1. Burden of NCDs in India Burden of NCDs in India Dr. Ashoo Grover Scientist ICMR Headquarters, Delhi

2. THE WORLD HEALTH IS IN TRANSITION EPIDEMIOLOGICAL : NCDS OVERRIDING INFECTIOUS DISEASES AND DOUBLE BURDEN OF DISEASES IN MANYDEVELOPING COUNTRIES LIFESTYLES: TOBACCO USE IS INCREASING DIETS ARE RAPIDLY CHANGING PHYSICAL ACTIVITY REDUCING ALCOHOL USE INCREASING OBESITY, DIABETES, HYPERTENSION ARE INCREASING IN MOST PARTS OF THE WORLD,WHILE UNDER-NUTRITION REMAINS A SEVERE ISSUE DEMOGRAPHIC : POPULATION AGEING. GLOBALIZATION : INCREASING GLOBAL INFLUENCES

3. HEALTH TRANSITION contd…… Rapid urbanization Increased industrialization Rising incomes Expanded education, and Improved health care. Improved public health measures have resulted in the control of many infectious diseases, and reduction in mortality and fertility

4. COMMUNICABLE VERSUS NON-COMMUNICABLE DISEASES Communicable diseases Sudden onset Single cause Short natural history Short treatment schedule Cure is achieved Single discipline Short follow up Back to normalcy Non-communicable diseases Gradual onset Multiple causes Long natural history Prolonged treatment Care predominates Multidisciplinary Prolonged follow up Quality of life after treatment

6. BY 2020 THESE DEATHS WILL ACCOUNT FOR 73% DEATHS AND 60% OF THE DISEASE BURDEN.

7. HALF OF THESE DEATHS ARE ATTRIBUTABLE TO CARDIOVASCULAR DISEASES.

9. DISTRIBUTION OF CAUSES OF DEATH WORLD, 2001 Total deaths: 56,554,000 Other NCDs Respiratory infections Respiratory diseases Neuropsychiatric disorders HIV/AIDS Digestive diseases Perinatal conditions Malignant neoplasms Diarrhoeal diseases Tuberculosis Childhood diseases Diabetes Malaria Maternal conditions Nutritional deficiencies Other CD causes Injuries Cardiovascular diseases Source: WHR 2002

10. WORLD, DALY’s, BY BROAD CAUSE GROUP, 2001 Noncommunicable conditions Injuries Communicable diseases, maternal and perinatal conditions and nutritional deficiencies Source: WHR 2002

11. DISEASE BURDEN (DALY’s) WORLD, 2001 Maternal conditions Perinatal conditions Nutritional deficiencies Respiratory infections Other NCDs Malaria Malignant neoplasms Childhood diseases Diabetes Diarrhoeal diseases Neuropsychiatric disorders HIV/AIDS Tuberculosis Other CD causes Sense organ disorders Cardiovascular diseases Injuries Respiratory diseases Congenital abnormalities Digestive diseases Musculoskeletal diseases Diseases of the genitourinary system Source: WHR 2002

12. Mortality BY BROAD CAUSE GROUP AND WHO REGION, 2001 Communicable diseases, maternal and perinatal conditions and nutritional deficiencies Noncommunicable conditions Injuries 75% 50% 25% AFR AMR EMR EUR SEAR WPR Source: WHR 2002

13. DALY’s BY BROAD CAUSE GROUP AND WHO REGION, 2001 Communicable diseases, maternal and perinatal conditions and nutritional deficiencies Noncommunicable conditions Injuries 75% 50% 25% AFR AMR EMR EUR SEAR WPR Source: WHR 2002

15. both the developed and developing world sharing the burden more or less equally.

16. All NCDs, account for at least 40 % of all deaths in developing countries and 75% in industrialized countries

17. Cardiovascular diseases (CVDs) are the first cause of mortality

19. Stroke Ischemic heart diseases Diabetes Burden of major non-communicable diseases, India, 2004

20. Six key “risk factors” for Non-Communicable Diseases Tobacco use in any form (smoking ,chewing, snuff). Alcohol abuse Life-style changes (easy dietary patterns, physical inactivity) Environmental risk factors e.g. air and water pollution, occupational hazards Failure or inability to obtain preventing health services (e.g. for hypertension control, tobacco control, management of diabetes etc. Stress factors

21. Lifestyle Risk factors Improper nutrition Sedentary life Alcohol and Tobacco

22. Cancer Scenario-India 2.5-3 million cases of cancer 8 million detected in 2001 3-3.5 lakh deaths each year 500% increase in cancer in India by 2025 280% due to ageing and 220% due to tobacco use Tobacco related cancers 50% (males) and 25% (females) 2/3rd are advanced at the time of diagnosis

23. Estimated Number of Incident Cancers in India, 2001

24. Cancer facts and figures One in about 15 men and one in about 12 women in the urban areas could develop cancer in their lifetime Cervical cancer and breast cancer are the commonest in females. The latter is more than former in Mumbai and Delhi Cancer lung is the commonest out of all tobacco related cancers in men Cancer of the oesophagus highest in women in Bangalore (8.3/100,000)

25. Tobacco Use – Global Scenario 1.2 billion users, expected to rise to 1.6 by the next two decades 3.5 to 4 million deaths annually due to tobacco use expected to rise to 10 million in 2020s. 7 million in developing countries.

