36 Strategies, prevention and management of non-communicable

Imkongtenla Pongen and Meenal Dhall

Contents:

1. Risk factors of NCDs

1.1. Modifiable behavioural risk factors

1.2. Non-Modifiable behavioural risk factors

1.3. Metabolic risk factors

2. Health Promotion

3. Surveillance

4. Prevention and control of NCDs

4.1. Reducing tobacco use

4.2. Reducing harmful use of alcohol

4.3. Reducing prevalence of physical inactivity

4.4. Reducing salt intake

4.5. Reducing prevalence of raised blood pressure

4.6. Halt the rise in obesity

4.7. Providing drug therapy to prevent heart diseases

4.8. Providing essential medicines to treat NCDs

4.9. Influencing public nutrition (from community intervention to national programmes)

5. Policies, action plans and strategies

6. Prevention and management of NCDs

7. The biggest challenges

7.1. Global Burden of NCDs-

7.1.1. Cardiovascular Disease

7.1.2. Diabetes

7.2. NCD and Climate Change

Summary

Learning Objectives:

1. Delineate the risk factors of NCDs.

2. Discuss the importance of health promotion .

3. Discuss the importance of surveillance of NCDs.

4. Elucidate the strategies for prevention and control of non-communicable diseases.

5. Discuss the problems faced in the management and prevention of NCDs.

Introduction

Non-communicable diseases (NCD) are those diseases which are not caused by infectious agents but are caused and triggered by different habits or lifestyle of a person and are of long duration and progresses slowly. As such, non-communicable diseases can be prevented. Morbidity and mortality from preventable, non-communicable disease threatens the health of our populations and our economies. Both in developed and developing countries NCD’s are the greatest cause of morbidity and mortality accounting for twice as many deaths as that of communicable diseases such as HIV/AIDS, tuberculosis, malaria ,etc. accounting for 60% of all deaths and 44% of premature deaths. The recently labeled reason underlying the main causes of NCD are related to lifestyle, such as physical inactivity unhealthy diet, tobacco and alcohol abuse.

Among the non-communicable diseases cardiovascular diseases, cancer, diabetes and chronic respiratory diseases, are the leading causes of death globally and their key risk factors include use of tobacco, harmful use of alcohol, unhealthy diet and physical inactivity.

Figure : Number of deaths from NCDs per year in men aged 15-59 years Source: Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults (R Beaglehole, D Yach)

1. Risk factors of NCDs

People of all age groups- children, adults and the elderly, different regions and countries are at risk of NCDs. Often associated with older age groups, but evidence shows 17 million of all deaths attributed to NCDs occur before the age of 70.

NCDs are driven by forces including rapid unplanned urbanization, globalization of unhealthy lifestyles and population ageing.

1.1. Modifiable behavioural risk factors

Modifiable behaviours include factors such as tobacco and alcohol use, physical inactivity and unhealthy diet. Annually:

tobacco accounts for 7.2 million deaths (including exposure to second-hand smoke)
alcohol accounts for almost 3.3 million deaths
salt/sodium intake accounts for 4.1 million deaths
insufficient physical activity accounts for 1.6 million deaths)

Source Link: https://www.cdc.gov/globalhealth/healthprotection/fetp/training_modules/new-8/overview-of-ncds_ppt_qa-revcom_09112013.pdf

1.2. Non-Modifiable behavioural risk factors:

-age

-gender

-race

-family history (genetics)

1.3. Metabolic risk factors:

Metabolic risk factors attributable to elevated death tolls consists of :

-raised blood pressure

-overweight/obesity

-hyperglycemia

-hyperlipidemia

2. Health Promotion

The Health Promotion team promotes action across sectors for health and health equity, the reduction of health risks and the promotion of healthy lifestyles. Oral Health and School Health are two key work programmes of the team. The former aims to integrate oral health into NCD prevention and control, and the latter to intensify action for achieving NCD related health and education outcomes at the population level, in collaboration with key stakeholders within and beyond WHO.

3. Surveillance

Surveillance are fundamental to A mission to prevent deaths from NCDs. It is a strategy that focuses on broad policy, program and environmental interventions targeted at the general population more than just the high-risk individuals.

