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 Non-communicable diseases

The Global Status Report on non-communicable diseases 2010 developed by WHO is the first report on the worldwide epidemic of cardiovascular diseases, cancer, diabetes and chronic respiratory diseases.

This report reviews the current status of non-communicable diseases and provides a road map for reversing the epidemic by strengthening national and global monitoring and surveillance, scaling up the implementation of evidence-based measures to reduce risk factors like tobacco use, unhealthy diet, physical inactivity and harmful alcohol use, and improving access to cost-effective healthcare interventions to prevent complications, disabilities and premature death.

Burden
Of a total of 57 million deaths occurred in the world during 2008, 36 million were due to NCDs, principally cardiovascular diseases, diabetes, cancer and chronic respiratory diseases. Nearly 80 percent of these NCD related deaths (29 million) occurred in low -and middle-income countries. NCDs are the most frequent causes of death in most countries in the Americas, the Eastern Mediterranean, Europe, South East Asia, and the Western Pacific in the African Region.

The leading causes of NCD deaths in 2008 were: Cardiovascular diseases (17 million deaths, or 48 percent of NCD deaths); cancers (7.6 million, or 21 percent of NCD deaths); and respiratory diseases, including asthma and Chronic Obstructive Pulmonary Disease (COPD), (4.2 million).Diabetes caused an additional 1.3 million deaths.

More than two thirds of all cancer deaths occur in low- and middle-income countries. Lung, breast, colorectal, stomach and liver cancers cause the majority of cancer deaths. In high-income countries, the leading causes of cancer deaths are lung cancer among men and breast cancer among women. In low- and middle-income countries cancer levels vary according to the prevailing underlying risks.

Most NCDs are strongly associated and causally linked with four behaviours: Tobacco use, physical inactivity, unhealthy diet and the harmful use of alcohol.

Tobacco
Tobacco use and exposure comes in both smokeless and smoking forms. Smokeless tobacco is consumed in un-burnt forms through chewing or sniffing and contains several carcinogenic, or cancer-causing, compounds. Smokeless tobacco has been associated with oral cancer, hypertension, heart disease and other conditions. Smoking tobacco, by far the most commonly used form globally, contains over 4000 chemicals, of which 50 are known to be carcinogenic.

Risks to health from tobacco use result not only from direct consumption of tobacco, but also from exposure to second-hand smoke. Almost six million people die from tobacco use and exposure each year, accounting for six percent of all female and 12 percent of all male deaths in the world. Of these deaths, just over 600, 000 are attributable to second-hand smoke exposure among non-smokers, and more than five million to direct tobacco use (both smoking and smokeless)

Insufficient physical activity
Approximately 3.2 million deaths each year are attributable to insufficient physical activity. People who are insufficiently-physically active have a 20–30 percent increased risk of all-cause mortality compared to those who engage in at least 30 minutes of moderate intensity physical activity on most days of the week.

Participation in 150 minutes of moderate physical activity each week (or equivalent) is estimated to reduce the risk of ischemic heart disease by 30 percent, the risk of diabetes by 27 percent, and the risk of breast and colon cancer by 21–25 percent. Additionally, physical activity lowers the risk of stroke, hypertension and depression. It is a key determinant of energy expenditure and thus fundamental to energy balance and weight control.

Alcohol consumption
There is a direct relationship between higher levels of alcohol consumption and rising risk of some cancers, liver diseases and cardiovascular diseases. The relationship between alcohol consumption and ischemic heart and cerebrovascular diseases is complex. It depends on both the amount and the pattern of alcohol consumption.

Unhealthy diet
Adequate consumption of fruit and vegetables reduces the risk for cardiovascular diseases, stomach cancer and colorectal cancer. There is convincing evidence that the consumption of high levels of high-energy foods, such as processed foods that are high in fats and sugars, promotes obesity compared to low-energy foods such as fruits and vegetables.

The amount of dietary salt consumed is an important determinant of blood pressure levels and overall cardiovascular risk. A population salt intake of less than five grams per person per day is recommended by WHO for the prevention of cardiovascular disease. However, data from various countries indicate that most populations are consuming much more salt than this quantity. It is estimated that decreasing dietary salt intake from the current global levels of 9–12 grams per day – to the recommended level of 5 grams per day – would have a major impact on reducing blood pressure and cardiovascular disease. There is convincing evidence that saturated fat and trans-fat increase the risk of coronary heart disease and that replacement with monosaturated and polyunsaturated fat reduces the risk.

Blood pressure
Worldwide, raised blood pressure is estimated to cause 7.5 million deaths, about 12.8 percent of the total of all annual deaths. Raised blood pressure is a major risk factor for coronary heart disease and ischemic as well as hemorrhagic stroke). Blood pressure levels have been shown to be positively and progressively related to the risk for stroke and coronary heart disease.

In addition to coronary heart diseases and stroke, complications of raised blood pressure include heart failure, peripheral vascular disease, renal impairment, retinal hemorrhage and visual impairment. Treating systolic blood pressure and diastolic blood pressure so they are below 140/90 mmHg is associated with a reduction in cardiovascular complications.

Overweight and obesity
Overweight and obesity lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance. Risks of coronary heart disease, ischemic stroke and type 2 diabetes mellitus increase steadily with increasing Body Mass Index (BMI), a measure of weight relative to height. Raised BMI also increases the risk of cancer of the breast, colon/rectum, endometrial, kidney, esophagus (adenocarcinoma) and pancreas. Mortality rates increase with increasing degrees of overweight, as measured by BMI.
The prevalence of raised BMI increases with income level of countries, up to upper-middle-income levels. The prevalence of overweight in high-income and upper-middle-income countries was more than double that of low- and lower-middle-income countries.

