10/22/2024

Chapter 9
Noncommunicable
Diseases
October 9, 2024
Prof Wilson

Copyright ©2020 F.A. Davis Company

Learning Outcomes
1. Describe the impact of noncommunicable
diseases on the health of a population.
2. Define the burden of noncommunicable diseases
using current epidemiological frameworks.
3. Describe risk factors at individual and population
levels related to development of a
noncommunicable disease.
4. Apply current evidence-based population
interventions to the prevention of
noncommunicable diseases.

Noncommunicable Disease (NCD)

• Diseases not passed from one person to the next (directly or indirectly)
• Not caused by an infectious agent
• Chronic
• Usually slow progression
• Require medical attention over time
• Tend to limit ability to perform ADL’s
• Caused by combination of factors:
• Genetic
• Physiological
• Environmental
• Behavioral
• Four main categories for NCD’s:
Cardiovascular diseases
•
Cancers
•
Chronic respiratory diseases
•
Diabetes
•
• Some communicable diseases such as HIV/AIDS, syphilis, or post-COVID
can become chronic

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Treatment and Prevention of NCD’s

• Cannot be prevented or cured through vaccination or
medication
• They require:
• Maintaining a healthy lifestyle
• Early diagnosis and treatment
• Long-term management
• Pt needs to be active part of maintaining symptoms and
needs to be apart of it. Reduces ER visits
• Leading cause of death gblobally
• Annually, a total of
15 million people between ages 30-69
die from an NCD
• 77% occur in low- and middle-income countries

NCD’s in the United States

• Modifiable risk factors:
• 1. Tobacco use
• 2. Excess sodium intake
• 3. Harmful alcohol use
• 4. Lack of physical activity
• Metabolic risk factors:
• 1. obesity
• 2. high blood pressure
• 3. hyperglycemia
• 4. hyperlipidemia
• Other risk factors:
• Genetic
• Environmental
• Sociodemographic
• The first goal of HP 2030:
• “Attain healthy, thriving lives and well-being, free of
preventable disease, disability, injury, and premature death.”

Care Delivery for NCD’s

• Affordable Care Act
• More focus on the chronic care model: care over time. More focus on
preventative care as well.
• Decreasing mortality and morbidity
• Integrated care delivery model
• Less focus on the acute care model

• Integrated care delivery model

• Long-term care in the community
• Secondary and tertiary prevention, focus on early detection and treatment

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Burden of Disease and NCD’s

• Burden of disease:
• Uses the disability-adjusted-life-year (DALY) measure to determine the
extent of the burden a disease has on a population
• Involves calculating cost of treatment but also social and economic impacts
• Allows for the assessment of the comparative importance of a disease,
injury, or risk factor. Considers how much the disease, injury, or risk factor
contributes to overall disability and premature death in a population
• Helps a community prioritize health promotion and prevention efforts
target specific diseases that account for greatest burden to the community
• Life Expectancy
• Based on mortality rates
• The number of years a person could be expected to live based on the
current mortality rates in a specific setting, usually a country
• Health-Adjusted Life Expectancy (HALE)
• Average number of years that a person can expect to live in good health by
adjusting for disease and/or injury
• WHO uses HALE’s to measure the average level of health in countries and
regions by evaluating population-specific prevalence of disease and injury
as well as severity distribution of health states.*

Burden of Disease Example

•In a hypothetical U.S. town of 8,000 adults called Berryton, the
prevalence of type 2 diabetes rose from 160 (2%) to 800 (10%)
cases.
• The impact of the disease goes beyond individual cost in this
rural farming community. Berryton has been recently hit with a
shortage of migrant farm workers, resulting in an inability to
harvest all the tomatoes, the town’s main crop.
•New cases are occurring for the most part in 35- to 45-year-old
males, and the closest medical center is 100 miles from the town.
• With a depressed economy, rural setting, and reduced access
to care, the potential for adverse consequences and premature
death associated with diabetes increases.
•This could decrease the number of able-bodied people to work
on the farms, further depressing the economy.
• For this community, the disease contributed to reduced
productivity and adversely affected the economic viability of the
town.

