PREVENTION AND CONTROL OF LIFESTYLE DISEASE

Proportion of global deaths under the age70 years, by cause of death, comparable estimates, 2012

Age-standardized NCD death rates by WHO region

Probability of dying from the four main noncommunicable diseases between the ages of 30 and 70 yearscomparable estimates, 2012

NCD and risk factors

Cardiovascular diseases

Cardiovascular diseases

Cardiovascular diseases is the leading cause of mortality in Kerala contributing to as much as 40% of all deaths.

The age adjusted death rate due to cardiovascular in the state is 490 per lakh for men and 231 per lakh for women every year

Coronary artery diseases

State reports a higher prevalence of coronary artery diseases when compared to other states in India 7.4% in rural (in 1991) 13.5% in urban(in 1995)

The estimated prevalence of coronary artery disease in the age group 20-69 years for 2015 is 10.1 %.(31)

*Kutty VR, Balakrishnan KG, Jayasree AK, Thomas J. Prevalence of coronary heart disease in the rural population of Thiruvananthapuram district, Kerala, India. Int J Cardiol [Internet]. 1993 Apr [cited 2015 Apr 24];39(1):59–70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8407009**Begom R, Singh RB. Prevalence of coronary artery disease and its risk factors in the urban population of South and North India. Acta Cardiol [Internet]. 1995 Jan [cited 2015 May 7];50(3):227–40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7676762***National Commission on Macroeconomics and Health. NCMH Background Papers·Burden of Disease in India. New delhi; 2005. p. 1–388. Available from: http://www.who.int/macrohealth/action/NCMH_Burden of disease_(29 Sep 2005).pdf

Death due to coronary artery disease in kerala

Kerala China Japan United states

0

50

100

150

200

250

300

350

400

450

382

64 50

170

128

4115

70

malesfemales

Per

10

0,0

00

Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al. Presentation, management, and outcomes of 25 748 acute coronary syndrome admissions in Kerala, India: results from the Kerala ACS Registry. Eur Heart J [Internet]. 2013 Jan 7 [cited 2015 May 8];34(2):121–9. Available from: http://eurheartj.oxfordjournals.org/content/early/2012/09/06/eurheartj.ehs219

Acute coronary event in Kerala CAD in Kerala is both premature and

malignant Average age is 60 years (56 in males and 69 in

females)

60% of CAD deaths in men and 40% of CAD deaths in women occur before the age of 65 (USA-18%)

1 month case fatality rate following STEMI- 8.5% ( around 4 in developed countries)

Soman CR, Kutty VR, Safraj S, Vijayakumar K, Rajamohanan K, Ajayan K. All-cause mortality and cardiovascular mortality in Kerala state of India: results from a 5-year follow-up of 161,942 rural community dwelling adults. Asia Pac J Public Health [Internet]. 2011 Nov [cited 2015 Apr 23];23(6):896–903. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20460280

Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al. Presentation, management, and outcomes of 25 748 acute coronary syndrome admissions in Kerala, India: results from the Kerala ACS Registry. Eur Heart J [Internet]. 2013 Jan 7 [cited 2015 May 8];34(2):121–9. Available from: http://eurheartj.oxfordjournals.org/content/early/2012/09/06/eurheartj.ehs219

Stroke

Prevalence stroke among adults (>18 years ) in the state was 0.3%

The age adjusted annual incidence of stroke in Kerala in 2010 was 135 per 100,000 were more in males (143 )compared to females (128)

Ischemic stroke was the most common type of stroke ( 73 per 100000)

#Menon J, Joseph J, Thachil A, Attacheril T V, Banerjee A. Surveillance of noncommunicable diseases by community health workers in Kerala: the epidemiology of noncommunicable diseases in rural areas (ENDIRA) study. Glob Heart [Internet]. 2014 Dec [cited 2015 Apr 1];9(4):409–17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25592794

