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Behavioral and Biological Risk Factors of Non Communicable Diseases Prof. Dr. M. S. A. Behavioral and Biological Risk Factors of Non Communicable Diseases Prof. Dr. M. S. A. Mansur Ahmed Professor Dept. of Public Health DIU

Global scenario of NCD • Of 56 million global deaths in 2012, 38 million, Global scenario of NCD • Of 56 million global deaths in 2012, 38 million, or 68%, were due to noncommunicable diseases. • The four main NCDs are cardiovascular diseases, cancers, diabetes and chronic lung diseases. • The burden of these diseases is rising disproportionately among lower income countries and populations. • In 2012, nearly three quarters of noncommunicable disease deaths -- 28 million -- occurred in low- and middle-income countries with about 48% of deaths occurring before the age of 70 in these countries.

Leading causes of NCD deaths in 2012 • The cardiovascular diseases (17. 5 million Leading causes of NCD deaths in 2012 • The cardiovascular diseases (17. 5 million deaths, or 46% of all NCD deaths), • cancers (8. 2 million, or 22% of all NCD deaths), and • respiratory diseases, including asthma and chronic obstructive pulmonary disease (4. 0 million). • Diabetes caused another 1. 5 million deaths.

Contd. • The importance of addressing noncommunicable diseases at the global level has also Contd. • The importance of addressing noncommunicable diseases at the global level has also become a major element of the ongoing discussion concerning the post-2015 development goals, which is being steered by the United Nations. • Noncommunicable diseases were omitted from the Millennium Development Goals in 2000, • A consensus is emerging among the various United Nations agencies and other international organizations that • A life-course perspective must be adopted, with an emphasis on noncommunicable diseases as part of the health goal to be included in the set of post-2015 Sustainable Development Goals.

Bangladesh scenario • NCDs have already appeared as a major public health problems. • Bangladesh scenario • NCDs have already appeared as a major public health problems. • Major NCDs (DM, CVDs, Cancer, COPD &Accidents)were among the top twenty causes of deaths in 2000(BBS 2000).

NCD risk factor survey 2010 • NCD may account for 61% of the total NCD risk factor survey 2010 • NCD may account for 61% of the total disease burden. • Among adults(15+years) 97% had at least one risk factor half of whom had 2 risk factors. • 40 million (app. 25%) people are tobacco users • 17 million (nearly 20%) are not doing adequate physical activities. • 18% adults with Hypertension • 4% documented Diabetes.

Table 1: Findings of Bangladesh NCD risk factor Survey 2010 at a glance. Prevalence Table 1: Findings of Bangladesh NCD risk factor Survey 2010 at a glance. Prevalence (%) with selected risk factors among the adult population aged ≥ 25 years Risk factors Men Women Both sexes Current smoker 54. 8 1. 3 26. 2 Smokeless tobacco user 29. 4 33. 6 31. 7 Tobacco user (any form) 70. 0 34. 3 51. 0 Low vegetable/Fruits intake a 97. 6 94. 1 95. 7 Low physical activity b 10. 5 41. 3 27. 0 Overweight (BMI > 25 kg/m 2) 13. 0 21. 6 17. 6 Large waist circumference c 8. 0 33. 7 21. 7 Hypertension d 18. 5 17. 3 17. 9 Diabetes Mellitus e 4. 3 3. 6 3. 9

Behavioral and Biological Risk Factors of Non Communicable Diseases • Behavioural risk factors, including Behavioral and Biological Risk Factors of Non Communicable Diseases • Behavioural risk factors, including tobacco use, physical inactivity, and unhealthy diet, are responsible for about 80% of coronary heart disease and cerebrovascular disease.

Biological risk factors comprise • raised blood pressure, • raised blood glucose, • raised Biological risk factors comprise • raised blood pressure, • raised blood glucose, • raised total serum cholesterol, • Dyslipidemia • overweight and obesity, • fat intake and • salt intake.

