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Burden of NCDs in India
Burden of NCDs in India
Dr. Ashoo GroverScientist
ICMR Headquarters, Delhi
EPIDEMIOLOGICAL : NCDS OVERRIDING INFECTIOUS DISEASES AND DOUBLE BURDEN OF DISEASES IN MANY DEVELOPING COUNTRIES
LIFESTYLES: TOBACCO USE IS INCREASING DIETS ARE RAPIDLY CHANGING
PHYSICAL ACTIVITY REDUCINGALCOHOL USE
INCREASING OBESITY, DIABETES, HYPERTENSION ARE INCREASING IN MOST PARTS OF THE WORLD,
WHILE UNDER-NUTRITION REMAINS A SEVERE ISSUEDEMOGRAPHIC : POPULATION AGEING.GLOBALIZATION : INCREASING GLOBAL INFLUENCES
THE WORLD HEALTH IS IN TRANSITION
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
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
NONCOMMUNICABLE DISEASE CONTRIBUTE 60 % OF DEATHS AND 43 % OF THE GLOBAL BURDEN OF DISEASE. ALREADY 79% OF THESE NCDS ARE OCCURRING IN DEVELOPING COUNTRIES.
BY 2020 THESE DEATHS WILL ACCOUNT FOR 73% DEATHS AND 60% OF THE DISEASE BURDEN.
HALF OF THESE DEATHS ARE ATTRIBUTABLE TO CARDIOVASCULAR DISEASES.
THERE ARE MORE CVD DEATHS IN INDIA OR CHINA THAN IN ALL DEVELOPED COUNTRIES ADDED TOGETHER.
THE GLOBAL NCD REALITY
32.5%
58.5%
9.0%Injuries
(5.1 million)
Noncommunicableconditions
(33.1 million)
WORLD Mortality BY BROAD CAUSE GROUP, 2001
Communicable diseases, maternal
and perinatal conditions and
nutritional deficiencies
(18.4 million)
Total deaths: 56,554,000
Source: WHR 2002
3%3%
5%5%
7% 3% 6%4%
13%
30%9%
DISTRIBUTION OF CAUSES OF DEATH WORLD, 2001
Total deaths: 56,554,000
Cardiovascular diseases
Diabetes
Malignant neoplasmsDigestive diseases
Neuropsychiatric disordersRespiratory diseases
Other NCDs
InjuriesOther CD causes
Nutritional deficienciesMaternal conditions
MalariaChildhood diseases
TuberculosisDiarrhoeal diseasesPerinatal conditions
HIV/AIDSRespiratory infections
Source: WHR 2002
42.0%
45.9%
12.2% Injuries
Noncommunicableconditions
WORLD, DALY’s, BY BROAD CAUSE GROUP, 2001
Communicable diseases, maternal and perinatal
conditions and nutritional deficiencies Source: WHR 2002
6%
6%
4%3%
3%6% 7%
5%
13%
3%
10%4%3%
12% Cardiovascular diseases
DiabetesMalignant neoplasms
Digestive diseases
Neuropsychiatric disorders
Other NCDs
Injuries
Other CD causes
Maternal conditions
MalariaChildhood diseases
Tuberculosis
Diarrhoeal diseases
Perinatal conditions
HIV/AIDS
Respiratory infections
Respiratory diseases
Nutritional deficiencies
Sense organ disorders
Diseases of the genitourinary system
Musculoskeletal diseasesCongenital abnormalities
DISEASE BURDEN (DALY’s) WORLD, 2001
Source: WHR 2002
75%
50%
25%
AFR AMR EMR EUR SEAR WPR
Mortality BY BROAD CAUSE GROUP AND WHO REGION, 2001
Communicable diseases, maternal and perinatal conditions and nutritional
deficienciesNoncommunicable
conditions Injuries
Source: WHR 2002
75%
50%
25%
AFR AMR EMR EUR SEARWPR
DALY’s BY BROAD CAUSE GROUP AND WHO REGION, 2001
Communicable diseases, maternal and perinatal conditions and nutritional
deficiencies
Noncommunicableconditions Injuries
Source: WHR 2002
Major NCDs responsible for some 19 million deaths worldwide annually
both the developed and developing world sharing the burden more or less equally.