26. Tobacco Use in India No. of tobacco Users in India. 150 Million Men 34 Million women No. of smokers 105 Million Men 7 Million Women No. of Smokeless Tobacco Users 66 Million Men 30 Million Women

27. CHD prevalence studies in India Urban Rural

28. Cardio-vascular diseases (CVD) Morbidity and mortality data CHD deaths=8 lakhs Stroke deaths=6 lakhs Hypertension= 10-15 % RHD deaths=1.5 lakhs RHD prevalence=1-5/1000 (5-15 years) CVD and stroke deaths 23% Source: WHO infobase

29. Burden of Rheumatic Fever/Rheumatic Heart Disease 5.4/100,000 2.9/100,000 1.0/100,000

30. Projected proportional increase in population > 65 years age, 2000-2030 Italy Japan UK USA China India Chile Mexico 0% 50% 100% 150% 200% 250% Proportion (%) Social Determinants of Health Inequalities, Marmot M, Lancet 2005

31. Projected population pyramid of India

32. Growth of elderly population aged 60 and over, by sex, in India 1901-2001

33. (Source: ICMR Collaboraitve Studies) Estimated Load of NCDs in Older Persons(in millions)

34. (Source: World Bank Health Sectoral Priorities Review) Estimated and projected mortality rates (per 100,000) by major causes of death in 60+ population INDIA

35. ESTIMATED BURDEN OF NEUROLOGICAL DISORDERS IN INDIA

36. Severe mental morbidity in India

38. The national program for control of blindness was initiated on this basisCataract was the commonest --due to senile degeneration

39. Cataract Study on cataract prevalence found different figures for different areas Increasing backlog of cataract due to less surgeries Different strategies applicable to different areas

40. Burden of diabetes In the developing countries majority of people with diabetes are in the age range 45-64 years diabetes will be increasingly concentrated in the urban areas Increasingly, there would be more women than men with diabetes DALYS 5.3 millions

41. Burden of Diabetes in India Mortality Number of deaths (000) Diabetes as a cause 104 Attributable to DM 473.7 DALYS 5.3 million Murray, Lopez. 1996

42. Prevalence of Type 2 DM in India Year Author Place Prevalence urban rural Tripathi Cuttack 1.2 - Ahuja N. Delhi 2.3 - Gupta Multi-centric 3.0 1.3 Murthy Tenali 4.7 - Ramachandran Kudramukh 5.0 - Rao, PV Multicentric - 2.8 Ramachandran Chennai 11.6 - Reddy, KS Delhi 11.0 2.7 2000 NUDS (DESI) Multicentric 13.2 -

43. Prevalence of Type 2 diabetes in India Source: King H et al - Global burden of diabetes 1995-2025 Diabetes Care1998;21:1414-1431.

44. NON COMMUNICABLE DISEASE PROGRAMMES IN INDIA National cancer control programme National mental health programme National blindness control programme Cardiovascular diseases, stroke and diabetes programme Trauma and accident programme Oral health programme Rehabilitation programme Geriatric care programme

45. Sources of NCD related data in India

46. EXISTING REPORTING SYSTEMS FOR NON COMMUNICABLE DISEASES IN INDIA Sentinel surveillance systems National Cancer Registry Programme Periodic surveys/studies Census of India Sample registration systems National sample surveys National family health survey National nutrition monitoring programme

47. SOURCES OF DATA COLLECTION FOR NON COMMUNICABLE DISEASES IN INDIA Mortality data Medical certificates for death Cause of death surveys Hospital records Morbidity data Registry (Cancer) Special surveys Hospital reports Risk factors Special surveys Registries Cancer (Shift from hospital to community based) RF/RHD (Jai Vigyan Mission) Thalasemia (Jai Vigyan Mission)

48. NCD Mortality Profile 1998 (Source: WHO NCD Info-base)

49. NCD Morbidity Profile in India 1998

50. NCD Risk Factors in India

51. HETEROGENEITY OF NON-COMMUNICABLE RISK FACTORS IN INDIA Kerala High literacy rate, developed Different dietary patterns Metropolitan city, highly urbanized, heterogeneous population Delhi Different body composition Nested population Terrain, relatively underdeveloped Jammu& Kashmir Different habits Nested population Underdeveloped, Tribes and Terrain Nagaland Bihar Illiterate, Poor population Rural, Agricultural, Tribals

52. Challenges Huge population Many programmes Rural population Emerging epidemics Unemployed youth Burden of non communicable diseases Opportunity Good sample size Different strategies Complex exposures Interventions Trained workforce Challenges and opportunities

54. Lack of activity

55. Diet

56. Alcohol,

57. Smoking

59. Nutrition

60. Diseases

61. Linear growth

63. Maternal nutritional status & obesity,

64. Fetal growthAccumulated risk Accumulated risk Age Life course approach for the prevention of non communicable diseases

65. Public health interventions Educational interventions Policy interventions Health beliefs and behaviours (Community; Individual) Enabling environment (Financial, Social, Physical) Desired change

66. FACTS ABOUT NCDS The burden of diseases due to non communicable diseases in India became almost equal to that due to communicable diseases in 1990 The burden of non communicable diseases is increasing while it is declining in developed countries because of surveillance and interventions The life style related modifiable risk factors for non communicable diseases have been identified and the magnitude of their impact is documented

67. FACTS ABOUT NCDS The major non communicable diseases share common, preventable life style risk factors There is sound evidence that non communicable diseases can be reduced through a package of simple, effective and feasible life style changes The treatment of non communicable diseases is expensive and therefore the key to control is in its primary prevention

68. THANK YOU