Current status and trends in risk factors Common, preventable risk factors underlie most NCDs. Current status and trends in risk factors Common, preventable risk factors underlie most NCDs. These risk factors are a leading cause of the death and disability burden in nearly all countries, regardless of economic development. The leading risk factor globally for mortality is: 1. raised blood pressure (responsible for 13% of deaths globally), 2. followed by tobacco use (9%), 3. raised blood glucose (6%), 4. physical inactivity (6%), 5. overweight and obesity (5%). 10

Current status and trends in risk factors contd. The prevalence of these risk factors Current status and trends in risk factors contd. The prevalence of these risk factors varied between country income groups, with the pattern of variation differing between risk factors and with gender. High-, middle- and low-income countries had differing risk profiles. Several risk factors have the highest prevalence in high-income countries. These include: 1. physical inactivity among women, 2. total fat consumption, 3. raised total cholesterol. Some risk factors have become more common in middleincome countries. These include: 1. tobacco use among men, 2. overweight and obesity. 11

Parameters for estimation of behavioural and metabolic risk factors • current daily tobacco smoking: Parameters for estimation of behavioural and metabolic risk factors • current daily tobacco smoking: the percentage of the current daily tobacco smoking population aged 15 or older who smoke tobacco on a daily basis. • physical inactivity: the percentage of the population aged 15 physical inactivity or older engaging in less than 30 minutes of moderate activity per week or less than 20 minutes of vigorous activity three times per week, or the equivalent. • raised blood pressure: the percentage of the population raised blood pressure aged 25 or older having systolic blood pressure ≥ 140 mm. Hg and/or diastolic blood pressure ≥ 90 mm. Hg or on medication to lower blood pressure. 12

contd. • raised blood glucose: the percentage of the population aged raised blood glucose contd. • raised blood glucose: the percentage of the population aged raised blood glucose 25 or older having a fasting plasma glucose value ≥ 7. 0 mmol/L (126 mg/dl) or on medication for hyperglycemia. • overweight: the percentage of the population aged 20 or overweight older having a body mass index (BMI) ≥ 25 kg/m 2. • obesity: the percentage of the population aged 20 or older obesity having a body mass index (BMI) ≥ 30 kg/m 2. • raised cholesterol: the percentage of the population aged 25 raised cholesterol or older having a total cholesterol value ≥ 5. 0 mmol/L (190 mg/dl). 13

Study findings in Bangladesh Study findings in Bangladesh

BANGLADESH MEDICAL RESEARCH COUNCIL Project Title: Prevalence of NCD Related Risk Factors Among Population BANGLADESH MEDICAL RESEARCH COUNCIL Project Title: Prevalence of NCD Related Risk Factors Among Population Aged 35 -60 in Dhaka City. Principal Investigator(s): Prof. Dr. M. S. A. Mansur Ahmed, Head, Dept. of Community Medicine, Bangladesh Institute of Health Sciences, Dhaka. Co-investigator(s): 1. Dr. Md. Shahjahan, Assistant professor, Dept of Epidemiology and Biostatistics, BIHS, Dhaka. 2. Mr. Moniruzzaman , Senior Research Fellow, Dept. of Community Medicine, BIHS, Dhaka. Place of the study/ Institution(s): Bangladesh Institute of Health Sciences Date of Commencement: January, 2011 Date of Completion: June, 2011

Table 1. Distribution of respondents according to their sociodemographic characteristics (n=400). Variables Number Percent Table 1. Distribution of respondents according to their sociodemographic characteristics (n=400). Variables Number Percent 225 141 34 56. 2 35. 2 8. 5 Sex Male Female 324 76 81. 0 19. 0 Levels of education Junior school certificate and below SSC HSC Graduation and above 84 68 81 167 21. 0 17. 0 20. 2 41. 8 Occupation GOB Employee NGO Employee Businessman Technician 264 98 34 4 66. 0 24. 5 8. 05 1. 0 118 187 57 19 20 29. 5 46. 8 14. 0 4. 8 5. 0 Age 35 -44 yrs 45 -54 yrs =>55 yrs (Mean = 43. 4, SD ± 6. 9 yrs) Monthly Income (TK) ≤ 10000 10001 -20000 20001 -30000 30001 -40000 40001+ Mean income: 18582 ± 17705 /=TK

Smoking habit • About 25 percent of the respondents were currently exposed to smoking Smoking habit • About 25 percent of the respondents were currently exposed to smoking during time of conducting the survey. • The mean number of stick per day was 10 with SD ± 6 (Table 2).