Surveillance focuses on coordinating and providing direction and support to strengthen NCD surveillance worldwide, with particular emphasis on low and middle-income countries, and provides global information resources on risk factor burden, trends and distributions.

Surveillance provides major areas of focus on very cost-effective policy options that are contained within the WHO Global Strategy on Diet, Physical Activity & Health and the Global NCD action Plan 2013 – 2020. These include physical activity promotion, salt reduction, WHO recommendations on marketing of foods and non-alcoholic beverages to children, and fiscal policies for diet amongst others. The team also provides technical and administrative support to the Commission on Ending Childhood Obesity. The Commission has been tasked by the WHO Director-General with producing a report specifying which approaches and combinations of interventions are likely to be most effective in tackling childhood and adolescent obesity in different contexts around the world.

4. Prevention and control of NCDs

One of the most important way to control NCDs is to focus on reducing the risk factors associated with these diseases. Progress in monitoring and trends of NCDs and their risk is very important for guiding policy and priorities .Reducing major risk factors for noncommunicable diseases (NCDs) such as tobacco use, physical inactivity, unhealthy diet and the harmful use of alcohol should be the focus to prevent deaths from NCDs. (Source–http://www.who.int/ncds/prevention/en/)

On individual and society level to decrease the impact of NCDs, a comprehensive approach is needed that requires all sectors of health, finance, transport, education, agriculture, planning and others, to collaborate for reducing the risks associated with NCDs, and to promote interventions to prevent and control them.

Targets for preventive measures are discussed below:

4.1. Reducing tobacco use

Tobacco Free Initiative

WHO in July 1998 established the Tobacco Free Initiative (TFI) being conscious of the global tobacco epidemic’s massive toll of death, sickness and misery, and mindful of the need to raise the profile of its tobacco control work. TFI focuses international attention, resources and action on the global tobacco epidemic.

The tobacco control team works in three core areas: tobacco control economics, national capacity building, and surveillance and information systems for tobacco control.

The tobacco control economics team aim to demonstrate that tobacco control policies, in particular tobacco taxation, make good economic sense. They work with countries to strengthen their tobacco tax systems, carry out research, develop tools and manuals to support research and policy development, and survey tobacco taxation in countries.

The national capacity building team provide assistance to countries to enhance their ability to resist the epidemic of tobacco and to reduce the demand for tobacco, in line with the WHO Framework Convention on Tobacco Control (WHO FCTC).

The comprehensive information systems team seeks to improve the availability of surveillance data on tobacco use, exposure and related health outcomes.

In addition to its core area of work, PND is involved in two cross-cutting projects: the Bloomberg Initiative to Reduce Tobacco Use, and the Bill & Melinda Gates Foundation Tobacco Control in Africa project. WHO partners with both projects to focus on reducing the burden of tobacco control in the most at-risk countries worldwide.

4.2. Reducing harmful use of alcohol

The global monitoring framework for NCDs will track the implementation of the NCD action plan through monitoring and reporting on the attainment of the global targets in 2015-2020. The 25 indicators and the 9 voluntary global targets of the framework provide overall direction and the action plan provides a road map for reaching the targets.

4.3. Reducing prevalence of physical inactivity

4.4. Reducing salt intake

4.5. Reducing prevalence of raised blood pressure

A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances.

4.6. Halt the rise in obesity

4.7. Providing drug therapy to prevent heart diseases

At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes. The global monitoring framework for NCDs will track the implementation of the NCD action plan through monitoring and reporting on the attainment of the global targets in 2015-2020. The 25 indicators and the 9 voluntary global targets of the framework provide overall direction and the action plan provides a road map for reaching the targets.

4.8. Providing essential medicines to treat NCDs

An 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major NCDs in both public and private facilities

The “Global monitoring framework for NCDs” will track the implementation of the NCD action plan through monitoring and reporting on the attainment of the global targets in 2015-2020. The 25 indicators and the 9 voluntary global targets of the framework provide overall direction and the action plan provides a road map for reaching the targets.

4.9. Influencing public nutrition (from community intervention to national programmes)

Replacement of a traditional diet rich in fruit and vegetables by a diet rich in calories provided by animal fats and low in complex carbohydrates, is happening in all but the poorest countries.

