Download Epidemiology of Non-Communicable Diseases

‫بسم هللا الرحمن الرحيم‬
‫الحمد هلل رب العالمين والصالة‬
‫والسالم على نبينا محمد خاتم‬
‫األنبياء وسيد المرسلين وعلى آله‬
‫وصحبه أجمعين وبعد‬
Epidemiology of Chronic
diseases
Non communicable
diseases
Chronic diseases have been
defined as :
Chronic illnesses.
 Non-Communicable.
 Degenerative.
Characteristics:
 Uncertain
etiology.
 multiple risk factors.
 long latency period .
 Prolonged course of illness.
 non- contagious origin.
 functional disability and sometimes
incurability .

Latency period is the period between contact of
the causative agent with susceptible host to the
onset of first sign a symptoms.
 The cause of many chronic diseases remains
obscure, but risk factors identified for some of
the leading chronic diseases. The most
important among these risk factor is Tobacco
use especially in COPD .
Strategies for the prevention
 Approach
to prevention of chronic
diseases can be considered
under three headings :

1-Primordial prevention: prevention or
avoiding the development of risk factors
in the community to prevent the disease
in the population and as such protects
the individuals. This involves the
avoidance of risk behaviors.



prevention of disease occurrence by
altering susceptibility of the host or
reducing exposure of susceptible
persons to the risk factors
Examples : immunization , good
nutrition , health education ,
counseling, environmental sanitation,
purification of water , protection against
accidents at work place and seat belts.
 Requires
: accurate knowledge of
causative agent and process of disease.
 2-Primary
prevention : Modifying or
reducing the risk factors associated with
the development of a disease in
individuals with or without the use of
interventions, It involves modification of
established risk behavior and risk factors
with specific interventions to prevent
clinically manifest disease


That is by early detection , screening by
examinations altering the course of
disease
Examples : high blood pressure , T.B.
Diabetes , Cancer of the breast , Cancer
of the cervix colo-rectal cancers, lung
cancer etc.

3- Secondary prevention : Modifying the
risk factors in the presence of the
manifested disease by changes in
lifestyle and/or use of drugs.

4- Tertiary Prevention : alleviation
and limitation of disability
improvement of quality of life ,
Rehabilitation and follow up.
What would be the top 10 causes
of their deaths?
9
The major non communicable
diseases are :
 Cardiovascular
Diseases.
 Chronic Obstructive Pulmonary Disease
 Diabetes
 Hypertension
 Cancers
• Accidents in its different types
 Non
communicable diseases also include
injuries, which have an acute onset, but
may be followed by prolonged
convalescence and impaired function, as
well as chronic mental diseases.
 Out
of all non-communicable illnesses,
cardiovascular diseases stay as the
leading cause of morbidity and mortality ,
especially in developed and rich countries.
All over the world, almost 1.5 million
adults and elderly died in 1995 from heart
disease, stroke or other forms of
circulatory disease.
 Cancer
is a growing health problem in
developing countries, where more than
half of the global total of six million deaths
occur.
 Noncommunicable
diseases (NCDs) are a
global challenge. During the next several
decades, NCDs will govern the health care
needs of populations in most low- and
middle-income countries because of
declines in communicable diseases,
conditions related to childbirth and
nutrition, changes in lifestyle factors (eg,
smoking), and population aging (1).
 We
examined the burden of NCDs in the
Hashemite Kingdom of Jordan. We
computed the projected prevalence of
diabetes, hypertension, and high blood
cholesterol. All of these risk factors are
associated with an increased risk of
cardiovascular disease (CVD) — the
leading cause of death in Jordan — and
increased health care use.
 In
2005, Jordan’s population was
approximately 5.5 million. By 2050, the
population is expected to increase to
between 8.5 and 14.8 million people. (2)
The proportion of older people (aged 60
years or older) is expected to be 15.6% (or
approximately 1.8 million people) in 2050,
more than 3 times that in 2000 (2).
 During
2005, NCDs accounted for more
than 50% of all deaths in Jordan. Heart
disease and stroke (International
Statistical Classification of Diseases, 10th
Revision, codes I00-I99) accounted for
35% of all deaths; malignant neoplasms
(C00-C97) were responsible for 13% of
deaths (3).
 Nearly
60% of deaths from malignant
neoplasms occurred among people
younger than 65 years, and approximately
one-third of those who died from CVD
were aged 65 or younger
 During
2004, approximately 400,000
(15%) Jordanian adults had diabetes (an
increase from 7% in 1996), and an
estimated 350,000 (12%) had impaired
fasting glucose (4,5). Approximately 15%
of adults reported hypertension, and
roughly 23% had high blood cholesterol —
an increase from 9% in 1996 (4,5).
 The
proportion of all deaths attributable to
NCDs in the World Health Organization's
Eastern Mediterranean Region is
projected to increase from 51% during
2005 to 66% by 2030 (6).
 Assuming
prevalences are similar to that
in Jordan, diabetes may affect nearly 10
million people in Egypt, one of the region’s
largest countries, and 3 million people in
Saudi Arabia. Hypertension may affect 18
million Egyptians and 6.5 million people in
Saudi Arabia by 2050.
 Programs
to monitor and control risk
factors, clinical services, and a robust
health care system will be important to
successfully improve NCD outcomes and
reduce the burden of disease.
 Reducing
the prevalence of NCDs will
require a renewed commitment by
governmental and nongovernmental
institutions, by public health professionals
and clinical practitioners, and by
communities and individuals to
acknowledge the burden of NCDs and the
need for timely action.
 Moreover,
stimulating, strengthening, and
sustaining regional efforts and programs
are necessary to reduce the prevalence of
NCDs through coordinated and integrated
programs of health promotion and disease
prevention.
 These
programs should involve networks
for risk factor surveillance, information
sharing, capacity building, advocacy,
policy development, and collaboration in
generating, disseminating, and applying
knowledge.
Common CVD Risk Factors
 1-Tobacco
use.
 2-Physical inactivity.
 3- Unhealthy diet.
 Life expectancy in developing countries is
rising sharply and people are exposed to
these risk factors for longer periods.
Newly merging CVD risk factors:
 Like
low birth weight.
 folate deficiency.
 Infections.
 Social class: more frequent among the
poorest in low and middle income
countries.
Hypertension

Prevalence:
 Hypertension is estimated to cause 4.5% of
current global disease burden and is as
prevalent in many developing countries, as in
the developed world. Blood pressure-induced
cardiovascular risk rises continuously across the
whole blood pressure range. Countries vary
widely in capacity for management of
hypertension, but worldwide the majority of
diagnosed hypertensive are inadequately
controlled.
 Hypertension
affects one in four adults,
putting them at higher risk for heart
 attacks, kidney disease, atherosclerosis,
macular degeneration and stroke. It is
 often termed the "silent killer" because
as many as 35% of those who have
 hypertension do not realize it.