Table 2. Distribution of respondents according their smoking habits (n= 400). Variable Current Smoker Table 2. Distribution of respondents according their smoking habits (n= 400). Variable Current Smoker (male) Yes No Current Smoker (Female) Yes No History of smoking (n=301) Ex smoker Never smoked Duration of Smoking in yrs (n=99) 1 -5 6 -10 11 -15 15+ Mean Duration: 17. 58± 9. 0 yrs No. of stick per day (n=99) 1 -5 6 -10 10+ Number Percent 150 174 46. 3 53. 7 2. 6 2 74 97. 4 48 253 15. 9 84. 1 12 20 14 53 12. 1 20. 2 14. 1 53. 5 30 39 30 30. 3 39. 4 30. 3

Figure 1. Distribution of the respondents according to the habit of smokeless tobacco consumption Figure 1. Distribution of the respondents according to the habit of smokeless tobacco consumption (Betel nut, Zarda and Gool) Mean Duration of current users: 9± 8 yrs and mode: 10 yrs

Table 3. Distribution of respondents according to the habit of alcohol consumption (n=400). Variable Table 3. Distribution of respondents according to the habit of alcohol consumption (n=400). Variable Drinking of alcohol Number Percent Yes 10 2. 5 No 390 97. 5

Table 4. Distribution of respondents according to the status of doing physical exercise (n=400). Table 4. Distribution of respondents according to the status of doing physical exercise (n=400). Variables Number Percent 119 29. 8 281 400 70. 3 100. 0 312 78. 0 88 400 22. 0 100. 0 Have any physical exercise Yes No Total Maintained recommended physical exercise No yes Total

Figure 2: Distribution of the respondents according to BMI categories (n=400) BMI (Mean ±SD): Figure 2: Distribution of the respondents according to BMI categories (n=400) BMI (Mean ±SD): 24. 6 ± 3. 3 kg/m 2

Table 5: Number of servings of fruits taken by the respondents per day No. Table 5: Number of servings of fruits taken by the respondents per day No. of servings Frequency Percent <5 servings 399 99. 8 =>5 servings 1 . 2 400 100. 0 Total

Table 6: Number of servings of vegetables taken by the respondents per day No. Table 6: Number of servings of vegetables taken by the respondents per day No. of servings < 5 servings =>5 servings Total Frequency 395 Percent 98. 8 5 1. 2 400 100. 0

Conclusion • Majority of the study population are in economically productive age group. • Conclusion • Majority of the study population are in economically productive age group. • Mean Duration of smoking was found to be 17. 58± 9. 0 yrs and the mean number of stick perday was 10 with SD ± 6 compared to higher rates in some industrialized and developed countries • About one third of the respondents reported doing any form of physical exercise. Among them, 22% maintained recommended physical exercise (minimum 30 min of physical exercise for at 5 days a week). • The recommended fruits intake of at least 5 servings per day by respondents was very low (0. 2%). and the recommended vegetable intake of at least 5 servings per day by respondents was very low (1. 2%). • Building awareness for behavioral and lifestyle related risk factors should be an agenda for advocacy of the policy planners. • Further studies needed.

CARDIOVASCULAR RISK ASSESSMENT AMONG URBAN POPULATION AGED 40 -70 YEARS USING WHO/ISH RISK PREDICTION CARDIOVASCULAR RISK ASSESSMENT AMONG URBAN POPULATION AGED 40 -70 YEARS USING WHO/ISH RISK PREDICTION CHART SPONSOR: MINISTRY OF SCIENCES AND TECHNOLOGY, GOV’T OF BANGLADESH Principal investigator: Prof. Dr. M. S. A. Mansur Ahmed, Dept. of Community Medicine, BIHS Co-investigators • Dr. Shahanaz Choudhury, Asstt. professor, Community Medicine, BIHS • M. Moniruzzaman, Sr. Lecturer, Community Medicine, BIHS NAME AND ADDRESS OF THE CONTRACTING INSTITUTE: Bangladesh Institute of Health Sciences (BIHS) Duration of the Project: 1 year Date of Commencement: July 2012 Date of Completion: June, 2013

