sde_rep-2011-dec

8/2/2019 sde_rep-2011-dec

1/104

Noncommunicable

Diseases in theSouth-East Asia Region

2011Situation and Response

8/2/2019 sde_rep-2011-dec

2/104

8/2/2019 sde_rep-2011-dec

3/104

Noncommunicable

Diseases in the

South-East Asia Region

2011

Situation and Response

8/2/2019 sde_rep-2011-dec

4/104

WHO Library Cataloguing-in-Publication data

World Health Organization, Regional Office for South-East Asia.

Noncommunicable diseases in the South-East Asia Region: Situation and response 2011.

1. Mortality. 2. Chronic Disease - prevention and control. 3. Risk Factors. 4. Cost of illness. 5. Risk factors.

6. Epidemiologic surveillance. 7. Delivery of Health Care. 8. Health Care Sector

ISBN 978-92-9022-413-6 (NLM classification: WT 500)

World Health Organization 2011

Requests for publications, or for permission to reproduce or translate WHO publications whether for sale or for

noncommercial distribution can be obtained from Publishing and Sales, World Health Organization, Regional Office for

South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail:

[email protected]).

The designations employed and the presentation of the material in this publication do not imply the expression of any

opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory,

city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps

represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or

recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.

Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this

publication. However, the published material is being distributed without warranty of any kind, either expressed or

implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World

Health Organization be liable for damages arising from its use.

This publication does not necessarily represent the decisions or policies of the World Health Organization.

Printed in India

8/2/2019 sde_rep-2011-dec

5/104

i

2011

Contents

Acknowledgments iiForeword iiiAcronyms iv

EXECUTIVE SUMMARY 1

1. INTRODUCTION 5

2. BURDEN OF NONCOMMUNICABLE DISEASES IN WHO SOUTH-EAST ASIA REGION 9

NCD Mortality 10Trends in NCD Mortality and Morbidity 12Disease-Specific Burden and Trends 13

Cardiovascular diseases 14Cancers 15Diabetes mellitus 17Chronic respiratory diseases 18Other NCDs 19

3. RISK FACTORS 23Behavioural Risk Factors 24

Tobacco use 24Unhealthy diet 30Physical inactivity 31Harmful use of alcohol 32

Metabolic Risk Factors 33

Overweight and obesity 33Raised blood pressure 35Raised cholesterol 36Cluster of risk factors 37Other risk factors 38

IV. DRIVERS OF NCDs 43Population ageing 43Urbanization 44Globalization 47Poverty 47Illiteracy 48Underdeveloped health system 48

V. ECONOMIC BURDEN OF NCDs 51Economic burden of NCDs at the National Level 51

Economic burden of NCDs at household level 52VI. NATIONAL RESPONSE TO NCDs 59

Institutional Capacity for NCD Prevention and Control at the Central Level 59National Policies, Strategies, Plans and Programmes for NCD Prevention and Control 60Surveillance and Monitoring 62Heath System Capacity for NCD Prevention, Early detection, Treatment and Care 65Health Financing 68Partnerships and Collaboration 69

VII. MAJOR CHALLENGES IN PREVENTION AND CONTROL OF NCDs 71Lack of strong national partnerships for multisectoral actions 71Weak surveillance systems 71Limited access to prevention, care and treatment services for NCDs 72Limited human resources for NCDs 72Insufficient allocation of funds 72Difficulties in engaging the industry and private sector 72Lack of social mobilization 73

VIII. WHO INITIATIVES IN NCD PREVENTION AND CONTROL 75Global initiatives 75Regional initiatives 76

IX. THE WAY FORWARD 79Guiding Principles for NCD Prevention and Control 79

Health promotion and primary prevention to reduce risk factors for NCDs 80using multisectoral approach

Health system strengthening for early detection and management of NCDs 80Surveillance and research 81

Specific Strategies for NCD Prevention and Control 81Role of Different Agencies in NCD Prevention and Control 82

ANNEXES 85Tables 85Note on data sources and limitations 92

8/2/2019 sde_rep-2011-dec

6/104

ii

2011

Acknowledgements

We thank the Member countries of the South-East Asia Region for providing the latest data on risk

factors, morbidity and mortality, as well as updates on national responses and key achievements. We are

grateful to national experts from Member countries of the Region for contributing to selected sections of

the report. We acknowledge the assistance of staff in the World Health Organization country offices for

their contribution in preparing this report. We are grateful to Dr Anton Fric for preparing an earlier

version of the report and Dr Abhaya Indrayan and Dr Niki Shrestha for extensive inputs to the report as

well as data verification, review of literature and references checking. Mr Ravinder Kumar prepared

charts and graphs. Ms Vani Kurup edited and designed the Report.

8/2/2019 sde_rep-2011-dec

7/104

Foreword

This report describes the current burden of

noncommunicable diseases (NCDs) in the South-

East Asia Region (SEAR), their underlying risk

factors and socioeconomic determinants, and

summarizes national responses to the epidemic.

NCDs are top killers in SEAR, causing 7.9

million deaths annually. One third of these deathsare premature and occur before the age of 60

years, in the economically productive age groups.

With the projected number of deaths expected to

increase by 21% over the next decade, the scale of

the problem we face is clearly serious.

Demographic changes (ageing population), rapid

unplanned urbanization, negative aspects of global

trade and marketing, progressive increase in

unhealthy lifestyle patterns, as well as social and

economic determinants are accelerating the

burden of NCDs.

While there is a growing recognition among

Member States of the need to tackle NCDs, the

current focus is largely on providing medical

services to those who have already developed

NCDs, rather than on promoting health and

eliminating the risk factors for NCDs. In an era of

spiralling health-care expenses, NCDs are

exacerbating poverty and widening inequities,

particularly in SEAR where most health-care costs

are met by out-of-pocket expenditures. Thus there

is a need for greater emphasis on health

promotion and primary prevention of NCDs based

on the principles of primary health-care, equity

and social justice.