More than 60% of all women over age 65
have hypertension. Women over age 75
are much more likely to develop the
disease than men..
 HTN
is a major public health problem of
worldwide distribution and is the most
common cardiovascular disease (CVD)
risk factor . It is responsible for one half of
coronary heart disease (CHD) and about
two thirds of cerebrovascular accidents.
By 2030, 23 million cardiovascular deaths
are projected to have HTN, with about
85% occurring in low and middle-income
countries .
 Research
published between 1980 and
2002 indicate the prevalence of HTN in
developing countries increased at a higher
rate than in developed countries .
Prevention of HTN is possible, and early
detection and treatment can reduce the
incidence of complications including
stroke, CHD, heart failure, and kidney
disease , and yet the levels of control of
hypertension are low worldwide.
 Economically
developed countries have
higher rates of HTN than in developing
countries . However, data reported in the
last decade indicate that the prevalence,
awareness, treatment, and control of
hypertension in economically developing
countries are coming closer to those in
economically developed countries .
 Recent
epidemiological studies on
prevalence, awareness, treatment, and
control of HTN in Jordan are scarce. The
few community-based studies conducted
between 1994 and 1996 in Jordan
demonstrated a 16.1 and 16.3%
prevalence rates of HTN (cut-off point
160/90 mm Hg) with concomitant low
levels of awareness, treatment, and
control.
 Since
that time, several activities have
been implemented to face this challenge in
HTN which have not been evaluated.
Moreover, the last decades showed a
remarkable improvement in treatment of
hypertension due to introduction of new
antihypertensive medications and the
development of international guidelines for
detection and management .
 Meyasser
Zindah, head of the Health
Ministry's cardiovascular disease
department, warned of the high
prevalence of heart disease, noting that
662,527 citizens over the age of 18
suffered from high blood pressure in 2007.
Risk Factors
Uncontrollable risk factors:
 Increasing age.
 Family history.
 Race, African-Americans are at higher risk
than Caucasians).
 Sodium sensitivity. .

Controllable risk factors:
 Overweight
or obesity.
 Physical inactivity.
 Heavy alcohol consumption.
 Use of oral contraceptives.
 Excessive sodium intake. .
Diet:
 Dairy,
Fruits & Vegetables, and low fat,
high Fibers food may Lower Blood
Pressure
 a recent study suggests that adding
certain foods to the diet may also help.
The dairy products act in lowering blood
pressure in mildly hypertensive adults.
 Fat: Fatty food increases the risk.
Coronary heart disease ( CHD)
 is
the leading cause of death in
Industrialized countries
 CHD is also called Ischemic heart disease
or coronary artery disease . These are
several disorders that reduce the blood
supply to the heart muscle . The
underlying impairment is the
atherosclerosis which remains sub clinical
.
Heart Disease Leading Cause of
Death in Jordan 2008

Heart disease has become a leading
threat to the health of the Jordanian
population, with 40.5 percent of
deaths last year found to be related
with heart ailments .
High risk groups:

Gender: Men have a higher CHD mortality rates
than women twice for men than women , never
the less, CHD is the single greatest mortality risk
in women : 3 times the risk of breast cancer.
 Age : CHD is the leading cause of death for men
and women over 65 years of age.
 For men- major increases in CHD begin in 35-44
year age group.
 For women – marked increase is delayed until
after menopause
 Sub-
clinical CHD is more prevalent in
older than younger persons.
 Black women die at a higher rate than
white women from CHD
 The Asians in American have
approximately half( ½) the CHD mortality
than white Americans.
Risk factors:







Coronary risk factors are modifiable and nonmodifiable .
Modifiable :
Most important factors are :
high blood cholesterol
elevated blood cholesterol
physical inactivity
smoking
Other modifiable include :
 diabetes
 obesity
dietary factors
 alcohol use
 stress
Non- modifiable risk factors are
:




Ethnicity.
age.
gender.
socioeconomic status
Classification of risk factors by
magnitude of the risk
 moderate
relative risk :
 high B.P  140/90
 : cigarette smoking
 : elevated cholesterol ( 200mg)
 : diabetes FBS  140 mg
Weak relative risk
 obesity



physical inactivity
environmental tobacco
smoke exposure
Possible relative risk :
 Excessive
alcohol use
 Elevated plasma homocysteine
 Infectious agents
Selected Risk factors:
 Cigarette
smoking is a major cause of
CHD among men and women
 Smokers have twice the risk of heart
attack than non-smokers.
 Risk of sudden death from heart attack 24 times higher than the risk of nonsmokers Heavy smokers , CHD death is 23 times than non-smokers
 Stop
smoking : rapid reduction of CHD
mortality it takes 10 years to become
normal.
 Passive smoking – increased risk of CHD
than non-exposed.
 Arteriography of non-smoking exposed
women with CHD showed number of
stenotic arteries correlated with exposure.
 Importance of this health problem.



Cholesterol : CHD increases steadily
with increase of cholesterol blood level.
< 200 mg : low risk of CHD
 240 mg : risk doubles.
 Excess
CHD occurs with levels 220-310
mg for people with cholesterol levels 250300 mg range. Each 1% reduction in
cholesterol level results in about a 2%
reduction in CHD morbidity and mortality .
 High
levels of LDL are leading factor in
progression of atherosclorosis and
development of CHD.
 Evidence supporting the association of
elevated blood triglycerides and CHD has
been mounting in recent years. The level
of HDL is inversely related to CHD
however the lower level of HDL < 35mg
increases the risk of CHD.




