophrenia: mental illness with main symptom of hallucinations, delusions, and
changes in outlook and personality
- Caused 7.1% of DALYs lost in high income countries and 4.6% of DALYs globally in 2016
- Unipolar depressive disorder (depression, low moods), schizophrenia, anxiety disorders, and
bipolar affective disorder contribute the largest share
- Often start at young ages, are chronic, often cannot be cured, and produce large amounts of
disability
- Here in Canada, about 1 in 5 are suffering

Vision and Hearing loss

- Aging of populations globally and improved life expectancy increase importance

- Over 80% of vision loss can be prevented or cured
- About 90% of those who suffer visual impairments live in low-and middle-income countries
- In 2014, 5% of the worlds population had disabling hearing loss, including 432 million adults and
34 million children

Tobacco Use

- Third leading attributable risk factor for death globally

- About 7 million deaths annually associated with tobacco use
- Most common tobacco-related deaths are CVD, diseases of respiratory system, and cancer
- Usage increasing in men in low-and middle income countries and women in all regions
- Table 14-7
Alcohol

- use disorders make up 0.7% of all DALYs globally

- ninth leading attributable risk factor for global deaths
- high-risk drinking increases risk for hypertension, heart disease, hormonal problems, and liver
and pancreatic damage
- intoxication associated with injuries and high risk sexual encounters

Costs and consequences

The costs of noncommunicable diseases Broadly

- Direct costs of treatment

- Indirect costs from lost productivity
- Low-income countries are simultaneously facing burden of communicable diseases and
noncommunicable disease as well as injuries

Cardiovascular disease

- Study conducted in south Africa suggested that the direct costs of treating cardiovascular
disease were about 25% of all healthcare expenditures
- High indirect costs because affects people at relatively younger ages in low and middle income
countries than in high income countries

COPD

- Limited data on costs and consequence

- Studies in Canada and Sweden suggest that indirect costs vary by severity of illness

Diabetes

- Cost of treating diabetes varies between 2.5% and 15% of health expenditures in different
countries
- Latin America and Caribbean have highest expenditures, sub-Saharan Africa has lowest
- Indirect costs are probably high because many people do not receive proper treatment; suffer
from disability and productivity losses

Mental disorders

- Little data from low and middle income countries

- Studies done in US indicate that direct and indirect costs of mental illness were equal to 2.5% of
GNP; Europe 3-4% of GNP
- Significant losses in worker productivity

Hearing and vision loss

- Very little data

- Associated costs: constraints and/or high costs for educating children, children missing school,
costs for additional medical visits, difficulties for adults for finding employment, lower income
levels
Tobacco use

- Estimates from high income economies suggest that costs of somking range from 0.1% to 1.1%
of GDP and likely as high in low and middle income countries
- If present trends in smoking/tobacco use continue, an additional 150 million people will die of
smoking related causes between 2000 and 2025

Alcohol Use Disorders

- Have to take into account of the costs of health care and indirect costs for the user and others
who were injured by the user
- A 2009 study found that the costs were greater than 1% of GDP in all countries
o USA $200 090 billion

Addressing Noncommunicable diseases Broadly

UN NCD Meeting in September 2011:

- All countries should focus on prevention and the main risk factors of tobacco, alcohol, dietary
risks, and lack of physical activity
- Countries should engage all government parties in the battle against NCDs
- All countries should increase funding to address NCDs

Addressing the burden of noncommunicable diseases

Tobacco use

- Reducing tobacco consumption is the single most important investment in reducing the burden
of noncommunicable diseases
- Framework convention on tobacco (2003)
o Taxing cigarettes at higher rates
o Legal restrictions on smoking
o Ban cigarette advertising – kids identify with commercials and visual media
o Biggest impact in high-income settings has come from comprehensive control programs

Alcohol

- Very few countries have made coherent efforts to reduce alcohol consumption
- Tax, but beware of illicit alcohol consumption
- Limiting hours when alcohol can be bought or sold and checking sobriety of drivers showed
some success
- Countries should take step-wise approach to reducing alcohol by adding policies over time

High BP, High cholesterol, and obesity

- Food labeling
- Work with producer to reduce sugar and salt in food
- Mass health education programs combined with interventions involving direct communication
 - Public policies and community layouts that promote physical activity

Sandy bay first nation and diabetes

 75% of all people in reserve had diabetes

 Instalment of walking trails, community activities
 Diabetes rates fell to 25%

Further addressing diabetes

- Avoiding being overweight is the single most important way to prevent type 2 diabetes
- Treating people with type 1 diabetes with insulin is a cost-effective investment, although difficult
to afford or manage in the poorest countries
- For all diabetics, it is cost-effective to control hypertension because of complications

Cancer

- Tobacco control is first priority

- Address infectious agents associated with cancer like hepatitis B, H. Pylori, and schistosomiasis
- Prevention is the most cost-effective method because cancer treatment can be long terms and
expensive
- Early detection is also very important

Mental Health

- Who recommends:
o Have mental health policy and ensure there is a unit of government responsible for
mental health programs
o Budget for mental health programs
o Train primary healthcare workers in mental health
o Integrate mental health into the primary healthcare program
o Community-based approaches to psychosocial support, basic treatment and referral,
with task shifting as needed

Vision and hearing loss

- The world health assembly approved in 2013 a global action plan for universal eye health
- No coherent plan for hearing loss yet but half of all cases can be addressed by primary
prevention

Future challenges

- Number of new cases of noncommunicable diseases will grow because fo aging, urbanizations,
globalization, and lifestyle changes
- Number of people with disease will also rise because the diseases are CHRONIC
- Low-income countries will have to deal with communicable and noncommunicable disease
simultaneously, and injuries
 - Spread as rapidly as possible to low and middle-income countries the lessons that the high
income countries have already learned
- Lessons will also need to be generated and disseminated on the operational efforts need to put
effective NCD programs in places in low-resource settings.

Main messages

- Noncommunicable diseases constitute the largest burden of diseases worldwide

- Cardiovascular disease is the largest cause of death worldwide
- The costs of noncommunicable diseases and tobacco use are substantial
- Reducing tobacco use will be the single most important step to reduce the burden of
noncommunicable diseases in low-and middle-income countries
- Alcohol-related harm can be reduced through measures similar to those used for tobacco use
reduction
- Tax policies can be used to subsidize healthy foods and tax unhealthy foods to address obesity
- Low resource countries will need to embed approaches to mental health in their communities
and at the family level
- To meet global goals on addressing vision loss, countries will need to take additional measures to
establish comprehensive eye programs at all levels of their healthcare system
- Half of hearing loss can be addressed in primary prevention, including maternal nutrition