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1. EPIDEMIOLOGY OF
NON-COMMUNICABLE
DISEASES
Prabesh Ghimire

2. Non-communicable diseases
 Cardio-vascular diseases (Coronary Heart
Disease, Stroke)
 Cancer
Chronic respiratory disease
Diabetes
Chronic neurological diseases (Alzheimer’s,
dementia)
Arthritis/Musculoskeletal diseases
Prabesh Ghimire 2

3. Global status of NCDs
NCDs kill 41 million people each year (71% of all deaths
globally)
Four major NCDs account for over 80% of all premature
NCDs deaths (in 2016)
• Cardio-vascular disease: 17.9 million
• Cancer: 9 million
• Chronic respiratory diseases: 3.8million
• Diabetes: 1.6 million
Over 85% of premature deaths in low and middle income
countries
Source: World Health Statistics, 2018
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4. Growing nature of NCDs
 Deaths by NCDs- more than all other causes combined
 Projected to increase from 38 million in 2012 to 52 million
by 20301.
42% of all NCD deaths occurred before age of 70 years1
• 17 million in 2015
• 16 million in 2012
• 14.6 million in 2000
Risk of dying from any one of the four main NCDs
between 30-70 yrs decreased from 22% in 2000 to 18%
in 20162.
1. Global Status Report on NCDs, 2014
2. World Health Statistics, 2018
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5. Growing nature of NCDs-Nepal
NCDs account for estimated 65% of total deaths in Nepal
(121,000 NCD deaths)1
• In 2014- 60% of total deaths2
 The probability of dying between 30-70 years from 4
main NCDs – 22%
1. NCD progress monitor; WHO, 2017
2. NCD country profiles, 2014
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6. Risk Factors for NCDs
Modifiable behavioral risk factors
• Tobacco consumption: 7.2 million deaths every year
• Excess salt/sodium intake: 4.1 million deaths
• Insufficient physical activity: 1.6 million deaths
• Alcohol use: More than half of 3.3 million annual deaths
attributable to alcohol use are from NCDs
Non-modifiable risk factors
• Age, race, gender, genetics
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7. Risk Factors for NCDs
Metabolic risk factors
• Increased blood pressure: 19% of global deaths
• Obesity/ overweight
• Increased blood glucose levels or hyperglycemia
• Increased levels of fat in the blood or hyperlipidemia
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8. Critical pathway in NCDs causation
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9. Consequences of NCDs
 NCDs exacerbate poverty
• Excessive health care costs >> Quickly drain
household resources>>> Catastrophic
expenditure>>>impoverishment
 NCD is a major contributor to premature
mortality
 NCD threatens progress towards 2030 agenda
for Sustainable Development
• SDG goal: Reduce premature deaths from NCDs by
one-third by 2030
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10. Strategies for prevention and control
1. Advocacy and partnership
• Integrating NCDs into health and development plans
with special attention to social determinants of health
• Raising political awareness
2. Health promotion and risk factors minimization
a) Reducing tobacco use
• Raising taxes and prices
• Warning people about dangers of tobacco
• Ban on tobacco advertising and promotion
• Establishing tobacco surveillance
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11. Strategies for prevention and control
b) Reducing harmful use of alcohol
• Increasing access to consumer information about harmful
effects of alcohol
• Ban on alcohol advertising and promotion
• Prevention and treatment services to individual and
families affected by alcohol-use disorders
c) Promoting healthy diet
• Reducing food with high transfat content and other junk
food
• Strengthening food safety and labeling regulations
• Raising awareness on benefits of reducing salt and high
unsaturated fatty acids.
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12. Strategies for prevention and control
d) Promoting physical activity
• Implementation of improved urban planning
• Improving access to right information on physical activity
promotion and healthy lifestyle.
e) Reducing indoor air pollution
• Promoting alternative sources of energy for cooking and
heating at homes
• Promote change in structural designs of housing for better
ventilation
• Encouraging the use of improved cooking stoves
• Behaviour change communication
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13. Strategies for prevention and control
3. Health system strengthening for early detection
and management
• Efficient procurement and supply chain mechanism for basic drugs
and diagnostic equipment and tests.