Diabetes is considered a major CHD risk
factor CHD is the most common cause of
morbidity and mortality among diabetics – 2-4
times higher than non-diabetics.
Risk is higher in diabetic women than diabetic
men.
Homocysteine , increased attention as a
potential modifiable risk factor for acute CHD.
Plasma levels of homocysteine , positively
associated with risk of CHD.
 Homocysteine
: an inborn metabolic error
leads to extremely high levels of
homocysteine people with this error, have
strokes before age 30 years .
 People with moderately high
homocysteine levels have not been shown
to be at increased risk of CHD.
Obesity :
. Body mass index (kg/m2)
BMI (
weight)

ratio of weight to height >
(height ) 2
 Overweight : BMI > 27.8 kg/m2 in
males

: BMI > 27.3 kg /m2 in
females

prevalence of overweight increased dramatically
in the USA
 Poverty is related to obesity in women
 Death from CHD is associated with obesity at
the upper range of body weight BMI  30 kg/m2
.
 Under the age of 50 years, men and women with
relative weight of 130% or more – associated
with two fold increase in risk of CHD.
 Recent
studies suggest that the
distribution of fat is the body may effect
CHD risk
 Central obesity – upper body and
abdominal fat increases risk more than
lower body fat.
Physical Activity
 6)
Physical in-activity is recognized as a
major risk factor for CHD.

Physical activity decreases body weight
blood pressure and improves insulin
sensitivity .
 The greatest benefits appear to occur with
very moderate level of activity.
7) Alcohol consumption:
 Moderate
to heavy increases blood
pressure levels and CHD mortality ,
however , light regular drinking has been
associated with modest reduction of CHD
risk through increasing HDL.
 8)
Psychological factors and stress :
especially type A behavior pattern
characterized by excessive
competitiveness, hostility , impatience, fast

speech and quick motor movements
have been studied along with anger, job
stress, anxiety and social support.
 9)
Risk factors for CHD tend to work in
cluster than individual the patient likely to
have more than one risk factor.
 CHD increases markedly when risk
factors manifest simultaneously there is an
additive contribution to CHD risk factors .
 "This
number is much higher than 10
years ago," The prevalence of
cardiovascular disease in Jordan is mostly
due to diet, smoking and pollution,
according to Bassam Hijjawi, director of
the ministry's disease control department.
 He
also tied the prevalence of the chronic
disease to a lack of exercise, noting that
over 60 percent of Jordanians suffering
from heart conditions do not participate in
physical exercises.
 In
Jordan, the average life expectancy in
2002 was 72 years, and chronic diseases
are becoming increasingly prevalent.
Because personal behavior can influence
the occurrence and progression of many
chronic diseases.
 the
Jordan Ministry of Health (JMOH)
established surveillance for behavioral risk
factors, particularly those related to
cardiovascular diseases and diabetes.
 This report summarizes the key findings of
the 2002 Behavioral Risk Factor Survey,
the first reporting segment in Jordan's
surveillance program for chronic diseases.
 The
findings indicate that:
 A- Smoking
 B- Physical inactivity
 C- Obesity
contribute substantially to the burden of
chronic disease in Jordan and
underscores the need for effective public
health interventions.
 Reported
by: F Shehab, MD, Field
Epidemiology Training Program; A
Belbeisi, MD, Jordan Ministry of Health. H
Walke, MD, Div of International Health,
Epidemiology Program Office, CDC.
‫بسم هللا الرحمن الرحيم‬
‫الحمد هلل رب العالمين والصالة‬
‫والسالم على نبينا محمد خاتم‬
‫األنبياء وسيد المرسلين وعلى آله‬
‫وصحبه أجمعين وبعد‬
What is diabetes?
 Diabetes
mellitus is a group of diseases
characterized by high levels of blood
glucose resulting from defects in insulin
production, insulin action, or both.
Diabetes can be associated with serious
complications and premature death, but
people with diabetes can take steps to
control the disease and lower the risk of
complications.
Types of diabetes
 Type
1 diabetes was previously called
insulin-dependent diabetes mellitus
(IDDM) or juvenile-onset diabetes.(510%).
 Type 2 diabetes was previously called
non-insulin-dependent diabetes mellitus
(NIDDM) or adult-onset diabetes. Type 2
diabetes may account for about 90 percent
to 95 percent of all diagnosed cases.
 Gestational
diabetes: After pregnancy, 5
percent to 10 percent of women with
gestational diabetes are found to have
type 2 diabetes. Women who have had
gestational diabetes have a 20 percent to
50 percent chance of developing diabetes
in the next 5-10 years.
 Other
specific types of diabetes result
from specific genetic conditions (such as
maturity-onset diabetes of youth), surgery,
drugs, malnutrition, infections, and other
illnesses. Such types of diabetes may
account for 1 percent to 5 percent of all
diagnosed cases of diabetes.
Risk Factors
 The
primary risk factor for type 1
diabetes


Genetics and family history. Having family members
with diabetes is a major risk factor. The American
Diabetes Association recommends that anyone with
a first-degree relative with type 1 diabetes -- a
mother, father, sister, or brother -- should get
screened for diabetes. A simple blood test can
diagnose type 1 diabetes.
 Diseases
of the pancreas. Injury or
diseases of the pancreas can inhibit its
ability to produce insulin and lead to
type 1 diabetes.
 Infection or illness. A range of relatively
rare infections and illnesses can
damage the pancreas and cause type 1
diabetes.
Risk Factors for Type 2 Diabetes

.
Type 2 diabetes occurs when the body can't
use the insulin that's produced, a condition
called insulin resistance. Though it typically
starts in adulthood, type 2 diabetes can
begin anytime in life. Because of the current
epidemic of obesity among U.S. children,
type 2 diabetes is increasingly found in
teenagers.
 Obesity
or being overweight is a major
risk factor for Diabetes Type 2. Diabetes
has long been linked to obesity and
being overweight. Research at the
Harvard School of Public Health
showed that the single best predictor of
type 2 diabetes is being obese or
overweight

Obesity and diabetes are both epidemic in the
U.S. The most-used measure for obesity is BMI,
which stands for body mass index. BMI is a
ratio, and can be determined using standard
tables of height and weight (kg/m2) . A BMI of 25
to 29.9 is considered overweight. A BMI of 30 or
higher defines obesity. BMI of 40 would be
diagnosed with "extreme obesity" or as
having “clinically severe morbid obesity”.