WHO/ISH risk prediction chart WHO/ISH risk prediction chart

Table 2: Distribution of respondents according to History of Behavioral Risk Factors (n=150) Variables Table 2: Distribution of respondents according to History of Behavioral Risk Factors (n=150) Variables History of smoking Number(n) Percent (%) Mean±SD Current smoker Ex-smoker Never smoked Duration of smoking (current smoker) Duration of smoking category 21 13 116 14 8. 7 77. 3 20. 14± 12. 8 years <10 years ≥ 10 years Number of stick per day 7 14 33. 3 66. 7 8. 1± 5. 6 47 40 63 31. 3 26. 7 42 17. 1± 14. 5 Number of betel nut/day 6. 4± 5. 6 Consume alcohol Yes No Fruit taking history/ day 8 142 5. 3 94. 7 Adequate ( at least 5 *servings/day) Inadequate Mean fruit servings/day 0 150 0 100 0. 8± 0. 7 2 48 1. 3 98. 7 2. 03± 0. 85 Regular Occasional Never Exercise history 73 24 53 48. 7 16 35 Yes No Recommended Exercise(at least 30 min/day for at least 5 days in a week) 68 82 45. 3 54. 7 Yes No Mean duration of exercise per day(minutes) 38 112 25. 3 74. 7 33. 6± 33. 3 Consume smokeless tobacco(betel nut, zorda, gul etc) Yes (current) Occasional Never Duration of smokeless tobacco Vegetables intake Adequate (at least 5 servings/day) Inadequate Mean vegetables intake history in a day Extra table salt intake history *1 servings= 80 gm

Table 4: Distribution of respondents according to Physical Measurement (n=150) Variables Number(n) Percent (%) Table 4: Distribution of respondents according to Physical Measurement (n=150) Variables Number(n) Percent (%) Mean±SD Height (cm) 151. 2± 19 Weight (kg) 62± 16 *BMI category(kg/m 2) Underweight (<18. 5) 52 34. 7 Normal(18. 5 to 23) 65 43. 3 22. 09± 13. 8 Overweight (23 to 27. 5) 24 16 Obese(>27. 5) 9 6 Waist circumference of the respondents 93. 3± 11. 8 Hip circumference (cm) 98. 3± 11. 7 Waist hip) ratio (WHR) Male 27 53. 0 95 93. 0 Hypertensive (≥ 140/90 mm. Hg) 20 13. 3 Normotensive 130 86. 7 Systolic mean pressure 120± 17 Diastolic mean pressure 80± 11 Cholesterol level High (≥ 200 mmol/dl) 31 20. 7 Normal 119 79. 3 171± 42 Non Diabetes 97 64. 7 Diabetes 53 35. 3 High WHR (≥ 90 cm) Female High WHR (≥ 80 cm) BP status Glycemic status *BMI – Asian cut off has been used

CONCLUSION • About 19% of the study population are at moderate to high risk CONCLUSION • About 19% of the study population are at moderate to high risk of developing CVD event in next 10 years. • The proportion of CVD risk calculated by the chart may be higher if we include other known risk factors (over wt/obesity, physical inactivity, inadequate fruits and vegetable intake, use of extra table salt etc).

