Overview of Chronic Disease Risk Factors and STEPS Framework

Department of Chronic Diseases and Health Promotion
Overview of the STEPS Framework:
Rationale for Risk-Factor Selection

Chronic Disease
Risk-Factor Surveillance
 In 2020, chronic diseases responsible for 60% deaths
globally and 47% of global burden of disease.
 80% of chronic disease deaths occur in low- and middle-
income countries.
 Common, preventable risk factors (RFs) underlie most
chronic diseases.
 The major risk factors account for 80% of deaths from
heart disease and stroke.

Objectives of STEPS Surveillance
 Develop standardized tools to enable comparisons
over time and across countries/sites.
 Prevent chronic disease epidemics before they occur.
 Help health services plan priority .
 Collect consistent data across and within countries
programmes and interventions.
 Predict future caseloads of chronic diseases.
 Monitor and evaluate population-wide interventions.

 It is a very simple system.
 It is hierarchical, depending on the
need of the country.
 It is a method with standardized
tools.
 It is flexible regarding risks,
conditions, age groups, geographic
areas, and cultural and local
adaptations.
 It can be added to existing systems.
Why Use the STEPwise Framework
for Surveillance?

Different levels:
 Questionnaire
 Physical measurement
 Blood sample
Different levels of evaluation of
each RF:
 Core-basic
 Expanded
 Optional
STEPS for Risk Factors

Demography and
behaviour:
 Basic socio-demographic
information
 Tobacco use
 Alcohol consumption
 Fruit and vegetable
consumption
 Physical inactivity
STEPS 1: Core-Basic
1

Physical
Measurement:
 Height
 Weight
 Waist circumference
 Blood pressure
STEPS 2: Core-Basic
1
2

STEPS 3: Core-Basic
Biochemical
measurements:
 Glucose
 Cholesterol total

STEPS 1: Expanded
Demography and
behaviour:
 Use of other types of
tobacco
 Tobacco cessation
 Excessive use of alcohol
 Consumption of Fat
 Family history

STEPS 2: Expanded
Physical
measurement:
 Hip circumference
 Heart rate

STEPS 3: Expanded
Biochemical
measurements:
 Triglycerides
 Cholesterol HDL

STEPS Methodology
 Household survey
 Representative sample of the population 25 – 64,
stratified by 10-year age groups and sex
 Use of standardized instrument to get
comparative data
 Biochemical measurement:
Dry method (capilar blood)
Wet method (vein blood)

Available STEPS Materials
 Manual
 Methodology for planning
and implementing a study
 Questionnaire
 Q by Q guide
 Data Analysis
 STEPS database with Epi
Info programmes
 Fact Sheet Analysis Guide
 Data Book
 Reporting
 Data Book
 Fact Sheet
 Site Report

The STEPS Surveillance Loop
Recognize
value of
population
information
Begin
STEPS
Planning
Survey Implementation
Workshop
• Sampling
• Survey administration
• Questionnaire
• Data entry & management
Conduct
STEPS
Report
Results
Implement
Interventions
Analysis & Reporting
Workshop
• Epi Info training
• Analysis of data
• Report writing
Application and Program
Planning Workshop
• Policies
• Programs
• Other interventions

STEPS Risk Factors
 Behavioural Risk Factors
 Tobacco use
 Harmful alcohol consumption
 Unhealthy diet (low fruit and vegetable consumption)
 Physical inactivity
 Biological Risk Factors
 Overweight and obesity
 Raided blood pressure
 Raised blood glucose
 Abnormal blood lipids

Rationale for STEPS Risk Factors
 These RFs have greatest impact on chronic disease
morbidity and mortality.
 Modification is possible through effective prevention.
 Measurement of RFs has proved to be valid.
 Measurements can be obtained using appropriate
ethical standards.

Disease
Outcomes
 Heart disease
 Stroke
 Diabetes
 Cancer
 Respiratory
Physiological RF
 BMI
 Blood pressure
 Blood glucose
 Cholesterol
Behavioral RF
Tobacco
Alcohol
Physical
inactivity
Nutrition
The Causal Chain

Rationale for Tobacco Use as a
Risk Factor for Chronic Disease
 History of tobacco use
 Current type of tobacco use
 Current frequency of tobacco use
*Tobacco is the fourth most common risk factor for disease and the
second major cause of death worldwide. It is currently responsible for
the death of one in ten adults worldwide (about 4.9 million deaths each
year).
*Smokers have a markedly increased risk of multiple cancers, particularly
lung cancer, and are at far greater risk of heart disease, stroke, Chronic
Obstructive Pulmonary Disease (COPD), diabetes, and other fatal and
non-fatal diseases. People who chew tobacco risk cancer of the lip,
tongue, and mouth.