• Capacity building of health workforce for early identification and
management of common NCDs
• Integrating cost-effective NCD interventions (PEN package) into
basic primary health care package
• Strengthening referral system for management of NCDs
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14. Government Efforts on NCDs
Multi-sectoral action plan on prevention and control of
NCD 2014-20
Scaling up PEN package to selected districts
 Ratified WHO FCTC in 2006-
• MPOWER package into implementation,
• Tobacco law in existence
 Population Based Cancer Registry System introduced in
Jan 2018.
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15. Government Efforts on NCDs
Cash support up to 100,000 to poverty stricken citizens
for treatment of selected NCDs: Cardiovascular diseases,
cancer, renal diseases…
Research: Risk factor STEPS survey
Commitments to SDG
Information, Communication and Education
Tobacco Quit-Line Telephone Counseling: 01-521200
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16. SELECTED
NON-COMMUNICABLE
DISEASES
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17. Cardiovascular Diseases (CVDs)
 Group of disorders of the heart and blood vessels
Includes
• coronary heart disease (blood vessels supplying heart
muscle)
• cerebrovascular disease (blood vessels supplying brain)
• rheumatic heart disease (damage to hear muscle and hear
valves for rheumatic fever)
• other conditions (Congenital heart disease, deep vein
thrombosis, pulmonary embolism)
Four out of five CVD deaths are due to heart attacks and
strokes.
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18. Growing nature of CVDs
Projected to be leading cause of death in all
countries by 2020
Estimated 17.9 million die people every year-
32% of all global deaths
• Coronary heart disease – 7.5 million
• Stroke- 6.7 million
Over 17 million premature deaths (under 70
years) due to non-communicable disease (2015)
• About 40% caused by CVDs
 Over 80% of CVD deaths occur in LMICs
By 2030, 25 million people will die from CVDs
Source: WHO Reports
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19. Growing nature of CVDs- Nepal
 Upto one-quarter (22.4) of all deaths in the Nepal were
caused by CVDs
Expected increase: 35% by 2030
One-fourth (25.7%) population 15-69 years were found
with raised blood pressure
Source: WHO STEPS survey, 2013
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20. Risk Factors for CVDs
Major 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
• Lipoprotein
Non-modifiable risk factors
• Age
• Heredity or family history
• Gender
• Ethnicity or race
Novel risk factors
• Excess homocysteine in blood
• Abnormal blood coagulation
(elevated blood levels of
fibrinogen)
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21. Underlying determinants of CVDs
Causes of the causes- “Social determinants of
health”
• Socio-economic and political contexts
• Socio-economic position
• Material circumstances
• Behavioral factors
• Health system factors
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22. Prevention and Control of CVDs
 Modifying risk factors: blood-pressure, alcohol use,
smoking cessation, physical activity (exercises)
Improving dietary practices, reduced salt intake
Lipid lowering pharmacotherapy
Antihypertensive medication
Action on Social Determinants of Health
Learning resource: Priority non-communicable diseases and conditions (wpro.who.int)
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23. Cancer
 Group of diseases affecting any part of body
Rapid creation of abnormal cells invading the adjoining
parts and organs >>metastases
Also called Malignant tumors and neoplasms
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24. Growing nature of cancer
 Second leading cause of death globally
 Globally, 1 in 6 deaths is due to cancer.
8.8 million deaths in 2015.
Common causes of cancer deaths
• Lung cancer: 1.69 million deaths
• Liver cancer: 788 thousand deaths
• Colorectal: 774 thousand deaths
• Stomach: 754 thousand death
• Breast: 571 thousand deaths
Source: Cancer factsheet, www.who.int
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25. Growing nature of cancer
70% of all deaths from cancer occur in low and
middle income countries1
Nepal: 7% of all deaths attributed to cancer2
By 2030 cancer deaths projected to increase by
30%2
 Mortality between 30-70 years of age: 6.7 per
10,000 population3
1. WHO.Cancer factsheet, www.who.int, 2018.
2. WHO Multisectoral action plan on NCD prevention and control.
3. NHRC, 2013
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26. Growing nature of cancer
Cancer deaths in Nepal1
• Males: 6,900 (17% respiratory tract, lung cancer, 13%
mouth cancer, 9% stomach)
• Females: 7,400 (18% cervical cancer, 14% respiratory
tract, lung cancer, 12% breast cancer)
1. WHO. Cancer country profiles, 2014
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27. Prediction of cancer incidence in Nepal
(2013-2020)
Figure source: Poudel, Krishna Kanta et al. “Prediction of the Cancer Incidence in Nepal.” Asian Pacific
Journal of Cancer Prevention : APJCP 18.1 (2017): 165–168. PMC.