TITLE: CARDIOVASCULAR RISK ASSESSMENT AMONG URBAN AND RURAL POPULATION AGED 40 -70 YEARS USING TITLE: CARDIOVASCULAR RISK ASSESSMENT AMONG URBAN AND RURAL POPULATION AGED 40 -70 YEARS USING WHO/ISH RISK PREDICTION CHART Principal investigator: Prof. Dr. M. S. A. Mansur Ahmed, Dept of Community Medicine, BUHS Co-investigator: 1, Dr. Shahanaz Choudhury, Asst Prof. , Dept of Community Medicine, BUHS. 2. M. Moniruzzaman, Sr. Lecturer, Dept. of Community Medicine, BUHS Sponsor: Ministry of Science and Technology, Gov’t of Bangladesh NAME AND ADDRESS OF THE CONTRACTING INSTITUTE: Bangladesh University of Health Sciences (BUHS), 125/1 Darus Salam, Mirpur 1, Dhaka 1216. Duration of the Project: One year Date of Commencement: July 2013 Date of Completion: June, 2014

Table 2: Distribution of respondents according to History of Behavioral Risk Factors (N=508) Variables Table 2: Distribution of respondents according to History of Behavioral Risk Factors (N=508) Variables History of smoking Current smoker Ex-smoker Urban(244) Rural(264) Number(N)/ Percent (%) Both(508) 33(13. 1%) 36(14. 1%) 69(13. 6%) Number(N)/ Percent (%) 19(7. 5%) 28(10. 9%) 47(9. 3%) 200(79. 4%) 192(75%) 392(77. 2%) Mean Duration of smoking(current smoker) yrs 16. 7± 8. 8 20. 8± 14. 8 18. 8± 12. 4 Mean Number of sticks per day 8. 3± 4. 3 9. 3± 5. 5 8. 8± 4. 9 Never smoked Consume smokeless tobacco(betel nut, zorda, gul etc) Yes (current) 75(29. 8%) 58(22. 7%) 133(26. 2%) Never 177(70. 2%) 198(77. 3%) 375(73. 8%) Mean Duration of smokeless tobacco yrs 11. 9± 1. 06 13. 2± 1. 5 12. 3± 0. 9 Consume alcohol Yes 6(2. 4%) 0(0%) 6(1. 2%) No 246(97. 6%) 256(100) 502(98. 8%) Fruit taking history/ day Adequate ( at least 5 *servings/day) Inadequate Mean fruit servings/day Vegetables intake Adequate (at least 5 servings/day) Inadequate 1(0. 4%) 10(3. 9%) 11(2. 2) 251(99. 6%) 246(96. 1%) 497(97. 8%) 1. 3± 0. 64 2. 1± 1. 5 1. 7± 1. 3 1(0. 4%) 27(10. 5%) 28(5. 5) 251(99. 6%) 229(89. 5%) 480(94. 5) Mean vegetables intake history (no of servings ) in a day 1. 8± 0. 7 3. 02± 1. 4 2. 4± 1. 3 Frequency of mean fast food intake per day 2. 0± 1. 1 1. 9± 1. 4 2. 0± 1. 2 Fast food intake/day Yes 23(9. 1%) 12(4. 7%) 35(6. 9%) No 229(90. 9%) 244(95. 3%) 473(93. 1%) 3. 1± 1. 9 2. 4± 1. 2 2. 7± 1. 6 Frequency of Mean Street Food Intake/week Fatty rich food intake/week Yes 49(19. 4%) 46(18%) 95(18. 7%) No 203(80. 6%) 210(82%) 413(81. 3%) 1. 8± 1. 2 1. 5± 1. 1 1. 7± 1. 2 Frequency of Mean Fatty rich food intake / week Empty caloric drink intake/week Yes 79(31. 3%) 59(23%) 138(27. 2%) No 173(68. 7%) 197(77%) 370(72. 8%) 2. 7± 1. 9 2. 2± 1. 7 2. 5± 1. 8 Frequency of Mean intake of empty caloric drink intake/week Extra table salt intake history Regular 129(51. 2%) 143(55. 9%) 272(53. 5%) Occasional 28(11. 1%) 23(9%) 51(10%) Never 95(37. 7%) 90(35. 2%) 185(36. 4%) Exercise history Yes 80(31. 7%) 128(50%) 208(40. 9%) No 172(68. 3%) 128(50%) 300(59. 1%) Recommended Exercise(at least 30 min/day for at least 5 days in a week) Yes 64(25. 4%) 96(37. 5%) 160(31. 5%) No 188(74. 6%) 160(62. 5%) 348(68. 5%)