Rationale for Tobacco Use as a
Risk Factor for Chronic Disease (cont’d)
*Intra-Uterine Growth Retardation, spontaneous miscarriages and low-
birth-weight babies are known outcomes of smoking during pregnancy.
*Non-smokers exposed to second-hand smoke have a 25% – 35%
increased risk of suffering acute coronary diseases, and increased
frequency of chronic respiratory conditions.
*Small children whose parents smoke at home have an increased risk of
suffering lower respiratory-tract infections, middle-ear infection and
Sudden Infant Death Syndrome (SIDS).
*The World Bank estimates that in high-income countries, smoking-related
healthcare accounts for between 6% and 15% of all annual health-care
costs.

Unhealthy Diet as a Risk Factor for
Chronic Disease
 Fruit and vegetable consumption
 Type of oil or fat used for cooking
*Low intake of fruits and vegetables is estimated to cause
about 19% of gastrointestinal cancer, 31% of ischemic
heart disease and 11% of stroke worldwide.
*The consumption of at least 400g of fruit and vegetables
per day is recommended as a population intake goal,
to prevent diet-related chronic diseases.

Unhealthy Diet as a Risk Factor for
Chronic Disease (cont’d)
*Adequate consumption of fruit and vegetables reduces the risk for
cardio vascular diseases, stomach cancer and colorectal cancer.
*There is convincing evidence that high intake of high-energy foods
such as processed foods high in fats and sugars promote obesity
compared to low-energy foods such as fruits and vegetables.
*Higher unsaturated fatty acids from vegetable sources and
polyunsaturated fatty acids have been associated with a reduced
risk of type 2 diabetes.
*Replacement of saturated and trans fatty acids by polyunsaturated
vegetable oils lower coronary heart disease risk.

Physical Inactivity as a Risk Factor
for Chronic Disease
 Physical activity at work
 Physical activity during travelling to and from places
 Recreational physical activity
 Sedentary behaviour
*Physical inactivity causes about 1.9 million avoidable deaths per year
worldwide.
*Physically inactive persons have a 20% – 30% increased risk of all-
cause mortality as compared to those who adhere to 30 minutes of
moderate intensity physical activity most days of the week.

Physical Inactivity as a Risk Factor
for Chronic Disease (cont’d)
*Globally, physical inactivity accounts for 21.5% of ischemic heart
disease, 11% of ischemic stroke, 14% of diabetes,
16% of colon cancer, and 10% of breast cancer.
*Physical inactivity is a major risk factor in promoting obesity, which
itself is a risk factor for other chronic diseases.
*Physical activity may have a protective effect against the
development of cognitive impairment and dementia, and it
reduces the severity of symptoms among the depressed.
*Physical activity is associated with the prevention of osteoporosis
and related fractures.

Overweight and Obesity as
Risk Factors for Chronic Diseases
 Height
 Weight
*At least 2.6 million people die each year as a result of being
overweight or obese.
*Overweight and obesity lead to adverse metabolic effects on
blood pressure, cholesterol, triglycerides and insulin resistance.
The risks of coronary heart disease, ischemic stroke and type 2
diabetes mellitus increase steadily with increasing BMI.
*Raised BMI also increases the risks of cancer of the breast, colon,
prostate, endometrium, kidney and gall bladder.
 Waist circumference
 Hip circumference

Overweight and Obesity as
Risk Factors for Chronic Diseases (cont’d)
*Optimum health, the median BMI for an adult population range of 21 –
23 kg/m2. The goal for individuals should be to maintain BMI in the
range 18.5 to 24.9 kg/m2.
*There is slightly increased risk of co morbidities for BMI 25.0 to 29.9,
and moderate to severe risk of co-morbidities for BMI greater than
30.4.
*Waist circumference is an approximate index of intra-abdominal fat
mass and total body fat.
*Changes in waist circumference reflect changes in risk factors for
cardiovascular disease and other forms of chronic diseases.
*Waist circumference or waist-to-hip ratio are more powerful
determinants of subsequent risk of type 2 diabetes than BMI.