Premature Death and NCD’s

• NCD’s often lead to premature death:
• Death that occurs earlier than the standard life
expectancy
• Premature death reflects the number of years of
potential life lost (YPLL)
• Calculated by subtracting the age at which a person
dies from his or her life expectancy
• YPLL for a 42-year-old who died of a heart attack in
the US in 2022 would be 33 because life expectancy
was 75 years.
• 75-42=33

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Disability-Adjusted Life Year (DALY)

• Most NCD lead to disability, affecting quality of life and productivity
• Method for quantifying the burden of disease that considers both
premature death and disability
• Measurement of the gap that exists between the ideal health status of a
disease- and disability-free population that lives to an advanced age
• Calculated as a sum of the years of life lost (YLL) related to premature
death plus the years lost to disability (YLD) related to the disease

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Top 11 Leading Causes of Death 2020

• Heart disease: 690,882 • Alzheimer’s disease:
• Cancer: 598,932 133,382
• COVID-19: 345,323 • Diabetes: 101,106
• Accidents • Chronic liver disease
(unintentional and cirrhosis : 53,495
injuries): 192,176
• Nephritis, nephrotic
• Stroke
syndrome, and
(cerebrovascular
diseases): 159,050 nephrosis: 52,262
• Chronic lower • Intentional self-harm
respiratory diseases: (suicide): 44,834
151,637

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Cardiovascular disease (CVD)

• Heart disease and stroke
• First and fifth leading causes of death (2021)
• Costly & widespread
• 1 in every 4 deaths in the US are attributable to heart disease
• Adults may have two or more risk factors
High blood pressure High cholesterol

Obesity Low levels of physical activity

Smoking (tobacco use)

• Dietary risk exposures are the most significant attributable risk

factors related to CVD burden of disease
• Before WWII, thought HTN was a normal part of aging, as life
expectancy increased, prevalence of CVD grew
• 1948 longitudinal cohort study, Framingham Heart Study,
learned about risk factors for CVD & stroke, individual- and
population-level interventions developed

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Cancer
• Second leading cause of death in the United States
• Leading cause of death globally
• Screenings have decreased death numbers
• Survival rate has increased
• Risk factors:
• Behavioral factors
• Tobacco & alcohol use, high BMI, low fruit & vegetable intake,
history of HPV infection, lack of physical activity
• Nonmodifiable: age, genetic factors, environmental factors
(carcinogen exposure)
• In breast cancer, both modifiable & non-modifiable risk factors apply:
• Family history, diet, exercise, reproductive history, alcohol use,
genetic mutations

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Chronic Lower Respiratory Disease

• COPD including emphysema & chronic bronchitis
• Asthma
• Occupational lung diseases
• Pulmonary hypertension
• Major risk factors:
• Tobacco use
• Abnormal inflammatory response of the lungs to the noxious particles or
gases present in tobacco smoke
• Exposure to air pollutants, chemical fumes, dust

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Diabetes
• Incidence has declined since 2008, but prevalence is growing
• American Indians and Alaska Natives are almost 3 times more likely
to be diagnosed with diabetes than non-Hispanic whites (23.5% vs
8%)
• Interventions to reduce risk of type 2
• Exercise
• Eat healthy
• Maintain healthy body weight

• Community level issues impacting prevention, diagnosis, and

treatment: access to healthy foods, safe environments for
exercising, access to health care resources, high cost of
diabetic medications

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Behavioral Risk Factors

• Nutrition, Exercise, Obesity
• More than 1/3 of US adults are obese (BMI ≥ 30)
• Obesity rates:
• Black 49.6%
• Hispanic non-black 44.8%
• White non-Hispanic 42.2%
• Asian 17.4%
• 1 in 5 children & adolescents are obese
• Main risk factors:
• Poor nutrition
• Lack of exercise
• Both linked to population level factors
• Changes in population behaviors
• Environmental factors
• Socioeconomic factors