Launch awareness campaigns – to make people aware of the links (e.g. between diet, cholesterol and heart disease) and of the possibilities to act upon this knowledge. The principles of the intervention are universal: defining the population base, defining the different level of objectives, planning the framework of activities, and planning the monitoring and evaluation. An example of a country with a successful nutrition policy and education intervention is Mauritius, where, during a five-year intervention, a remarkable effect was observed in the diet and in the serum cholesterol level.

The monitoring system is vital to assess the baseline situation for planning purposes and for monitoring of changes in the community and nation-wide. Each country has to develop its own appropriate monitoring activities after recognizing the main problems and the target groups for the interventions. Simple and rapid monitoring of target dietary behaviours (health behaviour monitoring) has proven to be an important intervention tool. Community health programmes should pay attention to the well-established principles and rules of general programme planning, implementation and evaluation.

Preventive community programmes should be concerned with both appropriate medical/nutritional frameworks to select the intermediate objectives, and with relevant behavioural/social theories in designing the actual programme.

Good understanding of the community (‘community diagnosis’), close collaboration with various community organizations and full participation of the people should be essential elements of intervention programmes.

Community intervention programmes should combine well-planned media and communication messages with broad-ranged community activities involving primary health care, voluntary organizations, food industry and supermarkets, work sites, schools and local media.

Community intervention programmes should seek collaboration and support from both formal community decision-makers and informal opinion leaders.

Community intervention programmes should combine sound theoretical frameworks with dedication, persistence and hard work to be successful.

Attempts to change social and physical environments in the community to be more conducive to health and healthy lifestyles should be a major emphasis and strength of a community intervention programme. Proper evaluation should be carried out and results disseminated concerning major community intervention programmes. These community programmes can be useful for a target community, but can also have broader impact as a national demonstration programme. The project, for national implications, should work in close contact with national health policy-makers throughout the programme. The majority of countries had a policy, strategy or action plan for all NCDs and their risk factors with the exception of overweight and obesity (44% of countries). With policies, strategies or action plans that were operational, the majority of countries addressed all main NCDs and risk factors, with the exception of overweight and obesity (31%). Tobacco use was the most widely addressed risk factor, with 80% of countries reporting an operational policy, strategy or action plan. Physical inactivity, unhealthy diet, cardiovascular disease, diabetes, cancer/cancer types, and harmful use of alcohol were each addressed by operational policies, strategies or action plans in approximately two thirds (67–72%) of countries and chronic respiratory disease in 58% of countries.

Source: World Health Organization (WHO), Noncommunicable Diseases 2015

5.Policies, action plans and strategies-

(Source: http://apps.who.int/iris/bitstream/10665/246223/1/9789241565363-eng.pdf)

NCDs have been widely adopted in national health plans (92% of countries) with 60% of countries having a set of time-bound national targets for their NCD indicators. Significant progress was made in the availability of operational integrated plans, with figures being almost double those of 2010. However, while 62% of countries reported having an operational integrated NCD plan, only 41% achieved NCD Progress. While 35% of countries reported having NCD-related research policies, only 24% reported such policies being operational, the prevalence being notably low in low-income (15%) and lower-middle-income (11%) countries. Implementation of cost-effective policies for NCDs related to diet was relatively low with approximately a third or less of countries overall, and almost no low-income countries,implementing a policy.

Table 5.1.- shows the overall percentage of countries with a policy, strategy or action plan for each NCD or risk factor. The figures represent the percentage of countries that either included an NCD or risk factor in their integrated policy, strategy or action plan, or had a specific policy, strategy or action plan for an NCD or risk factor.

Figure: Percentage of countries with policies, plans or strategies and whether or not these are optional or funded

(Source: WHO, Non Communicable Diseases 2015)

6. Management of NCDs

NCDs including cardiovascular diseases, cancer, chronic respiratory diseases and diabetes kills almost 38 million people every year. Prevention of NCDs is important,however, investing in better management can be the other key component of the NCD response.

Source Link: http://www.digitalistmag.com/files/2014/02/Healthcare21.jpg

Through comprehensive management of NCDs, and its integration into primary health care and universal health coverage, a majority of premature deaths and disability can be avoided. Management of NCDs includes :

-detecting

-screening

– treating ,of various diseases of NCDs and providing access to palliative care for people in need.