Prevention of NCDs is feasible through

empowering individuals, families and

communities to adopt healthy lifestyles, namely

avoiding tobacco and alcohol use, eating a healthy

diet including plenty of vegetables and fruits,

iii

2011

engaging in regular physical activity to maintain

body weight and managing mental stress. Effective

legislative policies that promote healthy

behaviours by default such as smoke-free zones,

restricted sale of alcohol below legal age,

regulation of marketing of unhealthy food tochildren are also required to create a conducive

environment where people can adopt healthy

lifestyles easily. There is a need to create

workplaces, schools, communities and

environment that make adoption of healthy

lifestyle choices possible. Additionally, health

services and systems need to be strengthened to

accommodate the needs of NCD prevention and

control.

Noncommunicable diseases constitute achallenge for socioeconomic development. NCDs

contribute to poverty and threaten the

achievement of Millennium Development Goals

(MDGs). Addressing NCDs requires interventions

not only from the health sector but many other

sectors, such as agriculture, education, urban

development and transport. The United Nations

High-Level Meeting on NCDs held in New York,

United States of America, earlier this year called

upon all Member States to integrate their NCD

policies and programmes into the broader health

and development agenda and to develop

multisectoral national policies and plans to tackle

NCDs.

I call upon our Member States to join the

efforts of WHO and the UN to accord a high

priority to prevention and control of NCDs in

national health policies and programmes, increase

domestic and international resources for NCDs

and galvanize a multisectoral response to NCDs.

Given the enormous burden of NCDs in the

Region and their serious socioeconomic

consequences, I urge national governments and

all developmental partners to tackle NCDs with a

sense of urgency.

Dr Samlee Plianbangchang

Regional Director, World Health OrganizationRegional Office for South-East Asia

8/2/2019 sde_rep-2011-dec

8/104

iv

2011

Acronyms

BMI body mass index

BP blood pressure

CHD coronary heart disease

COPD chronic obstructive pulmonary disease

CRDs chronic respiratory diseases

CURES Chennai Urban Rural Epidemiology Study

CVDs cardiovascular diseases

DALYs disability adjusted life years

DBP diastolic blood pressure

FCTC WHO Framework Convention on Tobacco Control

GATS Global Adult Tobacco Survey

GDP gross domestic product

GYTS Global Youth Tobacco SurveyHDL high density lipoprotein

HDSS Health and Demographic Surveillance System

ICMR Indian Council of Medical Research

IGT impaired glucose tolerance

INR Indian Rupee

LDL low density lipoprotein

MDGs Millennium Development Goals

MONICA Multinational Monitoring of Trends and Determinants of Cardiovascular Disease

NCDs noncommunicable diseases

NFHS National Family Health Survey

NPHF Nepal Public Health Foundation

NTCC National Tobacco Control Cell

PEN WHO package of essential NCD interventions

SEA-ACHR South East Asia-Advisory Committee on Health Research

SEANET South-East Asian Network of NCD

SEAR South-East Asia Region

SEARO Regional Office for South-East Asia

TFA trans fatty acids

UNHLM UN High-level Meeting

WC waist circumference

WEF World Economic Forum

8/2/2019 sde_rep-2011-dec

9/104

2011

1

Executive Summary

Four major noncommunicable diseases

(NCDs) cardiovascular diseases (including

heart disease and stroke), diabetes, cancer and

chronic respiratory diseases (including chronic

obstructive pulmonary disease and asthma)

are the leading cause of illness and death

worldwide including the South-East Asia Region

(SEAR). In addition to the health burden, NCDs

have serious social and economic consequences

particularly for poor and disadvantaged

populations.

Burden of NCDs in the South-East

Asia RegionI Of the estimated 14.5 million total deaths in

2008 in SEAR, 7.9 million (55%) were due

to NCDs. NCD deaths are expected to

increase by 21% over the next decade. Of the

7.9 million annual NCD deaths in SEAR,

34% occurred before the age of 60 years

compared to 23% in the rest of the world.

I NCD mortality rates increase with age and

are higher in males than females. Of the 7.9

million deaths due to NCDs in 2008,

cardiovascular diseases alone accounted for

a quarter (25%) of all deaths. Chronic

respiratory diseases, cancers and diabetes

accounted for 9.6%, 7.8% and 2.1% of all

deaths, respectively.

I Cardiovascular diseases claimed 3.7 million

lives in the Region. Ischeamic heart diseases

and stroke account for majority of the

cardiovascular disease deaths.

I An estimated 1.7 million new cases of cancer

occur each year in the Region and claims 1.1

million lives each year. Among males, lung

and oral cancers are most common, followed

by oral cancer, while among females, the

incidence of breast and cervix uteri cancers

is the highest.

I There are an estimated 81 million people

living with diabetics in the Region. The

prevalence of diabetes is consistently higher

in urban than rural areas, and is increasing

in both areas. Undiagnosed diabetes is a

significant problem in the Region.

I An estimated 1.4 million people died of

chronic respiratory diseases in SEAR in

2008; of these 86% were due to chronic

obstructive pulmonary disease and 7.8% due

to asthma.

NCD risk factors and socialdeterminants

I

The four major behavioural risk factors ofNCDs (tobacco use, unhealthy diet, lack of

physical activity and harmful use of alcohol)

that lead to four major metabolic risk

factors (overweight/obesity, high blood

pressure, raised blood sugar and raised

blood lipids) are highly prevalent in the

Region and on the rise. Hypertension,

raised blood glucose and tobacco use

together account for nearly 3.5 million

deaths in the Region every year.

8/2/2019 sde_rep-2011-dec

10/104

I The Region has nearly 250 million smokers

and an equal number of smokeless tobacco

users. Nearly half of all adult males and two

in every five adult females use some form of

tobacco. 6.8% of annual deaths in the

Region are attributed to tobacco use. The

smoking rate among boys is higher than

that among girls in the age group 1315

years. However, prevalence of smokeless

tobacco use among young girls and women

in the Region is on the rise.

I Three areas of particular concern regarding

unhealthy diet in the Region are low intake

of fruits and vegetables, high consumption

of salt and widespread use of transfats in

the food industry. Approximately 80% of

the population does not eat sufficient

quantities of fruits and vegetables and half

a million deaths in the Region are attributed

to low intake of fruits and vegetables.

I Annually, nearly 800 000 deaths in the

Region are attributed to inadequate

physical activity. The prevalence of

insufficient physical activity varies from 3%

to 41% among males and from 6.6% to 64%

among females; 5.1% of the total annual

deaths are attributed to physical inactivity.