All NCDs, account for at least 40 % of all deaths in developing countries and 75% in
industrialized countries Cardiovascular diseases (CVDs) are the first
cause of mortalityCancer is the third one
Estimated and projected proportion of deaths due to non-communicable
diseases, India, 1990-2010
0%10%20%30%40%50%60%70%80%90%
100%
1990 2000 2010Year
Prop
ortio
n (%
)
Injuries
Communicable diseasesNon communicable diseases
No. of cases No.of DALY No. of YLL No. of deaths05
1015202530354045 39.40
16.00
4.950.55
No. in mil-lions
No. of cases
No.of DALY No. of YLL No. of deaths
01234567
1.64
6.365.28
0.63
No. in mil-lions
No. of cases No.of DALY No. of YLL No. of deaths0
10
20
30
40
50
60
70
66.58
2.26 1.15 0.11
No. in mil-lions
Ischemic heart diseases Stroke
Diabetes
Burden of major non-communicable diseases, India, 2004
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
Lifestyle Risk factors
• Improper nutrition • Sedentary life• Alcohol and • Tobacco
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
Estimated Number of Incident Cancers in India, 2001
Site Male Female Both SexesLip, Oral cavity 39,000 31,000 70,000
Pharynx & Larynx
53,000 14,000 67,000
Oesophagus 31,000 26,000 57,000
Stomach 35,000 16,000 51,000
Lung 34,000 7,000 41,000
Breast - 80,000 80,000
Cervix uteri - 100,000 100,000
Others 201,000 139,000 340,000
Total 393,000 413,000 806,000
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)
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.
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
Rural Urban05
101520253035
33.6
23.2
8.8
4.0
Prevalence of Tobacco Use
Men Women
%
CHD prevalence studies in India
Place Year Prevalence
Agra 1996 1.05
Delhi 1962 1.04
Chandigarh 1968 6.60
Rohtak 1975 3.63
Delhi 1990 9.67
Jaipur 1995 7.59
Moradabad 1995 8.55
TVM 1995 12.65
Place Year Prevalence
Haryana 1974 2.06
Vidharabha 1988 1.04
Kerala 1993 7.48
Punjab 1994 3.09
Rajasthan 1994 3.53
Uttar Pradesh
1995 3.09
Urban Rural
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
Burden of Rheumatic Fever/Rheumatic Heart
Disease
Delhi Varanasi Vellore
1.0/100,000
5.4/100,000
2.9/100,000
Social Determinants of Health Inequalities, Marmot M, Lancet 2005
Projected proportional increase in population > 65 years age, 2000-
2030
0% 50% 100% 150% 200% 250%
MexicoChileIndia
ChinaUSAUK
JapanItaly
Proportion (%)
Projected population pyramid of India
Growth of elderly population aged 60 and over, by sex, in India 1901-2001
1901
1911
1921
1931
1941
1951
1961
1971
1981
1991
2001
01020304050607080
Number of Older Persons in India (in milllions)
No.of Older PersonsYear
Popu
latio
n
(Source: ICMR Collaboraitve Studies)
Estimated Load of NCDs in Older Persons
(in millions)
Diseases 1991 2001Cataract 46.47 63.61Hearing Impairment 33.85 46.30Heart Diseases 19.96 27.32Hypertension 5.34 7.33CHD 5.02 6.87Diabetes 2.74 3.75Blindness 2.40 3.30Cancers 1.48 2.10Mental Morbidities 1.10 1.53
(Source: World Bank Health Sectoral Priorities Review)
Estimated and projected mortality rates (per 100,000) by major causes of death in 60+
population INDIAMajor
causes1985 2000 2015
M F M F M FAll causes 1158 1165 879 790 846 745Infections 478 476 215 239 152 175Neoplasms
43 51 88 74 108 91
Circulatory
145 126 253 204 295 239
Pregnancy 0 22 0 12 0 10Perinatal 168 132 60 48 40 30Injury 85 65 82 28 84 29Others 239 293 280 285 167 171
ESTIMATED BURDEN OF NEUROLOGICAL DISORDERS IN INDIA
Disorder
Rate (per one lakh population)
Urban Rural TotalTotal Neurological DisordersEpilepsyHeadacheFebrile convulsionsCerebrovascular disorders Mental retardationTremors
2371
575986198138
105
57
4335
11931254466165
178
378
3348
8821119332151
141
414
Severe mental morbidity in India
Bangalore Baroda Calcutta Patiala0
100
200
300
400
500
600
700
800
Epilepsy Schiz Dep psychosis Org brain synd Mania
Prev
rate
/100
,000
Blindness
Senile Degeneration47%
Metabolic25%
Indefinite17%
Prenatal3%
Infections6%
Injuries2%
Others1%
Etiology of Blindness
Lens75%
Cornea7%
Optic Nerve7%
Others & Unknown6%
Bulbar atrophy4%
Site of blindness Nationwide study in 1970s for the first time
provided figures for blindness in the countryThe national program for control of blindness
was initiated on this basis
Cataract was the commonest --due to senile degeneration
Cataract
Series105
101520253035
2.18 3.566.28
8.6714.26
11.27
29.08
BACKLOG OF CATARACTCases in Lakhs
40-44
45-49
50-54
55-59
60-64
65-69
70 and aboveAge
Study on cataract prevalence found different figures for different areas
Increasing backlog of cataract due to less surgeries
Different strategies applicable to different areas
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
Burden of Diabetes in India
Mortality Number of deaths (000)
Diabetes as a cause 104
Attributable to DM 473.7
DALYS 5.3 millionMurray, Lopez. 1996
Prevalence of Type 2 DM in India
Year Author Place Prevalence
urbanrural
1971 Tripathi Cuttack 1.2 -1972 Ahuja N. Delhi 2.3 -1979 Gupta Multi-centric 3.0
1.31984 Murthy Tenali 4.7 -1988 Ramachandran Kudramukh 5.0 -1989 Rao, PV Multicentric -
2.81992 Ramachandran Chennai 11.6-1997 Reddy, KS Delhi
11.02.72000 NUDS (DESI) Multicentric 13.2-
1995 2000 20250
102030405060
19 23
57
Millions
1995 2000 202501234567
3.8 4
6
Prevalence (in %)
Prevalence of Type 2 diabetes in India
Source: King H et al - Global burden of diabetes 1995-2025 Diabetes Care1998;21:1414-1431.