The CDC ( Centers for Disease Control and
Prevention )estimates that more than one out of
every four Americans is obese, having a BMI of
30 to 39.9; 6% of Americans have clinically
severe obesity. That means they have a BMI of
40 or greater.
 Impaired glucose tolerance or impaired
fasting glucose. Prediabetes is a milder form
of diabetes that's sometimes called impaired
glucose tolerance. It can be diagnosed with a
simple blood test. Prediabetes is a major risk
factor for developing type 2 diabetes.
 Insulin
resistance. Type 2 diabetes
often starts with cells that are resistant
to insulin. That means they are unable
to take in insulin as it moves glucose
from the blood into cells. With insulin
resistance, the pancreas has to work
overly hard to produce enough insulin
so cells can get the energy they need.
This involves a complex process that
eventually leads to type 2 diabetes.
 Ethnic
background. Diabetes occurs
more often in Hispanic/Latino
Americans, African-Americans, Native
Americans, Asian-Americans, Pacific
Islanders, and Alaska natives.
 High
blood pressure . Hypertension, or
high blood pressure, is a major risk
factor for diabetes. High blood
pressure is generally defined as 140/90
mm Hg or higher. Low levels of HDL
"good" cholesterol and high
triglyceride levels also put you at risk.
 History
of gestational diabetes. If you
developed diabetes while you were
pregnant, you've had what is called
gestational diabetes. Having had
gestational diabetes puts you at higher
risk of developing type 2 diabetes later
in life.
 Sedentary
lifestyle. Being inactive -exercising fewer than three times a
week -- makes you more likely to
develop diabetes.
 Family history. Having a family history
of diabetes -- a parent or sibling who's
been diagnosed with this condition -increases your risk of developing type
2 diabetes.

Polycystic ovary syndrome. Women with
polycystic ovary syndrome (PCOS) are at
higher risk of type 2 diabetes.
 Age. Some doctors advise anyone over 45 to
be screened for diabetes. That's because
increasing age puts you at higher risk of
developing type 2 diabetes. It's important to
remember, though, that people at any age
can develop diabetes. If you're over 45 and
overweight or if you have symptoms of
diabetes, talk to your doctor about a simple
screening test.
Gestational Diabetes Risk Factors
 Obesity
or being overweight. Being
obese or overweight puts women at
risk of gestational diabetes.
 Polycystic ovary syndrome
 Previous glucose intolerance. A history
of glucose intolerance or previous
gestational diabetes increases the risk
of gestational diabetes in a current
pregnancy.
 Family
history. A family history of
diabetes -- a parent or sibling who's
been diagnosed with diabetes -increases the risk of gestational
diabetes.
 Age. The older a woman is when she
becomes pregnant, the higher her risk
of gestational diabetes.
Prevention
 Whatever
your risk factors for diabetes
may be, there's a lot you can do to delay
or prevent diabetes. To manage your risk
of diabetes, you should:
 manage your blood pressure
 keep your weight within or near normal
ranges
 get moderate exercise on most days
 eat a balanced diet
Prevention
 Lifestyle
interventions included diet and
moderate-intensity physical activity (such
as walking for 2 1/2 hours each week). In
the Diabetes Prevention Program, a large
prevention study of people at high risk for
diabetes, the development of diabetes was
reduced 58 percent over 3 years.
Prevention or Delay of Diabetes
 Research
studies have found that lifestyle
changes can prevent or delay the onset of
type 2 diabetes among high-risk adults.
These studies included people with IGT
and other high-risk characteristics for
developing diabetes.
Prevention of Diabetes
Complications

Diabetes can affect many parts of the body and
can lead to serious complications such as
blindness, kidney damage, and lower-limb
amputations. Working together, people with
diabetes and their health care providers can
reduce the occurrence of these and other
diabetes complications by controlling the levels
of blood glucose, blood pressure, and blood
lipids and by receiving other preventive care
practices in a timely manner.
Total Prevalence of Diabetes in
the United States, All Ages, 2002
 Total:
18.2 million people--6.3
percent of the population--have
diabetes.
 Diagnosed: 13 million people
 Undiagnosed: 5.2 million people
Diabetes in Jordan

An increase in prevalence of diabetes
mellitus in Jordan over 10 years.
The age-standardized prevalence of diabetes and
impaired fasting glycemia IFG was 17.1% and
7.8%, respectively, with no significant
differences between women and men. Journal
Diabetes Complications. 2008 SepOct;22(5):317-24. Epub 2008 Apr 16.
 Ajlouni K, Khader YS, Batieha A, Ajlouni H, ElKhateeb M.

The prevalence of type 2 diabetes and impaired
fasting glycemia (IFG) is high in Jordan and is
increasing. More than half of the patients with
diabetes have unsatisfactory control. Therefore,
they are likely to benefit from programs aimed at
encouraging behaviors toward achieving
optimum weight as well as physical activity
behaviors. Physicians caring for patients with
diabetes may need to adopt a more vigorous
approach for diabetes control.
CONCLUSION:
 Diabetes
mellitus and IGT are common
among adult Jordanians. Considering the
high prevalence of this sickness makes it
imperative to formulate a national plan to
face this disease and its complications.
Global Prevalence of Diabetes
 Estimates
for the year 2000 and
projections for 2030
 Sarah Wild, MB BCHIR, PHD1,
 Gojka Roglic, MD2,
 Anders Green, MD, PHD, DR MED SCI3,
 Richard Sicree, MBBS, MPH4 and
 Hilary King, MD, DSC2
RESULTS
 The
prevalence of diabetes for all agegroups worldwide was estimated to be
2.8% in 2000 and 4.4% in 2030. The total
number of people with diabetes is
projected to rise from 171 million in 2000
to 366 million in 2030. The prevalence of
diabetes is higher in men than women, but
there are more women with diabetes than
men.
 The
urban population in developing
countries is projected to double between
2000 and 2030. The most important
demographic change to diabetes
prevalence across the world appears to be
the increase in the proportion of people
>65 years of age.
CONCLUSIONS
 These
findings indicate that the “diabetes
epidemic” will continue even if levels of
obesity remain constant. Given the
increasing prevalence of obesity, it is likely
that these figures provide an
underestimate of future diabetes
prevalence.
Deaths Among People with
Diabetes, United States, 2000
 Diabetes
was the sixth leading cause of
death listed on U.S. death certificates in
2000. This ranking is based on the 69,301
death certificates in which diabetes was
listed as the underlying cause of death.
Diabetes is likely to be underreported as a
cause of death.
Risk for death