I The prevalence of alcohol consumption

varies from 2% to 44% among males and

from 0.1% to 26% among females. An

estimated 350 000 people died in SEAR of

alcohol-related causes in 2004.

I The prevalence of overweight varied from 8%

to 30% among males, and from 8% to 52%

among females. The prevalence of

overweight and obesity is higher in females

than in males. Annually, 350 000 deaths are

attributed to overweight and obesity in the

Region. Childhood obesity is an emerging

issue.

I Approximately 30% of the adult population

has high blood pressure, which accounts for

nearly 1.5 million deaths annually; and 9.4%

of the total deaths are attributed to high

blood pressure.

I There are remarkable variations in raised

cholesterol levels among adults, with the

highest prevalence (above 50% in both sexes)

in Maldives and Thailand. Females have a

higher prevalence of raised cholesterol than

males in several Member countries. 4.9% of

the total annual deaths in the Region are

attributed to raised cholesterol.

I In addition to population ageing, which is anon-modifiable determinant of NCDs,

poverty, urbanization, globalization,

inequity and poor health systems are major

drivers of NCDs and their risk factors.

Economic burden of NCDs

I There is a two-way link between NCDs and

household poverty. Poverty exposes

populations to risk behaviours and poorhealth outcomes; NCDs in turn exacerbate

poverty due to expenses incurred on

unhealthy behaviours, expenses on health

care and loss of wages.

I Similarly, the macroeconomic burden is

also enormous and includes health care

costs, loss of productivity due to premature

deaths and decreased gross domestic

product (GDP).

National responses to NCDs

I All 11 Member countries* initiated a public

health response to NCDs and have

allocation for NCD prevention and control

in the budget of their respective ministries

of health.

2011

2

8/2/2019 sde_rep-2011-dec

11/104

I All Member countries reported providing at

least one NCD-related service at the

primary care level in public health facilities.

This includes primary prevention and

health promotion (11 countries), early

diagnosis of NCD risk-factors (9 countries)

and risk factor and disease management (10

countries). All Member countries have an

essential drugs list and many of the NCD-

related drugs are included in the national

essential drugs list.

Major challenges in addressing NCDs

Major challenges that need to be overcome

to effectively address NCDs include lack of

strong national partnerships for multisectoral

actions, weak surveillance systems, limited

access to prevention, care and treatment

services for NCDs, limited human resources,

insufficient allocation of funds, and lack of

engagement of the private sector.

Way forward

High level of commitment is needed toreverse the growing burden of NCDs in the

Region. Key priorities for tackling NCDs

include: (1) reducing risk factors for NCDs

through multisectoral actions; (2) strengthening

surveillance systems to map the risk, burden

and national response, and (3) integrating

NCDs into the primary health care system as a

step towards universal coverage.

2011

3

I Nine Member countries have an integrated

policy on NCDs. Cancer and diabetes are

the most targeted diseases for control and

chronic respiratory disease are the least

covered. Guidelines on dietary counseling

are available in six countries, guidelines on

tobacco dependence and physical activity

are available in four countries and

guidelines on alcohol dependence are

available in five countries.

I Legislative support for tobacco is available

in 10 countries; there is alcohol legislation

in five countries. Only two countries

address diet and nutrition and one country

addresses physical activity through

legislative measures.

I At least one NCD risk-factor survey

(national or subnational) has been

completed in all 11 countries. Surveys for

tobacco use have been done more

frequently compared to other risk factors.

I Disease-specific morbidity data are

generally collected through the routine

health information system in all 11

countries; mortality data are included in

nine countries. Disease registries for NCDs

have been most commonly established for

cancers, followed by diabetes and stroke.

Most mortality/morbidity data and disease

-specific registries are hospital-based.

8/2/2019 sde_rep-2011-dec

12/104

Chapter 1

8/2/2019 sde_rep-2011-dec

13/104

Noncommunicable diseases (NCDs) are

defined as diseases of long duration, and are

generally slow in progression. NCDs are the

leading cause of adult mortality and morbidity

worldwide. Four main diseases are generally

considered to dominate NCD mortality and

morbidity: cardiovascular diseases (including

heart disease and stroke), diabetes, cancers and

chronic respiratory diseases (including chronic

obstructive pulmonary disease (COPD) and

asthma). These four NCDs are caused, to a large

extent, by four modifiable behavioural risk

factors: tobacco use, unhealthy diet, physical

inactivity and harmful use of alcohol.

NCDs have now reached epidemic

proportions in many countries. NCDs hit

hardest at the worlds low- and middle-income

groups and place a tremendous demand on

health systems and social welfare, cause

decreased productivity in the workplace,

prolong disability and diminish resources

within families. Globally, NCDs are estimated

to cost more than US$ 30 trillion over the next20 years, representing 48% of global gross

domestic product (GDP) in 2010 (1). NCDs are

expected to rise substantially in the coming

decades, partly due to a growing ageing global

population. Further, as urbanization and

globalization increase in the developing world,

there is likely to be an increase in the prevalence

NCDs. Therefore, unless the NCD epidemic is

aggressively confronted, the mounting impact

of NCDs will continue unabated.

In 2008, 63% (36 of 57 million) deaths

worldwide occurred due to NCDs (2). These

deaths are distributed widely among people

from high-income to low-income countries.

About one-quarter of all NCD deaths were

below the age of 60, amounting to

approximately 9 million deaths per year. Ninety

percent of premature deaths from NCDs occur

in developing countries. Nearly 80% of NCD

deaths (29 million) occur in low- and middle-

income countries. The leading causes of NCD

deaths in 2008 were cardiovascular diseases (17

million deaths, or 48% of NCD deaths); cancers

(7.6 million, or 21% of NCD deaths); andrespiratory diseases, including asthma and

COPD (4.2 million). Diabetes caused an

additional 1.3 million deaths. Over 80% of

cardiovascular and diabetes deaths, and almost

90% of deaths from COPD, occurred in low- and

middle-income countries. NCD deaths are

projected to increase by 15% globally between

2010 and 2020 (to 44 million deaths) and

annual NCD deaths are projected to rise

substantially, to 52 million by 2030. Thegreatest increases will be in the WHO regions of

Africa, South-East Asia and the Eastern

Mediterranean, where they will increase by over

20%. NCD mortality already exceeds that of

communicable diseases, maternal and perinatal

conditions, and nutritional deficiencies

combined in all Regions with the exception of

the African Region. It is projected that over the

next 20 years, annual infectious disease deaths

will decline by around 7 million, but annual

Introduction

2011

5

8/2/2019 sde_rep-2011-dec

14/104

cardiovascular disease mortality will increase by

6 million, and annual cancer deaths by 4

million. By 2030, in low- and middle-income

countries, NCDs will be responsible for three

times as many disability adjusted life years

(DALYs) and nearly five times the mortality

from communicable diseases, as well as from

maternal and perinatal conditions, and

nutritional deficiencies combined.