NON COMMUNICABLE DISEASE PROGRAMMES IN INDIA
A. National cancer control programmeB. National mental health programme C. National blindness control programmeD. Cardiovascular diseases, stroke and diabetes
programme E. Trauma and accident programme F. Oral health programme G. Rehabilitation programme H. Geriatric care programme
Sources of NCD related data in IndiaMortality Medical
Certification of Death
Causes of Death SurveyMOHFW DataCBHI data
Hospital Data
Morbidity Disease Registry (Cancer)AMI Under ProcessDM Under Process
Special SurveyMeta-analysis (Mental Health)NFHSNSSO
Hospital ReportsPGIMER Respiratory Disease SurveyJIPMER (Neuropsychiatricmorbidity)
Risk Factors
No regular surveyIDSP ???
Special Survey (ICMR-NCD Surv)MOHFW 10 Centre Study on ElderlyICMR Substance Abuse SurveyNFHSNSSO
ICMR ad-hoc StudiesMedical College
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
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)
NCD Mortality Profile 1998 (Source: WHO NCD Info-base)
Disease No of death (% of death)All cancers 292,557 (3.4)CVD 1,117,994 (13.0) IHD 423,600 RHD 57,272 Stroke 102620 Other HD 52502
Diabetes 21000 (0.2)Injuries 749,983 (8.7) RTA 85,003 Other Injuries including Poisoning
528,486
Suicides 91,324 Homicides 45,170
Chronic Respiratory Disease 577,837Neuro-psychiatric Disorders Not available
NCD Morbidity Profile in India 1998Disease No of casesNeuro-psychiatric Disorders 110,660,782Chronic Respiratory Disease 65,000,000Diabetes 28,702,100CVD NR IHD 25,000,000 RHD 1,882,987 Stroke 1,083,500 Other HD NR
Injuries 6,900,000 RTA 900,000 Other Injuries including Poisoning
6,000,000
Suicides NR Homicides NR
All cancers 593,803 (incidence)
NCD Risk Factors in India
Rask Factor
Definition Prevalence (%) in Urban Areas
Prevalence (%) in Rural Areas
Hypertension > 160/95 mmHg
10-15 (4) 3-8 (4)
Hypertension > 140/90 mmHg
20-30 (6) 15-25 (4)
Overweight BMI > 25 20-40 (2) 10 (1)Hypercholestrolemia
> 220 mg/dl 20 (1) 10 (1)
Sedentary Physical Activity
Varied 50-60 (6) 8-30 (3)
Kerala
Delhi
Jammu & Kashmir
Nagaland
Bihar
High literacy rate, developed
Metropolitan city, highly urbanized, heterogeneous populationNested populationTerrain, relatively underdeveloped
Nested populationUnderdeveloped, Tribes andTerrainIlliterate, Poor populationRural, Agricultural, Tribals
Differentdietary patterns
Differentbody
composition
Differenthabits
HETEROGENEITY OF NON-COMMUNICABLE
RISK FACTORS IN INDIA
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
Age
Deve
lopm
ent o
f non
com
mun
icabl
e di
seas
es
Foetallife
Adult Life Adolescence Infancy andchildhood
• SES• Nutrition• Diseases• Linear
growth• Obesity
• Obesity• Lack of
activity• Diet• Alcohol,• Smoking• SE
potential
• Established adult risk factors(behavioural/biological)
• SES• Maternal
nutritional status & obesity,
• Fetal growth
Accumulated risk
Range of individual risk
Accumulated risk
Life course approach for the prevention of non communicable
diseases
Public health interventions
Policy interventions Educational interventions
Health beliefs and behaviours
(Community; Individual)
Desired change
Enabling environment(Financial, Social, Physical)
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
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
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