Raised Blood Pressure as a
Risk Factor for Chronic Disease
 History of blood pressure
 Repeated elevated systolic and diastolic blood
pressure
*Blood pressure levels have been shown to be positively and
continuously related to the risk of stroke and coronary heart
disease.
*The risk of cardiovascular disease doubles for each increment of
20/10 mm Hg of blood pressure, starting at 115/75.
Reference
2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension.
Journal of Hypertension 2003; 21: 1983-1992.
Chobanian A V, Bakris G L, Black H R et al. The Seventh Report of the National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. Journal of American Medical Association, 2003; 289(19): 1206-1252.
Williams B, Poulter N R, Brown M J et al. British Hypertension Society guidelines for hypertension management 2004 (BHS IV): summary.
British Medical Journal, 2004; 328: 634-640.

Raised Blood Pressure as a Risk Factor
for Chronic Disease (cont’d)
*Treating systolic blood pressure and diastolic blood pressure to
targets that are less than 140/90 is associated with a decrease
in cardiovascular complications.
*Stage 1/Grade 1 hypertension: Mean blood pressure is => 140/90
and < 160/100 on two or more measurements on each of two or
more visits on separate days.
*Stage 2/Grade 2 hypertension: Mean blood pressure is =>
160/100 and < than 180/110 on two or more measurements on
each of two or more visits on separate days.
*Stage 3/Grade 3 hypertension: Mean blood pressure is =>180/110
during two or more measurements on each of two or more visits
Reference
2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension.
Journal of Hypertension 2003; 21: 1983-1992.
Chobanian A V, Bakris G L, Black H R et al. The Seventh Report of the National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. Journal of American Medical Association, 2003; 289(19): 1206-1252.
Williams B, Poulter N R, Brown M J et al. British Hypertension Society guidelines for hypertension management 2004 (BHS IV): summary.
British Medical Journal, 2004; 328: 634-640.

Raised Cholesterol & Triglycerides
 Total cholesterol
 Cholesterol HDL
 Triglycerides
Raised cholesterol is estimated to cause
• 18% of the global stroke disease and
• 56% of global ischemic heart disease.
*This amounts to about 4.4 million deaths (7.9% of total) and 40.4
million DALYs (2.8% of total).

Raised Cholesterol & Triglycerides (cont’d)
A 10% reduction in serum cholesterol in men aged 40 can
result in a 50% reduction in heart disease within 5 years;
an average of 20% reduction in heart disease occurs
within 5 years in men aged 70 years.
*Plasma HDL cholesterol is inversely related to coronary artery disease
incidence, and the relationship is independent of total cholesterol, LDL
and triglyceride levels.
*Increased triglycerides are an independent risk factor for coronary
heart disease after controlling for LDL and HDL cholesterol.

Raised Blood Glucose as a Risk Factor
for Chronic Diseases
 History of diabetes
 Fasting blood glucose
*Impaired glucose tolerance and impaired fasting
glycaemia are risk categories for future
development of diabetes and cardiovascular
disease.
*There is a long asymptomatic period during which
diabetes can be detected.

Raised Blood Glucose as a Risk Factor
for Chronic Diseases (cont’d)
*Clinical trials have shown that almost two-thirds of type 2
diabetes can be prevented or postponed.
*The excess mortality attributable to diabetes in the year
2000 was estimated to be 2.9 million deaths, equivalent to
5.2% of all deaths. In people 35–64 years old, 6%–27% of
deaths were attributable to diabetes.
*The age-adjusted mortality, mostly due to coronary heart
disease in many populations, is 2–4 times higher than in
the non-diabetic population.
* People with diabetes have a twofold increase risk of stroke.

Optional Modules
 Family history
 History of diabetes, hypertension, elevated cholesterol,
and elevated sugar
 Women’s health
 Mental health
 Violence and unintentional injury
 Oral health
 Any other behaviour

STEPS Advantages
 Standardized methods
 Capacity-building on a national and international level
 Human Resources
 Equipment
 Data analysis
 Continues aces and technical support
 Comparable data at international level
 Use for policy and planning

What do we as WHO-PAHO-CAREC offer?
 Instrument and standardized methodology, proved in
over 90 countries. Flexible to respond to various needs
 STEPS Manual
 STEPS Tools (software for data entry, data analysis
and report templates)
 Workshop for planning and field work and data
management
 Workshop for data analysis and interpretation

Conclusions
 The STEPwise framework is flexible to meet the
needs of any site or country.
 STEP Tools guide through data analysis and
reporting and can be adjusted as the site requires.
 The STEPS team is always available to help with
planning and data or reporting needs.

Overview of Chronic Disease Risk Factors and STEPS Framework

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