The good news is that NCDs are largely

preventable through interventions and policies

that reduce the major risk factors. Many

preventive measures are cost-effective,

including that for low-income countries. NCD

prevention can avert millions of deaths and

reduce billions of dollars in economic losses. A

recent WHO report underlines that population-

based measures for reducing tobacco and

harmful use of alcohol, as well as unhealthy diet

and physical inactivity, are estimated to cost

US$ 2 billion per year for all low- and middle-

income countries, which translates to less than

US$ 0.40 per person (3). Numerous options are

available to prevent and control NCDs, suchasthe WHO identified set of interventions called

Best Buys. NCD prevention can be further

strengthened by implementing programmes

aimed at behaviour change among youth and

adolescents, and more cost-effective models of

care. Cost-effective nutritional policies, such as

salt reduction initiatives in the United Kingdom,

Finland, France, Ireland and Japan, have

demonstrated positive and measurable results.

Declines in tobacco use prevalence are apparent

in several high-income countries (e.g. Australia,

Canada, Finland, the Netherlands and the

United Kingdom). Some low- and middle-

income countries have also documented decline

in tobacco use prevalence (Mexico, Uruguay and

Turkey). A number of low- and middle-income

countries (e.g. Egypt, Pakistan, Turkey and the

Ukraine) recently increased taxes on tobacco

products, generating substantial revenues and

saving lives (2).

The South-East Asia Region (SEAR)

suffers from a double disease burden, that of

communicable diseases that remain an

important public health problem, as well as

NCDs that have emerged as the leading cause of

death. The emergence of NCDs as a public

health problem in the Region stems mainly

from epidemiological transition, characterized

by a change in disease patterns from infectiousdiseases to NCDs, and from a demographic

transition due to increased longevity and a rise

in ageing population. The challenges in

addressing NCDs in the Region calls for a

paradigm shift in approach: from a clinical

approach to a more comprehensive approach;

from using a biomedical approach to a public

health approach and from addressing each NCD

separately to collectively addressing a cluster of

diseases in an integrated manner.

This NCD status report describes the

regional burden of NCDs, their risk factors and

socio-economic determinants. The report also

summarizes the progress countries are making

for tackling the NCD epidemic, provides the

base for regional and country responses,

highlights some good country practices and

recommends the way forward in addressing

NCDs and risk factors in a comprehensive and

integrated way. The report is intended for

policy-makers in health and development,

health professionals, researchers and academia,

and other key stakeholders involved in

prevention and control of NCDs.

2011

6

8/2/2019 sde_rep-2011-dec

15/104

REFERENCES

1. The global economic burden of non-communicable diseases. A report by the World Economic Forum and the Harvard

School of Public Health. September 2011

http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf

(accessed 28 December 2011).

2. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011

http://whqlibdoc.who.int/publications/2011/9789240686458_eng.pdf. (accessed 28 December 2011).3. World Health Organization. Scaling up action against noncommunicable diseases. How much will it cost? Geneva,

2011 http://whqlibdoc.who.int/publications/2011/9789241502313_eng.pdf. (accessed 28 December 2011).

2011

7

8/2/2019 sde_rep-2011-dec

16/104

Chapter 2

8/2/2019 sde_rep-2011-dec

17/104

Burden of Noncommunicable Diseases

in WHO South-East Asia Region

I Noncommunicable diseases (NCDs) are top killers in the South-East

Asia Region (SEAR), causing 7.9 million deaths annually; the numberof deaths is expected to increase by 21% over the next decade.

I NCDs kill people at a relatively younger age in SEAR compared to the

rest of the world; one-third (34%) of the 7.9 million deaths in SEAR

occur in those below the age of 60 years compared to 23% in the rest

of the world.

I Cardiovascular diseases (coronary heart disease and stroke), cancers,

chronic respiratory diseases and diabetes account for the majority of

NCD morbidity and mortality.

I Mortality and morbidity from major NCDs is on the rise and will

continue to be so in the future.

Member States in SEAR* are undergoing

epidemiological transition. NCDs are replacing

communicable diseases, maternal and child

health as well as malnutrition (the primary

causes of death until some decades ago) as the

leading cause of death. NCDs are killing millions

and disproportionately affecting people at a

younger age and in poorer sections in this

Region.

This chapter reviews the current burden

and trends of NCDs in SEAR and provides the

latest estimates and data as reported by

Member countries. Age- and sex-wise estimates

of mortality are available; however there is

limited availability of disaggregated data by

socioeconomic status.

2011

9

* Bangladesh, Bhutan, Democratic Peoples Republic of Korea, India,Indonesia, Maldives, Myanmar, Nepal, Thailand, Sri Lanka, Timor-Leste

8/2/2019 sde_rep-2011-dec

18/104

Cardiovasculardisease 25%

Cancers 7.8%

Chronic respiratory

diseases 9.6%

Diabetes 2.1%

Other

NCDs 10%

Communicable diseases,

maternal and perinatal

conditions, nutritional

deficiencies 35%

Injuries 11%

NCD Mortality

Of the estimated 14.5 million total deaths

in 2008 in SEAR, 7.9 million (55%) were due to

NCDs (1). Cardiovascular diseases (CVDs) alone

accounted for 25% of all deaths. Chronic

respiratory diseases (CRDs), cancers and

diabetes accounted for 9.6%, 7.8% and 2.1% of

all deaths, respectively (1) (Figure 2.1). Other

NCDs, such as kidney and liver diseases,

accounted for most of the remaining NCD

burden. In nine of the 11 SEAR Member

countries, the estimated percentage of NCD

deaths out of the total deaths already exceed

50%, with the highest percentage in Maldives(79%) followed by Thailand (71%) and Sri Lanka

(66%). At present, Timor-Leste and Myanmar

are the only two countries in this Region where

NCDs cause less than 50% deaths (1) (Figure

2.2). In terms of absolute numbers, India and

Indonesia together account for 80% of NCD

deaths in SEAR (Annex 1), owing to their large

population size.