Prabesh Ghimire 27

28. Major killers
Men Women
Lung cancer
Liver cancer
Stomach cancer
Colorectal cancer
Prostate cancer
Breast cancer
Lung cancer
Colorectal cancer
Cervical cancer
Stomach cancer
Source: WHO fact file, 2015 data
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29. Cervical Cancer
Cancer of female reproductive system
99% cases linked to genital infection with HPV
virus
Risk factors
• HPV infection
• Smoking
• Immune deficiency
• Family history of cervical cancer
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30. Lung Cancer
 Cancer that forms in tissues of the lung, usually in the
cells lining air passages
Leading cause of cancer deaths, 1.69 million deaths
globally
Affects more men than women
Risk factors
• Smoking
• Exposure to second hand smoke
• Radiation therapy of breast or chest
• Exposure to asbestos, radon, chromium, arsenic, soot or tar
• Exposure to air pollution
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31. Breast cancer
Cancer that forms in the tissues of the breast,
usually in the ducts or in the lobules
Occurs commonly in women, rarely occurs in
men
Risk factors
• Hormone therapies
• Weight and physical inactivity
• Age: risk increases with age
• Genetics or family history
• BRCA1 and BRCA2 genes
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32. Colorectal cancer
Third most common type of cancer
Forms in large intestine
Risk factors
• Aging
• Unhealthy diet
• Diabetes
• Family history of colorectal cancer
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33. Causes of cancer
Interaction of person’s genetic factors and 3
categories of external agents
• Physical carcinogens- UV and ionizing radiation
• Chemical carcinogens- asbestos, components of
tobacco smoke, aflatoxin (food contaminant), and
arsenic
• Biologic carcinogens- infections from certain viruses
and parasites
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34. Risk factors for Cancer
One third of deaths from cancer are due to the 5
leading behavioral and dietary risks:
• Tobacco use: 22% cancer deaths globally
• Alcohol use
• High body mass index
• Low fruit and vegetable intake
• Lack of physical activity
Cancer may also have infectious origin
• HPV and hepatitis virus: 25% cancer cases in LMICs
Source: Cancer factsheet, www.who.int
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35. Prevention and control
Risk factors modification
• Control of tobacco use including cigarettes and
smokeless tobacco
• Healthy eating with increased fruit and vegetable
intake
• Increasing physical activity
• Control of harmful use of alcohol
• Prevention from sexually transmitted HPV-infection
• Reduced exposure to indoor smoke from use of solid
fuels.
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36. Prevention and control
Vaccination against HPV and hepatitis B virus:
(can prevent 1 million cases each year)
Control of occupational hazards
Reducing exposure to ultraviolet radiation
Reducing exposure to ionizing radiation
(occupational and medical diagnostic imaging)
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37. Prevention and control
Screening and early detection
• VIA for cervical cancer
• HPV testing for cervical cancer
• PAP cytology test
• Mammography screening for breast cancer
 Treatment
• Surgery
• Radiotherapy
• Chemotherapy
Palliative care
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38. Chronic Respiratory Disease
 One of the leading causes of deaths globally
 High under-diagnoses rates
90% of deaths occur in low income countries
In Nepal, Mortality between 30-70 years of age: 8 per
10,000 population
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39. Chronic Obstructive Pulmonary Disease
(COPD)
Umbrella term for chronic disease of lung
Prevents proper airflow in the lungs
Chronic bronchitis, emphysema
Not curable
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40. Growing nature of COPD
 Prevalence: 251 million cases in 2016 (Global burden of
disease study)
 2015: 3.17 million deaths globally (5% of all deaths)
2016: 3.8 million deaths (9% of all deaths)
 Estimates show that COPD becomes in 2030 the third
leading cause of death worldwide.