##Soman CR, Kutty VR, Safraj S, Vijayakumar K, Rajamohanan K, Ajayan K. All-cause mortality and cardiovascular mortality in Kerala state of India: results from a 5-year follow-up of 161,942 rural community dwelling adults. Asia Pac J Public Health [Internet]. 2011 Nov [cited 2015 Apr 23];23(6):896–903. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20460280

Stroke

No urban rural difference in incidence

average age of stroke patients was 67 years stroke in the young( <40 years,)only 4%

case fatality rate within one month was 24.5% for urban and 37.1% for rural populations which is comparable to national figuresSridharan SE, Unnikrishnan JP, Sukumaran S, Sylaja PN, Nayak SD, Sarma PS, et al. Incidence,

types, risk factors, and outcome of stroke in a developing country: the Trivandrum Stroke Registry. Stroke [Internet]. 2009 Apr 1 [cited 2015 May 5];40(4):1212–8. Available from: http://stroke.ahajournals.org/content/40/4/1212.full

Cancer

Incidence of cancer in Kerala

Kerala (1) India (2) World (2)0

50

100

150

200

250

132

97

204

123

92

167

malesfemales

Per

10

0,0

00

1.Three Year Report of PBCR 2009-2011 [Internet]. [cited 2015 Apr 28]. Available from: http://www.ncrpindia.org/ALL_NCRP_REPORTS/PBCR_REPORT_2009_2011/ALL_CONTENT/Printed_Version.htm2 GLOBOCAN :Fact Sheets by Population [Internet]. [cited 2015 Apr 27]. Available from: http://globocan.iarc.fr/Pages/fact_sheets_population.aspx

Trend in incidence of cancer in Kerala

1991-92

1993-97

1998-02

2005-07

2009-11

0

20

40

60

80

100

120

140

109.2

87.896.6

132.3 132.6

87.181.1 80

114.9123.2

Thiruvananthapuram

males females

In 1

00

,00

0

1991-92

1993-97

1998-02

2005-07

2009-11

0

20

40

60

80

100

120

140

115.9 116.6

99.4 102.6

118.5

80.4 80.4 76 76.3

91.6

Kollam

Males Females

In 1

00

,00

0

*CI5 - Home [Internet]. [cited 2015 Apr 27]. Available from: http://ci5.iarc.fr/Default.aspx**Three Year Report of PBCR 2009-2011 [Internet]. [cited 2015 Apr 28]. Available from: http://www.ncrpindia.org/ALL_NCRP_REPORTS/PBCR_REPORT_2009_2011/ALL_CONTENT/Printed_Version.htm

Among males lung cancer (14.5%) was the leading site followed by cancer of oral cavity (14.2%).

Among females cancer of breast (29.8%) was the leading site of cancer followed by cancer of thyroid( 12.5%)

Children (0-14years) constituted 4.8% of all cancers and leukemia was the predominant cancer among them in both genders ( males 57.5% and females 47.5%).

-100

0

100

200

300

400

500

600

Change in cancer incidence in males from 1991-92 to 2009-11

%

Mul

tiple

mye

lom

a

Corpu

s ut

eri

Gallb

ladd

er e

tc.

Mel

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skin

Lung

Brea

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sinu

ses et

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geni

tal o

rgan

s

-100

-50

0

50

100

150

200

250

300

350

Change in cancer incidence in females from 1991-92 to 2009-11

%

Chronic Lung diseases

Chronic lung diseases

Chronic obstructive pulmonary diseases (COPD) accounted for 5.2% of the total NCD burden and 12.2% of the NCD related mortality.