NCDs are reported to be the commonestcauses of deaths in most countries in the

Region. According to a special survey of deaths

in India (2), NCDs were common both in urban

and rural areas. In urban areas of India, CVDs,

cancers and chronic obstructive pulmonary

disease (COPD), ranked first, second and fourth

respectively, claiming 33%, 11% and 7.7% of the

top 10 causes of deaths. In rural areas, CVDs,

COPD and cancers ranked first, second and

fourth, claiming 23%, 11% and 9% of the top 10

causes of deaths. In Sri Lanka, mortality reports

from hospital-based data showed that 86% of

deaths were caused due to NCDs (3). According

to the Thailand health profile 20052007, just

16% deaths were due to infectious diseases, 12%

were due to external causes of injuries and 35%due to diseases of the circulatory system

(including stroke) and cancers (4).

NCDs are causing deaths among younger

age groups in this Region compared to most

other parts of the world. Of the 7.9 million

annual NCD deaths in SEAR, 34% occurred

before the age of 60 years compared to 23% in

the rest of the world (Figure 2.3), and nearly

twice as much as in the European Region (16%)(1). In age groups 4559 years and 6069 years,

2011

10

Fig 2.1: Estimated percentage of deaths by cause, South-East Asia Region, 2008

Source: Global Health Observatory. World Health Organization 2011.Note: percentages do not add up to 100% due to rounding off.

NCDs are theleading cause

of death inthe Region

8/2/2019 sde_rep-2011-dec

19/104

India

InjuriesNoncommunicable

diseases

Percent

0

20

40

60

80

100

Communicable diseases/

maternal conditions/

nutritional deficiencies

Timor

-Leste

Myan

mar

Indon

esia

Nepa

l

Bang

lades

h

Bhut

anDP

RK

SriLank

a

Thail

and

Maldi

ves

Fig 2.2: Estimated percentage of deaths, by cause, Member countries of the South-East AsiaRegion, 2008

Source: Global Health Observatory. World Health Organization 2011.

NCD deaths account for a massive 70% and

76%, respectively of all deaths (1). This high

NCD mortality among the economically

productive age group is premature and largely

preventable.

2011

Similar observations were noted for all

major NCDs and occur in almost all countries

of SEAR (Figure 2.3). The proportion of

premature deaths among those below 60 years

of age in SEAR was the highest in Bangladesh

11

NCDs accountfor more than

half of all deathsin most SEAR

countries

All NCDs

South-East Asia Region

Percent

Rest of the world

Cancer Diabetes Cardiovascular

diseases

Chronic

respiratory

diseases

0

10

20

30

40

50

Fig 2.3: Estimated percentage of premature deaths (under 60 years of age), by cause,South-East Asia Region vs rest of the world, 2008


SEAR has ahigher

proportion ofpremature NCDdeaths than the

rest of the world

8/2/2019 sde_rep-2011-dec

20/104

Fig 2.4: Age-standardized mortality rates per 100 000 population by sex, South-East AsiaRegion, 2008

All NCDs

Male

Age-standardized

death

ratesper100

000 Female

Cancer DiabetesCardiovascular

diseases

Chronic

respiratory

diseases

0

100

200

300

400

500

600

700

800


2011

nutritional conditions would decrease to nearly

one third from 37% to 14% by 2030 (Figure 2.5)

(5). According to the same projections, increase

in NCD deaths among males and females would

be 22% and 25%, respectively, in just 11 years

from 2004 to 2015 (5).

National surveys from SEAR countries

also observed a steep increase in the proportion

of NCDs deaths. In Indonesia, the proportion of

NCD deaths increased from 42% in 1995 to 60%

in 2007 (6) (Figure 2.6). In Sri Lanka, during

the past half-century, the proportion of deaths

due to circulatory diseases increased from 3%

to 24% while those due to communicable

diseases decreased from 24% to 12% (7).

Similar trends have been observed in NCD-

related morbidities. The trend in hospitalization

of selected diseases in Sri Lanka showed a steady

increase in major NCD cases during 19702008,

and a reduction in hospitalizations due to

infectious diseases (Figure 2.7). A remarkable

increase in hospitalizations for the major NCDs

during the past two decades has also been

documented in Thailand (Figure 2.8).

12

38% of deaths were due to NCDs (1). High

premature mortality was noted particularly for

cancer deaths 48% of cancer deaths in the

Region occurred in those below 60 years of age

(Figure 2.3).

NCD death rates vary greatly among SEAR

Member countries (Annex 2). In 2008, Bhutan

had the highest age-standardized death rates per

100 000 population for NCDs among both males

and females (801 in males and 667 in females)

(1). Age-standardized NCD death rates were

higher among males than females for all major

NCDs, except for diabetes where males and

females had similar death rates (Figure 2.4).

Trends in NCD Mortality andMorbidity

Based on projections made in 2004, NCD

deaths in the Region are likely to increase by

nearly 60%, from 7.9 million to 12.5 million by

2030 (5). At the same time, the percentage of

total deaths due to communicable diseases,maternal and perinatal conditions as well as

NCD mortalityrates are

higher in malesthan females

8/2/2019 sde_rep-2011-dec

21/104

Communicable

diseases/maternal

and perinatal conditions/

nutritional deficiencies

2004

Percent

2030

NCDs Injuries

0

10

20

30

40

50

60

70

80

Fig 2.5: Trends in estimated percentage of deaths by cause of death, South-East AsiaRegion, 2004 and 2030

Maternal and

perinatal condition

HHS 1995

Percent

HHS 2001

Communicable

diseaseNoncommunicable

diseaseInjury

0

10

20

30

40

50

60

70

BHR 2007

Fig 2.6: Trends in percentage of deaths by cause, Indonesia, 1995-2007

Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine 2006, 3(11):e442.