Table 4: Distribution of respondents according to Physical, Biological and biochemical Measurement (N=508) Height Table 4: Distribution of respondents according to Physical, Biological and biochemical Measurement (N=508) Height (cm) Weight (kg) Mean BMI** *BMI category(kg/m 2) Underweight (<18. 5) Normal(18. 5 to 23) Overweight (23 to 27. 5) Obese(>27. 5) Mean Waist circumference of the respondents (cm) Mean Hip circumference (cm) Waist hip ratio (WHR) Blood Pressure status Hypertensive (≥ 140/90 mm. Hg) Normotensive Systolic mean pressure mm. Hg Diastolic mean pressure mm. Hg Cholesterol level High (≥ 200 mgl/dl) Normal(<200 mg/dl) Glycemic status Non Diabetes Urban Rural Both Number(n) Percent (%)/ Mean±SD Variables Number(n) Percent (%)/ Mean±SD 155. 8± 8. 5 59. 1± 11. 3 24. 3± 4 11(4. 4%) 99(39. 3%) 91(36. 1%) 51(20. 2%) 88± 10. 5 160. 5± 8 64. 4± 10. 4 25± 4 9(3. 5%) 60(23. 4%) 134(52. 3%) 53(20. 7%) 91. 7± 13. 1 158. 2± 8. 6 61. 7± 11. 3 24. 6± 4 20(3. 9%) 159(31. 3%) 225(44. 3%) 104(20. 5%) 89. 9± 12 91. 9± 10. 7 0. 96± 0. 1 56(22. 2%) 196(77. 8%) 118± 16. 3 77± 10 80(31. 7%) 172(68. 3%) 94± 12. 8 0. 99± 0. 2 62(24. 2%) 194(75. 8%) 121. 7± 12. 8 80. 2± 9. 7 165(64. 5%) 91(35. 5%) 93± 11. 9 0. 97± 0. 124 118(23. 2%) 390(76. 8%) 119. 9± 14. 7 78. 6± 10 245(48. 2%) 263(51. 8%) 219(86. 9%) 33(13. 1%) 209(81. 6%) 47(18. 4%) 428(84. 3%) 80(15. 7%) *BMI – Asian cut off has been used, **BMI-Body Mass Index

CONCLUSION • Overall 17. 5% of the study populations are at moderate to high CONCLUSION • Overall 17. 5% of the study populations are at moderate to high risk of developing CVD event in next 10 years. • The proportion of high risk was more in rural (11. 7%) area than in urban (8. 7%) area where as the proportion of moderate risk was more in urban (10%) area than in rural (4. 7%) area. • However, the proportion of moderate to high risk was almost similar in urban (18. 7%) and rural (16. 4%) area.

References 1. 2. 3. 4. April 2011 the World Health Organization (WHO) report. Bulletin References 1. 2. 3. 4. April 2011 the World Health Organization (WHO) report. Bulletin of the World Health Organization 2013; 91: 650 -660. doi: http: //dx. doi. org/10. 2471/BLT. 13. 117549 Ahmed, MSA M, Shahjahan M, Moniruzzaman M, Prevalence of NCD Risk Factors. BMRC project report, 2011. Ahmed, MSA M, Choudhury S, Moniruzzaman M. Cardiovascular Risk Assessment Among Urban Population Aged 40 -70 Years Using WHO/ISH Risk Prediction Chart. Ministry of Science & Technology, Gov’t of Bangladesh, Project report 2013 5. Ahmed, MSA M, Choudhury S, Moniruzzaman M. Cardiovascular Risk Assessment Among Urban And Rural Population Aged 40 -70 Years Using WHO/ISH Risk Prediction Chart. Ministry of Science & Technology, Gov’t of Bangladesh, Project report 2014 6. http: //www. who. int/gho/ncd/mortality_morbidity/en/, WHO Global health data, morbidity and mortality . 7 Hunter DJ, Reddy KS, Noncommunicable Diseases, N Engl J Med 2013; 369: 1336 1343 October 3, 2013 DOI: 10. 1056/NEJMra 1109345