In Kerala, 15.3% of the death were due to respiratory causes of which COPD was the main culprit

Prevalence of chronic respiratory disease in Kerala

Kerala India0

2

4

6

8

10

12

10.1

3.53.1

1.9

Chronic bronchitisAsthma%

Jindal SK. Indian Study on Epidemiology of Asthma , Respiratory Symptoms and Chronic Bronchitis ( INSEARCH ) A Multi ‐ Centre Study ( 2006 ‐ 2009 ) Department of Pulmonary Medicine [Internet]. 2010. Available from: http://icmr.nic.in/final/INSEARCH_Full _Report.pdf

urban rural0

2

4

6

8

10

12

14

16

5

13.5

4.5

1.9

Chronic bronchitisAsthma

Males Females0

2

4

6

8

10

12 11

9

2.53.7

Chronic bronchitisAsthma

Prevalence of chronic bronchitis

35-44 45-54 55-64 65-74 75-84 >840.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

6.29.4

14.618.7

27.0

37.5

Kerala

Kerala

Chronic Kidney disease

Age-adjusted incidence rate of ESRD in India to be 22.9 per lakh population. 7500 new chronic kidney diseases every year

in Kerala Prevalence in hospitalized patients is 17 %

33 % in Kerala Main causes are diabetes nephropathy

and hypertensive nephrosclerosis*Modi GK, Jha V. The incidence of end-stage renal disease in India: a population-based study. Kidney Int [Internet]. 2006 Dec 25 [cited 2015 May 2];70(12):2131–3. Available from: http://dx.doi.org/10.1038/sj.ki.5001958**Singh AK, Farag YMK, Mittal B V, Subramanian KK, Reddy SRK, Acharya VN, et al. Epidemiology and risk factors of chronic kidney disease in India - results from the SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol [Internet]. 2013 Jan [cited 2015 Apr 22];14(1):114. Available from: http://www.biomedcentral.com/1471-2369/14/114***Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK, Almeida AF, et al. What do we know about chronic kidney disease in India: first report of the Indian CKD registry. BMC Nephrol [Internet]. 2012 Jan [cited 2015 Apr 17];13:10. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3350459&tool=pmcentrez&rendertype=abstract

Diabetes

Age-standardized prevalence of diabetes, 2014

Comparison of current age standardized prevalence of diabetes in above 18 years

Kerala India world0

2

4

6

8

10

12

14

16 14.8

9.5 9

Age standardized prevalence of di-abetes among >18 years

Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, et al. Risk factor profile for chronic non-communicable diseases: Results of a community-based study in Kerala, India. Indian J Med Res. 2010;131(1):53–63.

World Health Organization. Global Status Report On Noncommunicable Diseases 2014. 2014.

Diabetes in Kerala over last 25 year

27.3

16.214.6

19.6

5.9

16.3

4

y = 1.0179x - 2023.9R² = 0.6882

0

5

10

15

20

25

30

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

%

Year

Prevalence of diabetes

Urban Rural0

5

10

15

20

25

14.8

20.6

Prevalence of di-abetes (%)

Males Females0

5

10

15

20

25

14.3

17.8

Prevalence of di-abetes (%)

Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, et al. Risk factor profile for chronic non-communicable diseases: Results of a community-based study in Kerala, India. Indian J Med Res. 2010;131(1):53–63.

1999 20100

2

4

6

8

10

12

14

3.4

13.1

Prevalence of diabetes in age group 30-40 years

Kutty VR, Soman CR, Joseph A, Pisharody R, Vijayakumar K. Type 2 diabetes in southern Kerala: variation in prevalence among geographic divisions within a region. Natl Med J India [Internet]. Jan [cited 2015 Apr 23];13(6):287–92

Jose R, Manojan KK, Augustine P, Nujum ZT, Althaf A, Haran JC, et al. Prevalence of Type 2 Diabetes and Prediabetes in Neyyattinkara Taluk of South Kerala [Internet]. Academic Medical Journal of India. 2013 [cited 2015 Apr 23]. Available from: http://medicaljournal.in/prevalence-of-type-2-diabetes-prediabetes

Detection , treatment and control of diabetes in Kerala

Aware Treated Controled0

10

20

30

40

50

60

70

8072

68

22

73

65

31

71 70

15

Allmalesfemales

Hypertension

Age standardized prevalence of hypertension in above 18 years

Kerala India World0

5

10

15

20

25

30 28

23 22

%

Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, et al. Risk factor profile for chronic non-communicable diseases: Results of a community-based study in Kerala, India. Indian J Med Res. 2010;131(1):53–63.