HHS: household survey; BHR: basic health researchSource: Ministry of Health, Indonesia, Country Report, March 2011

Disease-Specific Burden andTrends

CVDs, cancers, diabetes and CRDs are the

four major NCDs that contribute to more than

80% of NCD deaths in this Region. Significant

differentials exist across Member countries in

the burden of these diseases.

2011

13

Bhutan saw a 31% increase in alcohol-

related diseases (from 1217 in 2005 to 1602

cases in 2009); a 20% increase in circulatory

system-related diseases (from 21 345 in 2005 to

26 937 cases in 2009); and an alarming 63%

increase in diabetes (from 944 in 2005 to 2605

in 2009) (8).

NCD deaths areprojected to

increase in thecoming years

Increasingtrend in NCD

deaths in

Indonesia

8/2/2019 sde_rep-2011-dec

22/104

Intestinal infectious diseases

Casesper100

000

MalariaHypertensive diseases

0

200

400

600

800

1000

1200

Ishaemic heart diseasesDiabetes mellitus

200708

200406

200103

199800

199597

199294

198991

198688

198385

198082

1997-79

197476

197173

Fig 2.7: Trends in hospitalization rates per 100 000 population, by selected diseases,Sri Lanka, 19712008

Diabetes

Cases

per100

000

Heart diseases

Cancer

0

100

200

300

400

500

600

700

2005

2003

2001

1999

1997

1995

1993

1991

1989

1987

1985

Fig 2.8: Trends in hospitalization rates per 100 000 population, by selected diseases,Thailand, 19852006

Source: NCD Profile, Ministry of Health, Sri Lanka, 2010

Source: Thai Health Profile, 2005-2007

2011

Of the 7.9 million deaths attributed to

NCDs in SEAR in 2008, 3.6 million (45%) were

due to CVDs (1). The proportion of deaths due to

CVDs was the lowest in Maldives (34%) and

highest in Bhutan (53%). In India, CVDs are the

leading cause of death in both males and

females and in urban as well as rural areas (2).

14

Cardiovascular diseases

CVDs are a group of large number of

conditions relating to the heart and blood

vessels. The major CVDs include hypertensive

heart disease, ischaemic heart disease,

rheumatic heart disease and cerebrovascular

disease or stroke.

Consistentincrease in

hospitalizationdue to NCDs

and reduction

in infectiousdiseases

Significantincrease in

hospitalizationdue to NCDs in

Thailand

8/2/2019 sde_rep-2011-dec

23/104

Cerebrovascular diseases

Other cardiovascular diseases

Percen

t

0

5

10

15

20

25

30

35

Hypertensive heart disease

Ischaemic heart disease

DPRK

Indones

ia

Sri

Lan

ka

Bhu

tan

Bang

lades

h

Tha

ilan

d

Ma

ldives

Nepa

l

India

Myanmar

Timor-

Les

te

Fig 2.9: Percentage of deaths due to CVDs*, by type of CVD, South-East Asia Region, 2008

* CVDs = cardiovascular diseasesSource: Global Health Observatory. World Health Organization 2011. http://apps.who.int/ghodata/?region=searo (accessed on 13 May 2011).

related death rate increased from 7% to 18%

during the same period (11). In India, the

number of new cases of CVDs is projected to

increase to 64 million in 2015 (from 29 million

in 2000) (12); and stroke cases to increase to an

estimated 1.7 million in 2015 (from 1.1 million in2000) (12).

Cancers

Cancers are predicted to become an

increasingly important cause of morbidity and

mortality in the next few decades, all over the

world (13).

In SEAR, 1.1 million people died of cancers

in 2008 (14). Of the 569 000 cancer deaths in

males, the commonest sites of cancers were the

lungs (17%, including trachea and bronchus),

followed by mouth and oropharynx (15%), and

liver (7.5%) (14). Among women, cervical and

breast cancers accounted for 35% of all cancer

deaths (14). The estimated percentage of cancer

deaths varied from 6.4% in India to 13% in DPR

Korea and Indonesia (1).

2011

15

Types of CVDs vary among countries

(Figure 2.9). The commonest CVDs in the

Region are ischaemic heart disease, stroke and

hypertensive heart disease. Ischaemic heart

disease is the commonest cause of CVD deaths

in all countries except Thailand where deathsdue to cerebrovascular disease (stroke) exceeds

deaths due to ischaemic heart disease.

CVDs affect younger age-goups in SEAR

than in their counterparts in western countries.

For example, CVD mortality in India in the 30

59 years age-group is twice than that in the US

(9). Nearly 52% of CVD deaths in India occur

below the age of 70 years compared with 23%

in established market economies (10).

The trends for CVDs in the Region are of

concern. For example, in Bangladesh, CVDs

were the main cause of death in 2008 27% of

all deaths and are projected to rise to 37% by

2030 (5). DPR Korea reported stroke-related

death rate increase from 3.8% to 25% during a

30-year period (19601991) and heart-disease-

Ischaemic heartdisease is the

commonest typeof CVD death in

most SEARcountries

8/2/2019 sde_rep-2011-dec

24/104

MALESFEMALES

0 10 20 30102030

Lung

Breast

Cervix uteri

Lip/oral cavity

Oesophagus

Stomach

Colorectum

Liver

Non-Hodgkin lymph

Larynx

Ovary

BladderBrain/Nervous

Leukaemia

Thyroid

Hodgkins lymphoma

Kidney

Prostate

Corpus uteri

Testis

Gallbladder

Pancreas

Incidence/100 000 population

Fig 2.10: Incidence of selected cancers per 100 000 population, by sex, South-East AsiaRegion, 2008

Source: GLOBOCAN 2008. International Agency for Research on Cancer and World Health Organization

2011

in the Region. Figure 2.10 shows that among

males, lung cancers are most common followed

by oral cancer, while among females, breast and

cervix uteri cancers have the highest incidence.

There are differences in the incidence ofvarious cancers among Member countries.

Among women, the incidence of cervical cancer

exceeded that of other cancers in Bangladesh,

Bhutan, India and Nepal, whereas in

DPR Korea, Indonesia, Myanmar, Sri Lanka

and Thailand, breast cancer ranked first. Among

men, the incidence of lung cancer was higher

than that of other cancers in all Member

countries except Thailand, where the incidence

of liver cancer was the highest (14).