Studies have found that only about 35 percent to
40 percent of decedents with diabetes have
diabetes listed anywhere on the death certificate
and only about 10 percent to 15 percent have it
listed as the underlying cause of death.
 Overall, the risk for death among people with
diabetes is about two times that of people
without diabetes.
Complications of Diabetes

Heart disease and stroke
 Heart disease is the leading cause of diabetesrelated deaths. Adults with diabetes have heart
disease death rates about two to four times
higher than adults without diabetes.
 The risk for stroke is two to four times higher
among people with diabetes.
 About 65 percent of deaths among people with
diabetes are due to heart disease and stroke.





High blood pressure
About 73 percent of adults with diabetes have
blood pressure greater than or equal to 130/80
mm Hg or use prescription medications for
hypertension.
Blindness
Diabetes is the leading cause of new cases of
blindness among adults aged 20-74 years.
Diabetic retinopathy causes 12,000 to 24,000
new cases of blindness each year.
Kidney disease
 Diabetes
is the leading cause of end-stage
renal disease, accounting for 44 percent of
new cases.
 In 2001, 42,813 people with diabetes
began treatment for end-stage renal
disease.
 In 2001, a total of 142,963 people with
end-stage renal disease due to diabetes
were living on chronic dialysis or with a
kidney transplant.
Nervous system disease
 About
60 percent to 70 percent of people
with diabetes have mild to severe forms of
nervous system damage. The results of
such damage include impaired sensation
or pain in the feet or hands, slowed
digestion of food in the stomach, carpal
tunnel syndrome, and other nerve
problems.
Amputations
 More
than 60 percent of nontraumatic
lower-limb amputations occur among
people with diabetes.
 In 2000-2001, about 82,000 nontraumatic
lower-limb amputations were performed
annually among people with diabetes.
 Dental
disease
 Periodontal (gum) disease is more
common among people with diabetes.
Among young adults, those with diabetes
have about twice the risk of those without
diabetes.
 Almost one-third of people with diabetes
have severe periodontal diseases with
loss of attachment of the gums to the teeth
measuring 5 millimeters or more.
Complications of pregnancy

Poorly controlled diabetes before conception
and during the first trimester of pregnancy can
cause major birth defects in 5 percent to 10
percent of pregnancies and spontaneous
abortions in 15 percent to 20 percent of
pregnancies.
 Poorly controlled diabetes during the second
and third trimesters of pregnancy can result in
excessively large babies, posing a risk to the
mother and the child.
Other complications

Uncontrolled diabetes often leads to biochemical
imbalances that can cause acute life-threatening
events, such as diabetic ketoacidosis and
hyperosmolar (nonketotic) coma.
 People with diabetes are more susceptible to
many other illnesses and, once they acquire
these illnesses, often have worse prognoses.
For example, they are more likely to die with
pneumonia or influenza than people who do not
have diabetes.
 Cost of diabetes in the United States, 2002
 Total (direct and indirect): $132 billion
Prevalence of diabetes in Arab
World
Diabetes Risk Factors
Diabetes complications
Diabetes Complications
References






1-Mathers CD, Loncar D. Projections of global mortality and burden of
disease from 2002 to 2030. PLoS Med 2005;3(11):e442.
2-Population Division of the Department of Economic and Social Affairs of
the United Nations Secretariat. World population prospects: The 2006
revision. New York (NY): United Nations; 2007.
3-Directorate of Information Studies and Research, Ministry of Health, The
Hashemite Kingdom of Jordan. Mortality in Jordan 2005. Amman (JO):
Ministry of Health, The Hashemite Kingdom of Jordan; 2008.
4-Mokdad AH. Health issues in the Arab American community. Chronic
diseases and the potential for prevention in the Arab world: the Jordanian
experience. Ethn Dis 2007;17(2 Suppl 3):S3-55-56.
5-Zindah M, Belbeisi A, Walke H, Mokdad AH. Obesity and diabetes in
Jordan: findings from the Behavioral Risk Factor Surveillance System,
2004. Prev Chronic Dis 2008;5(1).
http://www.cdc.gov/pcd/issues/2008/jan/06_0172.htm.
6-Projections of mortality and burden of disease to 2030. Geneva
(CH): http://www.who.int/healthinfo/statistics/bodprojections2030/
en/index.html. Accessed July 16, 2008.
‫بسم هللا الرحمن الرحيم‬
‫الحمد هلل رب العالمين والصالة‬
‫والسالم على نبينا محمد خاتم‬
‫األنبياء وسيد المرسلين وعلى آله‬
‫وصحبه أجمعين وبعد‬
Chronic Diseases 2
 Disability
or chronicity may be the
outcome of many of these chronic
diseases and they will not be accounted
for by using the mortality indicators as the
only indicators for these chronic and
degenerative diseases is the resulting
morbidities and disabilities rates.
Examples :

1- Musculo-sketelal problems
 Osteoporosis






Artihritis and osteoarthritis which may reach in old age a
prevalence of 600/1000 persons, and over 300/1000
persons in males.
Rheumatoid arthritis
Low back pain
Foot problems in old age
Scoliosis in children
Congenital hip dislocation
2- Neurological disorders








Cerebral palsy
Mental retardation
Epilepsy and o
ther seizure disorders
Headache and migraine
Multiple sclerosis
Alzheimer and dementia
Parkinson disease.
Psychiatric Disorders
 Psychosis
 Schizophrenia
 6--Affective
psychosis
 4--Unspecified psychosis
 3--Senile & pre-senile dementia
 3--Psychosis associated with other cerebral
conditions1