A highly impact essential NCD interventions can be delivered through a primary health care approach for strengthening early detection and timely treatment. Providing early to patients reduces the need for more expensive treatment and these kind of interventions are known to be excellent in economic investments.

WHO supports countries by developing guidelines, tools and training materials on specific aspects related to the management of NCDs, and by identifying ways to improve access to cost-effective prevention, treatment and care. NCD management interventions are essential for achieving the global target of a 25% relative reduction in the risk of premature mortality from NCDs by 2025.

Figure: Public Health Surveillance

Source Link: https://www.cdc.gov/globalhealth/healthprotection/fetp/training_modules/new-

8/overview-of-ncds_ppt_qa-revcom_09112013.pdf

6.1. Prevention and management

Health has direct and indirect effects on economic growth. Good health increases work productivity and reduces absenteeism.At the household level,it helps individuals maximize their human potential avoiding financial distress and impoverishment, breaking the inter-generational cycle of maternal ill health, stunting and impaired productivity of children, and consequential poverty (Barker, 1990; Black et al., 2008; Bhutta, 2013). Thus, for maintenance of a better health preventive strategies and management should be implemented.

Non-communicable diseases prevention and management are multidisciplinary and multi-sectoral with multilevel implementation. It needs integrated joint work between different related directorates at the Ministry of Health with several multi-sectoral committees or organizations to develop with related ministries ,governmental sectors supporting the ministry of health in implementation of NCD prevention and control activities.

As the above discussed risk factors the main focus should contribute in the areas of tobacco control, promoting physical activity and healthy diet, prevention and control of obesity, prevention and control of cancers, production of evidence based national guidelines for chronic NCDs and risk factors, surveillance of NCDs and risk factors, networking for prevention of violence and accidents, and prevention of road traffic accidents, and capacity building processes.

The main international partners in this field currently are the WHO, European Commission, Centers for Disease control and prevention CDC and the United States Agency for International Development USAID, along with a number of international and local nongovernmental organizations NGOs, with future plans to include other related international organizations.

7. The biggest challenges

The problem of physical inactivity, poor diet and unhealthy lifestyle behaviours leads to the global advocacy for the sound ‘whole of government’ systems approach, including the direct and indirect costs of NCD that remains staggering and unsustainable due to the various factors involved such as financial, political and structural complexity.

Prevention also remains caught in the middle with policy makers by asking healthcare to implement change. Prevention remains a realm in the passive and suggestive theory and the vast amount of scientific evidence while true, has been useless for effecting change.

Human history shows that most people needs to be physically active to survive. Today, for instance, 20% of Norwegian, 8.2% of the USA and 5% of the UK adults meet physical activity guidelines. On the other hand physical activity in the US has declined by 32%, projected to decline even further to 46% by 2030, in China physical activity has declined by 45% and in the Arab regions , eight countries have physical inactivity levels ranging from 33% to 70% of the population.

There has been a marked decline over the past 50 years in energy expenditure for civilian occupation and household management sufficient to explain the rising prevalence of obesity. Worldwide deaths are mostly responsible by physical inactivity and smoking than any other modifiable risk factors . The clinical scientists are continuing to identify more characteristics that is responsible in magnifying the problems. For example, sitting time has been shown to be associated with increased cardiometabolic risk independent of levels of physical activity. Low aerobic fitness is a risk factor for all-cause mortality, cancer and cardiovascular disease, independent of body fatness.

Diabetes places particular health burdens on individuals and households, and financial burdens on PIC governments.

7.1. Global Burden of NCDs

7.1.1. Cardiovascular Disease: Cardiovascular disease are the first cause of death globally. In 2008 17.3 million people has been estimated death from cardiovascular disease accounting for 30% of all global deaths and has been estimated that by by 2030, almost 25 million people will die from cardiovascular disease.

• 7.3 million were due to coronary heart disease

• 6.2 million were due to stroke

7.1.2. Diabetes: Diabetes is usually a life-long disease and can have disabling

complications including blindness and amputations. Diabetes has particular financial consequences because drug treatments are usually required for the duration of the patient’s.