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Behavioral Risk Factors

• Tobacco Use
• Increased risk for cancer, pulmonary disease, CVD
• Leading cause of preventable death and disability in the US
• Cigarette smoking linked to 80-90% of lung cancer deaths in US
• Individual level change but also community and population levels
• 2003 WHO initiated an international tobacco treaty
• High-income & European countries had a decrease in use
• Low-income, middle-income, & Asian countries had an increased
annual consumption
• Alcohol Use
• Accounts for 5.1% of the global burden of disease
• Adversely affects health:
• Injury
• Breast cancer
• Hypertension
• Stroke
• Liver disease
• Brain damage

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Environmental Risk Factors for NCD

• Pollutants
• Asthma
• CVD
• Cancer
• Contaminants in air, home, water supply, ground
• Built environment
• Buildings, roads, sewage systems, parks & recreation facilities
• Most urbanized region in the world is North America
 82% of the population lives in urban areas

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Genomics & Risk for NCD

• Human genomics: study of the genetic structure or genome of a living human
• Genetic role in major NCDs
• Cancer
• Diabetes
• CVD
• Asthma

• Most chronic diseases are not monogenetic

• Linked to a single gene mutation (cystic fibrosis)
• Polygenetic
• Multiple genes act together to cause the disease
• Genetic risk
• Is not a linear source of complex chronic disease but rather a dynamic process
based in on interaction between the gene and environment
• Human genome epidemiology
• Scientific basis for the study of the distribution of gene variants, gene-disease
associations, and gene-environment and gene-gene interactions within and
across populations
• Allows PH scientists to estimate the absolute, relative, and attributable risks for
disease based on genomic factors

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SDOH & Risk for NCD

• Income and social status
• Higher income and social status linked to better health (wealth is health)
• The greater the gap between the richest and poorest people, the greater the
differences in health.
• Education
• Low education levels are linked with poor health, higher stress levels, and lower
self-confidence.
• Physical environment
• Safe water, clean air, healthy workplaces, safe houses, communities and roads
all contribute to good health
• Employment and working conditions
• People in employment are healthier, particularly those who have more control
over their working conditions
• Social support networks
• Greater support from families, friends and communities is linked to better
health
• Culture
• Customs, traditions, and the beliefs of the family and community all affect
health
• Health services
• Access to, and use of, services that prevent and treat disease influence health

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Prevention Strategies for NCDs

• Global priority
• Upstream causes

• Prevention efforts often focus on reducing individual risk

factors
• Success of these efforts requires multifaceted interventions
that include community and policy levels
• Primary Prevention
• Behavioral change, strong emphasis on healthy eating &
exercise
• Populations at greatest risk for NCDs are those with limited
access to resources necessary to maintain a healthy lifestyle
• Population-level primary prevention programs
 Change barriers to a healthy lifestyle
 Safe streets for walking & access to rec facilities

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Prevention Strategies for NCDs

• Secondary Prevention
• Screenings for breast cancer and colorectal cancer
• US Preventative Services Task Force
• Recommendations

• Tertiary Prevention
• Reduce the morbidity and disability associated with the disease and prevent
premature death
• Acute care for exacerbations, surgical procedures
• Chronic disease self-management (CDSM)

• Engage in self-management of medications,

symptoms, & health promotion
 Information seeking
 Communication with providers
 Confidence in one’s ability

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Health-Related Quality of Life (HRQoL)

• Central to Healthy People 2030’s overarching goals
• Attain and promote “a high quality of life for all
people, across all life stages”
• Defined as: self-perceived impact of physical and
emotional health on quality of life, including efforts on:
• general health
• physical functioning
• physical health and role
• bodily pain
• vitality
• social functioning
• emotional health and role
• mental health

• CDCs Healthy Days Measure

• 4 questions to measure HRQoL

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CDC Healthy Days Measure

1. Would you say that in general your health is excellent,
very good, good, fair or poor?
2. Now thinking about your physical health, which
includes physical illness and injury, how many days
during the past 30 days was your physical health not
good?
3. Now thinking about your mental health, which includes
stress, depression, and problems with emotions, how
many days during the past 30 days was your mental
health not good?
4. During the past 30 days, approximately how many days
did poor physical or mental health keep you from doing
your usual activities, such as self-care, work, or
recreation?

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