Neuroses.
 Phobias
 Anxiety
 Depression
 Obsessive Compulsive
Neuroses.
 Personality disorders & other nonpsychotic mental disorders
Depression
 Depression,
a mental illness in which a
person experiences deep, unshakable
sadness and diminished interest in
nearly all activities.
People also use the term depression to
describe the temporary sadness,
loneliness, or blues that everyone feels
from time to time.
 In
contrast to normal sadness, severe
depression, also called major
depression, can dramatically impair a
person's ability to function in
social situations and at work. People
with major depression often have
feelings of despair, hopelessness, and
worthlessness, as well as thoughts of
committing suicide
 Surveys
indicate that people commonly
view depression as a sign of personal
weakness, but psychiatrists and
psychologists view it as a real
illness. In the United States, the National
Institute of Mental Health has estimated
that depression costs society many billions
of dollars each year, mostly in lost work
time.
Why is depression important?
 Projections
are that by 2020, depression
will be second only to heart disease in its
contribution to the global burden of
disease as measured disability-adjusted
life years
PREVALENCE

Depression is one of the most
common mental illnesses. At least
8 percent of adults in the United
States experience serious
depression at some point during
their lives, and estimates range
as high as 17 percent.
Epidemiology of Depression
Among
Women
 In U.S. twice as many women (12.3%) as
men (6.7%) are affected each year

12.4M women and 6.4M men
 For
low-income women, the estimated
prevalence doubles to 25%
 Most prevalent among women of childbearing and child-rearing age (16 to 53)
Epidemiology of Depression
Among Mothers
 Estimated
rates of depression among
pregnant and postpartum women range
from 8 to 20%.
 For low-income women with young
children, prevalence rates are commonly
estimated at approximately 40%.
PREVALENCE
 Primary
Health Care Physicians are the
diagnosticians at the front line of the
health services, and untreated depression
has come to be viewed as a major public
health problem.
In Arab world
Communities in Arab world show
depression ranging from 13% to 32%.
Highest rate 32% was recorded in
Lebanese women after the civil war.
Urban population in Dubai and Cairo
showed lower rates 12% and 16%
respectively.
 The
illness affects all people, regardless of
sex, race, ethnicity, or socioeconomic
standing. However, women are two to
three times more likely than men to suffer
from depression. Experts disagree on the
reason for this difference. Some cite
differences in hormones, and others point
to the stress caused by society's
expectations of women.
Prevalence
 Depression
occurs in all parts of the world,
although the pattern of symptoms can
vary. The prevalence of depression in
other countries varies widely, from 1.5
percent of people in Taiwan to 19
percent of people in Lebanon. Some
researchers believe methods of gathering
data on depression account for different
rates.
A
number of large-scale studies
indicate that depression rates
have increased worldwide over
the past several decades.
Furthermore, younger
generations are experiencing
depression at an earlier age than
did previous generations..
 Social
scientists have proposed
many explanations, including
changes in family structure,
urbanization, and reduced cultural
and religious influences
Prevalence of Depression
 In
Jordan
• A study published last year, done
on Jordanian women reviewing
PHC centers for different reasons
showed a rate of 37% scored
positively.
Onset
 Although
it may appear anytime from
childhood to old age, depression
usually begins during a person's 20s
or 30s. The illness may come on
slowly, then deepen gradually over
months or years.
Symptoms.
 A)
Appetite and Sleep Changes
B) Changes in Energy Level
C) Poor Self-Esteem
CAUSES/Risk Factors

Some depressions seem to
come out of the blue, even
when things are going well.
Others seem to have an obvious
cause: a marital conflict, financial
difficulty, or some personal
failure.
 Yet
many people with these problems do
not become deeply depressed. Most
psychologists believe depression results
from an interaction between stressful life
events and a person's biological and
psychological vulnerabilities.
A) Biological/Genetic Factors

.
Depression runs in families. By studying twins,
researchers have found evidence of a strong
genetic influence in depression. Genetically
identical twins raised in the same environment
are three times more likely to have depression in
common than fraternal twins, who have only
about half of their genes in common. In addition,
identical twins are five times more likely to have
bipolar disorder in common.
 These
findings suggest that vulnerability to
depression and bipolar disorder can be
inherited. Adoption studies have provided
more evidence of a genetic role in
depression. These studies show that
children of depressed people are
vulnerable to depression even when
raised by adoptive parents.
Genetic/Biochemical Factors
 Genes
may influence depression by
causing abnormal activity in the brain.
Studies have shown that certain brain
chemicals called neurotransmitters play an
important role in regulating moods and
emotions.
 Neurotransmitters
involved in depression
include norepinephrine, dopamine, and
serotonin. Research in the 1960s
suggested that depression results from
lower than normal levels of these
neurotransmitters in parts of the brain.
 Support
for this theory came from the
effects of antidepressant drugs, which
work by increasing the levels of
neurotransmitters involved in depression.
However, later studies have discredited
this simple explanation and have
suggested a more complex relationship
between neurotransmitter levels and
depression.
 An
imbalance of hormones may also play
a role in depression. Many depressed
people have higher than normal levels of
hydrocortisone (cortisol), a hormone
secreted by the adrenal gland in response
to stress. In addition, an under active or
overactive thyroid gland can lead to
depression.
Medical causes

A variety of medical conditions can cause
depression. These include dietary deficiencies in
vitamin B6, vitamin B12, and folic acid (see
Vitamin); degenerative neurological disorders,
such as Alzheimer's disease and Parkinson's
disease ; strokes in the frontal part of the brain;
and certain viral infections, such as hepatitis and
mononucleosis.
 Many
chronic diseases:
 Cardiovascular
 Diabetes
 Epilepsy
 Multiple Scleroses
 Rheumatoid Arthritis and others
B) Psychological Factors
 As
a secondary to psychiatric illness
especially Neurotic (Obsessive
Compulsive Neurosis), or Affective
Schizophrenia.
C) Stressful
Events/Environmental

Psychologists agree that stressful
experiences can trigger depression in
people who are predisposed to the illness.
For example, the death of a loved one
may trigger depression. Psychologists
usually distinguish true depression from
grief, a normal process of mourning a
loved one who has died (Reactive
Depression).
Gender