7.2. NCD and Climate Change

In low- and middle-income countries with long coastlines millions of people are affected by flooding, growing sea levels and extreme weather events, heat exhaustion leading to displacement, poverty and malnutrition.

Climate change can have direct physiological effects also, for instance, obesity escalates heat exposure symptoms triggering the symptoms of cardiovascular diseases.

Summary

People of all age groups- children, adults and the elderly, different regions and countries are at risk of NCDs. The Health Promotion team promotes action across sectors for health and health equity, the reduction of health risks and the promotion of healthy lifestyles. Surveillance are fundamental to the mission to prevent deaths from NCDs. It is a strategy that focuses on broad policy, program and environmental interventions targeted at the general population more than just the high-risk individuals. Prevention also remains caught in the middle with policy makers by asking healthcare to implement change.

Prevention remains a realm in the passive and suggestive theory and the vast amount of scientific evidence while true, has been useless for effecting change.

Strategies to prevent NCDs in brief are as follows:

i. Strengthen tobacco control

ii. Reducing harmful alcohol consumption

iii. Reduce consumption of local and imported food and drink products that are high in sugar, salt, and fat content as they are directly linked to obesity, diabetes, heart disease, and other NCDs.

iv. Improve the efficiency and impact of the existing health budget by reallocating scarce health resources to targeted primary and secondary prevention measures for non-communicable disease interventions such as cardiovascular disease and diabetes.

v. To strengthen the evidence base to enable better investment planning and programme effectiveness; ensuring that interventions work as intended and provide effective measures.

-Detecting

-Screening

– Treating ,of various diseases of NCDs and providing access to palliative care for people in need.

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GLOSSARY

Action plan– a scheme, or course of action, which may correspond to a policy or strategy, with defined activities indicating who does what

when and how and with what resources an objective can be accomplished.

Hyperglycemia –high level of glucose in the blood

Hyperlipidemia– high levels of fat in the blood

Morbidity –the condition or the rate of prevalence of disease in a population. Mortality – the condition or the state of death on a large scale.

Policy– A policy is a specific official decision or set of decisions , of goals and priorities, and main directions for attaining the set goals designed to carry out a course of action endorsed by a political body.

Strategy– A strategy is a long-term plan designed to achieve a particular goal.

Surveillance– can be defined as “the continuous scrutiny or inspection of the factors that determine the occurrence and distribution of disease and other conditions of ill-health.

Did you know?

The World Health Organization estimates that NCDs account for 60 % (more than 35 million) deaths annually.
Roughly 80 % of NCD related deaths occur in low- and middle-income countries, where fragile health systems often struggle to meet the population’s most basic health needs.
WHO estimates that 48 percent of NCD deaths in low- and middle-income countries occur before 70 years old, compared with 26 percent in high income countries.

Interesting facts

Tobacco use is the most significant behavioral risk factor of chronic respiratory disease (CRD) and cancer (figure 4). WHO notes that “tobacco is the leading behavioral risk factor causing substantially large number of potentially preventable deaths worldwide…one death every six seconds” (WHO, 2012).
In 2012, all United Nations member countries committed to achieving a 25 percent reduction in premature mortality from NCDs by 2025 (the 25 x 25 target).

Points to ponder

Of the “premature” deaths, 87% are estimated to occur in low- and middle-income countries. In order to assess national capacity for NCD prevention and control, in 2001 WHO conducted the first NCD country capacity survey (NCD CCS) to gather detailed information on the progress of countries in addressing and responding to NCDs .

References

http://www.who.int/mediacentre/factsheets/fs355/en/

http://www.who.int/cancer/publications/national_capacity_prevention_ncds.pdf

https://www.researchgate.net/profile/Ulla_Uusitalo/publication/11345504_Influencing_public_nutriti

on_for_non-

communicable_disease_prevention_from_community_intervention_to_national_programme-

experiences_from_Finland/links/09e41513a06fd849e6000000/Influencing-public-nutrition-for-non-

communicable-disease-prevention-from-community-intervention-to-national-programme-experiences-from-Finland.pdf

Suggested Readings

http://www.who.int/substance_abuse/en/
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