World Health Organization. Global Status Report On Noncommunicable Diseases 2014. 2014.

Trend in prevalence of hypertension in Kerala (above 30 year of age)

Burden of hypertension

The prevalence was almost same in both genders as well as in urban and rural areas.

The burden of hypertension increases with age studies reports that 60-80% of people

above age of 60 were hypertensive

proportion of people in pre-hypertension stage is also very high (upto 40%).

Detection , treatment and control of hypertension in Kerala

Aware Treated Controlled0

5

10

15

20

25

30

35

40

45

50

37

27

9

30

21

6

44

33

11

Allmalesfemales

Status of risk factors in Kerala

Tobacco use in Kerala

Tobacco Smoked Smokeless0

5

10

15

20

25

30

35

40

21

1311

34

14

26

KeralaIndia

International Institute for Population Sciences.Ministry of Health and Family Welfare. Government of India. Global adult tobacco survey India 2009 2010. Global adult tobacco survey India 2009-10. Mumbai: International Institute for Population Sciences; 2010.

Tobacco use in Kerala

Tobacco Smoked Smokeless0

5

10

15

20

25

30

35

4035

28

13

8.5

0

8.5

MalesFemales

International Institute for Population Sciences.Ministry of Health and Family Welfare. Government of India. Global adult tobacco survey India 2009 2010. Global adult tobacco survey India 2009-10. Mumbai: International Institute for Population Sciences; 2010.

Smoking in Kerala over past 30 years

1990 2000 2010 20200

5

10

15

20

25

17.8

21.9

13.3

13

17.8f(x) = − 0.528616 x + 1075.156R² = 0.974845412181281

Current smoking

year

%

1980 1990 2000 2010 20200

10

20

30

40

50

60

38.7

50

2828

4338.7

f(x) = − 0.905341 x + 1848.265R² = 0.79586682387627

Current smoking in males

Year

%

Alcohol use in Kerala

Current use of alcohol ( within one month ) was seen in 20-23% of males aged above 15 years in Kerala.

Annual Per capita alcohol consumption was 10.2 L which is comparable to national average (11.4 L)

ICMR. NON-COMMUNICABLE DISEASE RISK FACTORS SURVEY India Phase - I 2008-09. 2007.

Obesity

The prevalence of overweight and obese (BMI>=25) in the state was estimated to around 30 % and is showing an upward trend.

Central obesity (based on waste circumference, WC) is more prevalent affecting as much as 40% of the population.

Obesity/overweight was more common in females (BMI-38%, WC-52%) when compared to males (BMI-24%,WC-26%).

Hyper-cholestrolemia

Thankappan et al

Vijayakumar etal

INDIAB study0

10

20

30

40

50

60

70

57

37

13.9

51

30

62

41

allmalesfemales

Dietary practice in Kerala

0

30

60

9087.9

9.9 3.5

Major cooking oil

Dietary practice in Kerala

Physical inactivity

Low level of physical activity was seen in 75% of the population as per the STEPS survey report.

Lack of physical activity was more common in women when compared to men.

The low level of physical activity was same in both urban and rural areas as well as across different age groups

Is there a solution?

Prevention oriented health care

Levels of prevention

Levels of prevention

Primodial prevention

Primary prevention

Secondary and tertiary prevention

prevention

Primary prevention

Promoting healthy diet Promoting recreational physical activity Avoiding tobacco , alcohol Stress management

Primary prevention

Health promotion Health education Environmental modification Lifestyle and behavioral changes

Specific protection Legislation and its proper implementation Immunization

Secondary prevention

Early diagnosis Screening

Proper treatment