In the United States, women are about as twice
as likely as men to be diagnosed and treated for
major depression. Approximately 20-25% of
women and 12% of men will experience a
serious depression at least once in their
lifetimes. Among children, depression appears
to occur in equal numbers of girls and boys.
However, as girls reach adolescence, they tend
to become more depressed than boys do. This
gender difference continues into older age.
 Other
stressful experiences may include
divorce, pregnancy, the loss of a job, and
even childbirth. About 20% of women
experience an episode of depression,
known as postpartum depression, after
having a baby. In addition, people with
serious physical illnesses or disabilities
often develop depression
TREATMENT
 Depression
typically cannot be shaken or
willed away. An episode must therefore
run its course until it weakens either on its
own or with treatment. Depression can be
treated effectively with antidepressant
drugs, psychotherapy, or a
combination of both.
Other Treatments

Electroconvulsive therapy (ECT) can often
relieve severe depression in people who fail to
respond to antidepressant medication and
psychotherapy. Regular aerobic exercise may
improve mood as effectively as psychotherapy
or medication. In addition, some research
indicates that dietary modifications can influence
one's mood by changing the level of serotonin in
the brain.
 Despite
the availability of effective
treatment, most depressive disorders go
untreated and undiagnosed. Studies
indicate that general physicians fail to
recognize depression in their patients at
least half of the time. In addition, many
doctors and patients view depression in
elderly people as a normal part of aging,
even though treatment for depression in
older people is usually very effective.
Conclusion
 Of
the estimated 17.5 million Americans
who are affected by some form of
depression, 9.2 million have major or
clinical depression
 Two thirds of people suffering from
depression do not seek necessary
treatment.
 80%
Of all people with clinical depression
who have received treatment significantly
improve their lives.
 The economic cost of depression is
estimated at $30.4 billion a year but the
cost in human suffering cannot be
estimated
 Women
experience depression about
twice as often as men
 By the year 2020, the World Health
Organization (WHO) estimates that
depression will be the number two cause
of "lost years of healthy life" worldwide

 According
to the U.S. Centers for Disease
Control and Prevention (CDC) suicide was
the ninth leading cause of death in the
United States in 1996

Recommendations
 Public
education.
 Provision of relevant posters and leaflets
in waiting rooms at PHC centers helps in
destigmatization of the disease.
 Improvements in depression screening
have paralleled improvements in
depression treatment and reduced stigma
 Encourage
patients to talk about their
symptoms with their Family doctors.
 Recognition of depression by the patient
and his or her family.
 PCPs
have embraced responsibility for
screening ,recognition, and treating
depression
 For additional efficiencies, we will need
 Advances in technology (e.g,computerized
screening and scoring)
 Improved Rx outcomes
Training courses for Primary Health
physicians to improve their diagnostic
skills in depression to improve the
recognition rate of depression in
Primary Health Care Settings in Jordan
is also recommended
Dementia
Dementia
is defined as
global impairment of
cognitive function which
interferes with normal
activities.

Impaired short and long-term
memory and other cognitive
functions (abstract thinking,
judgment, speech,
coordination, planning or
organization
 Alzheimer's
accounts for most cases of
dementia.
 10-20% cases are attributed to vascular
(multi-infarct) dementia
 Other causes-alcoholism, Parkinson, vit
B12 deficiency, hypothyroidism, CNS
infections, intracranial lesions
Prevalence of Dementia
 Increases
steadily with age, roughly
doubling every 5 years
 Common among institutionalized elderly
 Present in ½ to 2/3 of nursing home
residents
 Family history associated with an
increased risk of Alzheimer
Prevalence of Dementia
 disease
progresses over a period of 2-20
years, causing increasing functional
impairment and disability
 Care of the demented patient imposes an
enormous psychosocial and economical
factors.
• Alzheimer’s burden on the family
Risk factors
 Age:
Strongest risk factor particularly for
ALZ d
 annual incidence 0.6% for age 65-69
 1% for age 70-74
 2% for age 75-79
 3.3 % for age 80-84 and 8.4% for above
85
 1/2-2/3 of nursing home residents
Risk factors
 Family
history : Especially in relation to
ALZ D
 First degree relatives have 10-30%
increased risk for the disease
 Apolipoprotein E epsilon 4 genotype
predisposes to development of ALZD
Risk factors
 History
of head trauma especially with
the epsilon 4 allele
 History of low educational achievement
 Organic solvent exposure
 Female gender 16%/6%
 Relationship to blood pressure : a U
shape association
 Hypercholesterolemia /role of statins

Diabetes
Screening Tests
 Dementia
is easily recognized in advanced
stages, often overlooked in early stage
 Clinicians fail to detect 21-72% of patients
with dementia esp. in early stages
 Routing
physical examination and patient
history not sensitive for dementia,
especially if family members not present to
corroborate patient self-report
Alzheimer Warning Signs
Top Ten
Alzheimer Association
1. Recent memory loss affecting job
2. Difficulty performing familiar tasks
3. Problems with language
4. Disorientation to time or place
5. Poor or decreased judgment
6. Problems with abstract thinking
7. Misplacing things
8. Changes in mood or behavior
9. Changes in personality
10. Loss of initiative
AD is Under-diagnosed

Early Alzheimer’s disease is subtle, the diagnosis
continues to be missed
 it is easy for family members to avoid the problem
and compensate for the patient
 physicians tend to miss the initial signs and
symptoms
 Less than half of AD patients are diagnosed
 Estimates are that 25% to 50% of cases remain
undiagnosed
 Diagnoses are missed at all levels of severity: mild,
moderate, severe
Evans DA. Milbank Quarterly. 1990; 68:267-289



Undiagnosed AD patients often face avoidable social,
financial, and medical problems
Early diagnosis and appropriate intervention may lessen
disease burden
 Early treatment may improve overall course
substantially
No definitive laboratory test for diagnosing AD exists
 Efforts to develop biomarkers, early recognition by
brain scan
Prevalence of Alzheimer
 Alzheimer’s
disease (AD) is the most
common form of dementia. It represents a
worldwide medical challenge affecting
more than 18 million people; estimated to
reach 34 million by the year 2025 .
PREVALENCE of AD
 Estimated
4 million cases in US (2000)
• (2000 - 46 million individuals over 60 y/o)
 Estimated
500,000 new cases per year
 Increase