Data for the period 19842004 from five

urban and one rural cancer registry in India

16

Based on country reported data, of the

150 000 cancer-related deaths occurring

annually in Bangladesh, more than one half die

within five years of diagnosis (15). In India,

cancers caused a larger percentage of deaths

among females than males in both urban and

rural areas during 20012003 (2).

A large proportion of cancer deaths occur

in the economically productive age group. Fifty-

two per cent of cancer deaths among women and

45% of cancer deaths among men occur below

the age of 60 years (1). In a five-city study in

India, nearly 50% of cancer mortality was

reported among those below 55 years of age (16).

In addition to high mortality, SEAR has

high cancer-related morbidity. An estimated

1.7 million new cases of cancer occur each year

Lung and oralcancer in malesand breast and

cervical cancer infemales are most

common

8/2/2019 sde_rep-2011-dec

25/104

Based on results of the STEPS surveys, the

highest prevalence of diabetes was in Bhutan

(12% in males and 13% in females) and the

lowest in Indonesia and Myanmar (6%7% in

both sexes) (Figure 2.11). There are an

estimated 81 million people living with diabetes

in the Region. According to the International

Diabetes Federation, estimates were slightly

lower ranging from 7.0% in the 2079 years age

group in 2010 to a projected rise to 8.4% in

2030 (19). Diabetes prevalence was consistently

higher among the urban population than those

residing in rural areas. In Bangladesh, diabetes

prevalence in urban areas was twice as much as

that in rural areas (8% vs. 4%); in Nepaldiabetes prevalence was 3% in rural areas and

15% in urban areas (10); in Sri Lanka, diabetes

prevalence in urban areas was 16.4% while that

in rural areas was 8.7% in 200506 (20).

Late diagnosis of diabetes is a major

problem in the Region. A Nepal study found

high diabetes prevalence among the elderly, the

majority of whom were previously undiagnosed

(21). In Sri Lanka, one third of those withdiabetes were undiagnosed (20). In a national

sample of 24 417 persons over 15 years of age in

urban Indonesia, undiagnosed diabetes mellitus

was present in 4.2% and impaired glucose

tolerance (IGT) was present in 10.2%. IGT

prevalence was 5.3% in the youngest age group

(1524 years) (22).

An increasing trend in diabetes prevalence

has been reported from several countries. InBangladesh, prevalence increased threefold,

from 2.3% in the 1999 to 6.8% in 2004 (23).

Age-standardized diabetes prevalence in a rural

area in Sri Lanka increased from 2.5% in 1990

to 8.5% in 2000 (24). In India, diabetes

prevalence in urban areas increased tenfold

from 1.2% to 12.1% during 19712000 (25,26)

while that in rural areas trebled from 2.2% to

6.4% in just 14 years during 19892003 (27).

2011

17

indicated that, cancers of the prostate, colon,

rectum and liver increased significantly among

males, while cancers of the breast, corpus uteri

and lung increased among females (17).

Trends in cancer incidence from sevenmajor hospitals in Nepal revealed that among

women breast cancers were common during

younger age, cervical cancers were common

during middle age and lung cancers during old

age. In males, leukaemias and lymphomas

occurred more often during youth, lung and

stomach cancers occurred during middle age,

and cancers of the lung, stomach and larynx

were common in old age (18).

The present trend suggests that cancer

incidence is increasing in most Member countries

of the Region. The majority of cases of all cancer

types present at a late stage of the disease and

with complications, which imposes a heavy

burden on the family and health-care system.

Diabetes mellitus

Diabetes is defined as having a fastingplasma glucose value 7 mmol/l (126 mg/dl) or

being on medication for raised blood glucose.

Uncontrolled diabetes increases risk of CVD and

can lead to retinopathy, nephropathy and

gangrene, among other conditions (13).

Diabetes is growing significantly in SEAR

countries, placing enormous restrictions on

those who suffer this lifelong disease. An

estimated 305 000 deaths were attributed todiabetes alone in 2008; the number of deaths

were slightly more among males than females

(1). Diabetes specific death rates vary

enormously across countries in SEAR from 56

per 100 000 population in Thailand to 5.8 per

100 000 in the Maldives (1). DPR Korea,

Indonesia and Thailand showed substantially

higher deaths attributed to diabetes among

females than males (Annex 1; 1).

8/2/2019 sde_rep-2011-dec

26/104

Male

Percent

Female

0

2

4

6

8

10

12

14

Ind

onesia

Sri

Lanka

B

hutan

Bangladesh

Th

ailand

Ma

ldives

Nepal

India

My

anmar

Fig 2.11: Percentage of adult population with raised blood glucose level*, South-East AsiaRegion, 2008

* Fasting glucose >7.0 mmol/L or on medication for diabetes

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011Note: Data adjusted for 2008 for comparability

2011

Timor-Leste to 11% in India). Age-standardizeddeath rates of CRDs were lowest in DPR Korea

(60 per 100 000 population) and highest in

India (154 per 100 000 population) (1).

According to national reports from

Thailand, asthma prevalence was estimated at

4 million cases affecting 6.8% of the adult

population (29). Nation-wide asthma

prevalence in Indonesia was reported to be 4%

in 2007 (30). For 2011, the projected prevalencerate of chronic asthma in India in the age group

1559 years is 19 per 1000 population in urban

areas and 26 per 1000 in rural areas; and the

total number of chronic asthma cases is nearly

32 million (31).

Statistics on CRDs in SEAR are generally

limited. Consequently, the true burden of CRDs

is not appreciated. Intensive efforts are required

to generate robust data on CRDs.

18

According to the national Thailand healthsurvey, mean fasting blood sugar among those

aged 3559 years increased from 87 mg/dl in

1991 to 92 mg/dl in 1996, to 100 mg/dl in 2004

(4,28).

Chronic Respiratory Diseases

Chronic respiratory diseases narrow air

passages of the lungs and obstruct breathing,

thereby severely affecting quality of life. Major

chronic respiratory diseases include COPD,

asthma and occupational lung disease. These

diseases can affect all age groups and are not

predominant in old age unlike many other

NCDs. Most CRDs are preventable and curable.

Yet, an estimated 1.4 million people died of

CRDs in SEAR in 2008; of these, 86% deaths

were due to COPD and 7.8% due to asthma (1).