Cholesterol
Raised cholesterol levels increase the risks of heart disease and stroke. Globally, a third of ischemic heart disease is attributable to high cholesterol. Overall, raised cholesterol is estimated to cause 2.6 million deaths. Raised total cholesterol is a major cause of disease burden in both the developed and developing world as a risk factor for ischemic heart disease and stroke.

In low-income countries around a quarter of adults had raised total cholesterol, in lower-middle income countries. This rose to around a third of the population for both sexes. In high-income countries, over 50 percent of adults had raised total cholesterol; more than double the level of the low-income countries.

Cancer associated infections
A wide range of environmental causes of cancer, encompassing environmental contaminants or pollutants, occupationally-related exposures and radiation, together make a significant contribution to cancer burden and are often modifiable at low cost. Notable examples of environmental causes of cancer are asbestos, benzene, indoor and outdoor air pollution and contaminants such as arsenic. Ionizing radiation increases the risk for several cancer types.

Impact on development
The NCD epidemic exacts a massive socioeconomic toll throughout the world. It is rising rapidly in lower-income countries and among the poor in middle and high-income countries. Each year, NCDs are estimated to cause more than 9 million deaths before the age of 60 years with associated negative impacts on productivity and development. The increasing burden of NCDs also imposes severe economic consequences that range from poverty of families to high health system costs and the weakening of country economies.

Lack of monitoring
The WHO points out that current capacity for NCD surveillance are inadequate in many countries and urgently require strengthening. High quality NCD risk factor surveillance is possible even in low-resource countries and settings.  A surveillance framework that monitors exposures (risk factors and determinants), outcomes (morbidity and mortality) and health-system responses (interventions and capacity) is essential. A common set of core indicators is needed for each component of the framework.

Cancer morbidity data are essential for planning and monitoring cancer control initiatives. Population-based cancer registries play a central role in cancer control programs, because they provide the means to plan, monitor and evaluate the impact of specific interventions in targeted populations.

Interventions
The majority of NCD can be averted through interventions and policies that reduce major risk factors.  Many preventive measures are cost-effective, including for low-income countries.  Some preventive actions can have a quick impact on the burden of disease at the population level.  Interventions that combine a range of evidence-based approaches have better results. Comprehensive prevention strategies must emphasize the need for sustained interventions over time.

WHO states
That there is robust evidence that tobacco control is cost-effective compared to other health interventions.

Promoting physical activity and healthy diet through the media is a cost effective and highly feasible intervention.

Cost-effective measures for reducing harmful alcohol use include increasing alcoholic beverage taxes, regulating the availability of alcoholic beverages, restricting marketing of alcoholic beverages and drink-driving countermeasures.

The majority of non-communicable diseases can be averted through interventions and policies that reduce major risk factors.

Currently, many low- and middle income countries have health systems that do not meet the requirements for chronic care.

Cardiovascular mortality rates have declined substantially in high-income countries. The decline is due to both prevention and treatment interventions.

Access to care, oral morphine and staff trained in palliative care is limited in many low- and middle-income countries, so that most cancer patients die without adequate pain relief.
When cost-effective healthcare interventions are complemented with population-wide prevention strategies, a significant impact can be made on the global NCD epidemic.

To improve efficiency, health-system policies should prioritize interventions that are essential for preventing the progression of NCDs. Limited resources and weak health systems in low- and middle-income countries, demand prioritization of a package of essential NCD interventions, including best buys (high impact, very cost-effective, affordable and feasible interventions).

Financing and strengthening health systems to deliver the best buys through a primary healthcare approach is a realistic first step to achieve the long-term vision of universal coverage.

According to WHO, in the past decade, countries have expanded their capacities to respond to the epidemic of non-communicable diseases. Real progress, though uneven, has been made. Many countries have developed NCD strategies, plans and guidelines, although a substantial proportion of them are not yet operational. Some countries have created components of the health infrastructure that is essential to containing the spread of NCDs, but have not effectively funded or implemented them. However, the existence of initiatives to combat the NCD epidemic in a growing number of countries provides a strong foundation to extend progress in the coming years through increasingly robust efforts.
High-income countries were nearly four times more likely to have NCD services and treatments covered by health insurance than low-income countries.

The availability of NCD treatments in low-income countries is one quarter that of high-income countries. Even in hospital settings in low income countries, there is limited availability of basic technologies required for NCD care.

WHO states that Country capacity for the prevention and control of NCDs have seen significant improvements in the past decade.

Growing country capacity for combating the NCD epidemic indicates that there is a significant opportunity for progress over the coming years.

Current evidence unequivocally demonstrates that NCDs are largely preventable. Countries can reverse the advance of these diseases and achieve quick gains, if appropriate action is taken.

The WHO points out that reversing the epidemic of NCDs is not only a key responsibility of all governments. It also requires engagement from civil society and the business sector. Civil society institutions are uniquely placed to mobilize political awareness and support for NCD prevention and control. They play a key role in advocating for NCDs to be a part of the global development agenda. Civil society institutions and nongovernmental organizations contribute to capacity-building. They are also significant providers of prevention and treatment services for cardiovascular disease, cancer, diabetes and respiratory diseases, often filling gaps between services provided by the private and government sectors. At a global level, nongovernmental organizations have grouped together to collectively support and influence global tobacco control efforts and, more recently, wider NCD prevention control, providing a strong platform for advocacy and action. The role and capacity of civil society should be supported and strengthened at the national and international levels.

Companies should also adopt and strengthen programs to improve the health and well-being of their employees through workplace health promotion and specific NCD prevention schemes. Virtually all industries can help to reduce pollution and promote healthy lifestyles.