1%
2%
4%
8%
with age
of 60 - 65
of 65 - 70
of 70 - 75
of 75 - 80
• 16% of
(prevalence)
(10.7m)
( 9.4m)
( 8.7m)
( 7.4m)
80 - 85 (
= 107,000
= 188,000
= 350,000
= 595,000
5.0m) = 800,000
 With
over 1.5 million cases in the Arab
world.
Alzheimer’s disease is a devastating
illness which can affect all members of
society
Conclusions and
Recommendations
 Next
to Cancer and AIDS, the highest
medical budgets are allocated to
Alzheimer’s research. The Arab
Conference on AD 2005 seeks to develop
a regional and national plan to raise the
level of awareness on AD and reach
patients, caregivers, specialists, doctors,
nurses, specialized international agencies
and governmental and non-governmental
organizations
Multiple Sclerosis
Epidemiology and
Prevalence
Onset
Geographic Distribution
Population Studies
Genetic Factors
Who Has MS
 In
the United States, about 400,000
people have the disease, which is twice as
common in women as men.
 Approximately 2.5 million people may
have MS worldwide.
 Most people with MS are diagnosed
between the ages of 20 and 40.
 Onset
 Geographic
Distribution
 Population Studies

Genetic Factors
Onset

There are about 300,000 patients suffering from
Multiple Sclerosis in the North America today.
The age of onset peaks between 20 and 30
years. Almost 70% of patients manifest
symptoms between ages 21 and 40. Disease
rarely occurs prior to 10 or after 60 years of age.
However, patients as young as 3 and as old as
67 years of age have been described.
 Like
other immuno- mediated diseases,
females are affected more frequently than
males (1.4 to 3.1 times as many women
than men affected.)
Geographic Distribution
 There
is a very specific geographic
distribution of this disease around the
world. A significantly higher incidence of
the disease is found in the northernmost
latitudes of the northern and the southern
hemispheres compared to southernmost
latitudes.
 This
observation is based on the incidence
of the disease in Scandinavia, northern
United States and Canada, as well as
Australia and New Zealand. The data from
migration studies shows that if the
exposure to a higher risk environment
occurs during adolescence (before 15
years of age,) the migrant assumes the
higher risk of the environment..
What Is MS?
 Multiple
sclerosis (MS) is a disease that
attacks the central nervous system—the
brain and the spinal cord. Depending on
which nerves are damaged, people with
MS may experience problems with
balance, muscle coordination, vision,
speech, thinking, or other physical and
mental abilities.
Population Studies
 There
are also population studies that
show difference in susceptibility to MS
between different populations. Lapps in
Scandinavia appear to be resistant to the
disease, contrary to the expectations
based on their geographic distribution.
Native Americans and Hutterites very
infrequently suffer from MS, as opposed to
other residents of the North America. MS
is uncommon in Japan, China and South
America.
 It
is practically unknown among the
indigenous people of equatorial Africa and
among native Inuit in Alaska. When the
racial differences are correlated, White
populations are at greater risk than Asian
or African populations. We can not yet
explain these obvious inconsistencies in
disease distribution, but the knowledge of
them may be helpful in assessing specific
patients.
Prevalence of MS
Prevalence data imply that racial and
ethnic differences are important in
influencing the worldwide distribution of
MS and that its geography must be
interpreted in terms of the probable
discontinuous distribution of genetic
susceptibility alleles. Racially and
ethnically influenced differences in the risk
of MS, however, can be modified by
environment.
Genetic Factors

The incidence of MS in first degree relatives is
20 times higher than in general population,
suggesting the influence of genetic factors on
the disease. Monozygotic twin studies show the
concordance rate of 30%. Dizygotic twins show
concordance rate of less than 5%. These results
suggest that both the genetic factors and
environmental exposure are important in
disease expression.
Symptoms
 Symptoms
associated with MS vary
widely. There is not yet a way to predict
what symptoms people with MS may
experience. MS symptoms are divided into
three types:
.
 Primary
symptoms are those caused
directly by the disease process including
immune system activity, destruction of
myelin or the ensuing nerve damage.
The most common include
 problems
with walking or maintaining
balance, visual impairment (optic neuritis),
 lapses in memory,
 inability to solve problems or pay attention
for long periods of time,
 pain,
 sexual
dysfunction,
 dizziness,
 depression or mood swings,
 and disturbances in bladder or bowel
function.
 Less common symptoms include speech
and swallowing disorders, tremors and
seizures
 Secondary
symptoms are complications
that occur as a result of primary
symptoms. For instance, a person with MS
may have urinary burning, which could be
a sign of a urinary tract infection, resulting
from lack of bladder control caused by
nerve damage.
 Tertiary
symptoms may include lowered
self-esteem, which could affect a person's
family or social life.
Multiple sclerosis in Arabs in
Jordan
.
 Department
of Biochemistry and
Microbiology, Faculty of Medicine, Jordan
University, Amman.
 In a 2-year hospital-based study (1992
and 1993), there were 131 multiple
sclerosis patients attending 2 large referral
hospitals in Jordan. There were 126 Arabs
of whom 84 were Palestinians and 36
indigenous Jordanians.

Comparison of these subgroups, which had a
similar age distribution revealed that the disease
was twice as frequent in Palestinians (estimated
42.0/100,000) among Jordanians (estimated
20.0/100,000). Clinical presentation, pattern of
disease, disability associated with the disease
were similar to that in the disease reported in
Caucasians in the West. All investigations
including neurophysiology and imaging were
also very similar to Western reports
6- Genetic disorders
– Down’s syndrome
 Autosomal recessive defect chromosome 7
mutations are thought to be responsible for that
disease .

Cystic fibrosis : is the most lethal in Northern
European descent (1/3500 births) in USA(
1/14,000 births in Blocks) in Asian Americans
1/25,500 births , Median survival age for C.F.
improved between 1938 and 1998 from 5 y to
almost 30 y .

‫تم بحمد هللا‬