In Nepal, respiratory diseases (including COPD and
asthma) accounted for 7 percent of NCD burden
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41. Risk factors of COPD
Tobacco smoking
Indoor air pollution (use of solid fuel)
Outdoor air pollution
Occupational dusts and chemicals (vapours, irritants and
fumes)
Frequent lower respiratory infections during childhood
Age: usually becomes apparent after 40 or 50 years of
age)
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42. Asthma
Chronic disease of the air passages of the lungs which
inflames and narrows them
Recurrent attacks of breathlessness and wheezing
Common disease among children
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43. Growing nature of Asthma
383,000 deaths due to Asthma in 2015 (2016 WHO
estimates)
235 million people currently suffer from Asthma
80% asthma-related deaths occur in LMICs
Source: www.who.int
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44. Causes and risk factors of Asthma
Fundamental causes unknown
Risk factors are combination of genetic
predisposition with environmental exposures to
inhaled particles
• Indoor allergens (dust, mites, etc.)
• Outdoor allergens (such as pollens and moulds)
• Tobacco smoke
• Chemical irritants in workplace
• Air pollution
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45. Causes and risk factors of Asthma
Triggers of Asthma
• Cold air
• Extreme emotional arousal such as arousal, fear,
excitement
• Physical exercise
• Certain medications: aspirin, NSAIDs and beta blockers
(for high blood pressure, heart disease, migraine)
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46. Prevention and control
Primary prevention: Reducing exposure to risk factors
• Tobacco smoke
• Frequent lower respiratory tract infections in childhood
• Air pollution (indoor, outdoor and occupational exposure)
Secondary prevention: Cost-effective interventions and
medications
• Corticosteroids, inhalers
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47. Diabetes
 Disorder of metabolism
4 types of diabetes: Type 1, Type 2, Gestational and Pre-
diabetes (impaired glucose tolerance)
Type 2 is caused by modifiable risk factors and is most
common worldwide
• >90% of all adult diabetes cases are Type 2
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48. Growing nature of diabetes
Number of adults adults living with diabetes quadrupled
between 1980 and 20141
• 422 million adults with diabetes in 2014 (108 in 1980)
Global prevalence of diabetes double between 1980 to
2014 in adult population (4.7% to 8.5%)1
1.6 million deaths in 20162
WHO projects that diabetes death will increase by two
thirds between 2008 and 2030
1. Global Report on Diabetes, 2016
2. World Health Statistics, 2018
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49. Diabetes in South-East Asia & Nepal
In SEAR, prevalence (18+yrs) doubled from 4.1% in 1980
to 8.6% in 2014
National Prevalence- 3.6%
• 4.6% in men and 2.7% in women
Prevalence up to 11 percent in certain areas
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50. Risk factors for diabetes
Major Modifiable risk factors
• Unhealthy diets
• Physical inactivity
• Obesity and overweight
• High blood pressure
• High cholesterol
Other modifiable risk factors
• Low socioeconomic status
• Heavy alcohol use
• Psychosocial stress
• High consumption of sugar
sweetened beverages
• Low consumption of fiber
Non-modifiable risk factors
• Increased age
• Family history/ genetics
• Race
Other risk factors
• Low birth weight
• Presence of autoantibodies
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51. Prevention and control of diabetes
Promote healthier eating- Avoiding sugar and saturated
fat intake
Increasing physical activity and maintaining body weight
Control of blood glucose
Screening for early detection and treatment of
complications
Medications for associated CVD risk factors and diabetic
complications
• control of blood pressure
• Control of lipids
Action on social determinants of health
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52. Learning Resources
 World Health Statistics, 2018
Global Report on Diabetes
Non-communicable diseases progress monitor, 2017
Non-communicable disease country profiles, 2014
Multi-sectoral action plan on prevention and control of
NCD in Nepal 2014-20
Non-communicable diseases risk factors: STEPS survey
Nepal 2013
Global status report on NCDs 2014
CDC. Overview of non-communicable disease and
related risk factors
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53. Queries and Discussions…
Prabesh Ghimire 53