In the Region, CRDs accounted for an

estimated 9.6% of all deaths in 2008 (3.6% in

Nearly one in10 adults in the

Region hasraised blood

glucose

8/2/2019 sde_rep-2011-dec

27/104

disease and 0.15% of stage-V chronic kidney

disease (35).

The most common liver diseases are

hepatitis, cirrhosis and carcinomas. Cirrhosis

can affect all age groups but is more commonlyseen among men aged 4569 years. The

problem is particularly severe in SEAR with

about 284 000 cirrhosis deaths constituting

nearly 30% of global deaths (1). Hepatitis B

virus and Hepatitis C virus are significant

contributors to liver disease in this Region.

Maldives has the highest prevalence of

thalassaemia in the world with a carrier rate of

18% (36). The average frequency of -thalassaemia in India is 3%4% although it

greatly varies across the country (37). In

Indonesia, the carrier frequency of thalassemia

in some areas was 6%10% (38). Bangladesh

has a 7% thalassemia carrier rate which equals

more than 10 million people; and 7000 babies

are born each year with thalassemia (39). These

data suggest that screening and genetic

counseling for haemoglobinopathies should be

integrated into the health care system in

Member countries of SEAR so as to avert

exhorbitant treatment costs as well as human

suffering.

2011

19

Other NCDs

Besides the major NCDs, many other

chronic conditions and diseases contribute

significantly to the burden of disease on

individuals and families. Particularly significantin the Region are chronic kidney disease,

chronic liver disease and thalassaemia.

Chronic kidney disease is a slow

progressing disease and usually takes many

years to manifest clinically. This also is an

under-diagnosed disease resulting in lost

opportunities for prevention. A significant

number of people are affected by chronic kidney

disease in the Region. In a Bangladesh slum(n=1000) 16% had chronic kidney disease (32).

In a large cross-sectional study (n=3398), of the

apparently healthy Indian central government

employees 18 years, nearly 15% were in early

stages of chronic kidney disease (33). Data

obtained from various nephrology centres in

Indonesia showed that incidence and

prevalence of end-stage renal disease in Java

and Bali are increasing over time (34). In

Thailand, a nationally representative sample (of

3117 people aged 15 years) showed 8.1%

prevalence of stage-III chronic kidney disease

in 2004, 0.2% of stage-IV chronic kidney

REFERENCES

1. Global Health Observatory. World Health Organization 2011. http://apps.who.int/ghodata/?region=searo (accessed

on 13 May 2011).

2. Summary - report on causes of death: 2001-03 in India. Office of Registrar General, Government of India.

http://censusindia.gov.in/Vital_Statistics/Summary_Report_Death_01_03.pdf (accessed on 21 September 2011)

3. Sri Lanka health at a glance. Medical Statistics Unit. Ministry of Healthcare and Nutrition, Colombo, Vol 1, 2008.

4. Thailand health profile 20052007. Bureau of Policy and Strategy, Ministry of Public Health. Ministry of Public Health:

2008. http://www.moph.go.th/ops/thp/index.php?option=com_content&task=view&id=6&Itemid=2&lang=en

(accessed on 21 September 2011).

8/2/2019 sde_rep-2011-dec

28/104

2011

20

5. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS

Medicine 2006, 3(11):e442.

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0030442 (accessed on 21

September 2011).

6. Country report to the Regional Meeting on Health and Development Challenges of Noncommunicable

Diseases in the South-East Asia Region, Jakarta, Indonesia. Ministry of Health, Indonesia. March 2011

7. Country report to the Regional Meeting on Health and Development Challenges of NoncommunicableDiseases in the South-East Asia Region, Jakarta, Indonesia. Ministry of Health, Sri Lanka. March 2011

8. Country report to the Regional Meeting on Health and Development Challenges of Noncommunicable

Diseases in the South-East Asia Region, Jakarta, Indonesia. Ministry of Health, Bhutan. March 2011

9. Joshi R et al. Global inequalities in access to cardiovascular care: Our greatest challenge. Journal of the

American College of Cardiology2008;52:181725.

10. Ghaffar A et al. Burden of non-communicable diseases in South Asia. British Medical Journal 2004;328:807

10. http://www.bmj.com/content/328/7443/807.full.pdf (accessed on 21 September 2011).

11. Country Report, Ministry of Health, DPR Korea. March 2011

12. Indrayan A. Forecasting vascular disease cases and associated mortality in India. Background papers: Burden

of disease in India. New Delhi: National Commission on Macroeconomics and Health, 2005:198215.

13. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.

http://www.who.int/nmh/publications/ncd_report2010/en/ (accessed on 21 September 2011).

14. GLOBOCAN 2008. International Agency for Research on Cancer and World Health Organization

http://globocan.iarc.fr/ (accessed on 21 September 2011).

15. National cancer control strategy and plan of action 2009-2015. Bangladesh, Ministry of Health and Family

Welfare, 2008. http://www.whoban.org/LinkFiles/Publication_Cancer_Strategy.pdf.pdf (accessed on 21

September 2011).

16. Marimuthu P. Projection of cancer incidence in five cities and cancer mortality in India. Indian Journal of

Cancer2008;45:47.

17. India National Council of Medical Research. IMCR Bulletin, Vol 40, No. 2, February 2010.

http://www.icmr.nic.in/bulletin/english/2010/ICMR%20Bulletin%20February%202010.pdf (accessed on 9 July

2011).

18. Pradhananga KK et al. Multi-institution hospital-based cancer incidence data for Nepal: an initial report.

Asian Pacific Journal of Cancer Prevention 2009;10:25962. http://www.ncbi.nlm.nih.gov/pubmed/19537894(accessed on 21 September 2011).

19. International Diabetes Federation. http://www.idf.org/ (accessed on 21 September 2011).

20. Katulanda P et al. Prevalence and projection of diabetes and pre-diabetes in adults in Sri Lanka Sri Lanka

Diabetes, Cardiovascular Study (SLDCS). Diabetes Medicine 2008;25:10629.

http://www.ncbi.nlm.nih.gov/pubmed/19183311 (accessed on 21 September 2011).

21. Chhetri MR, Chopman RS. Prevalence and determinants of diabetes among the elderly population in the

Kathmandu valley of Nepal. Nepal Medical College Journal 2009;11:348.

http://www.ncbi.nlm.nih.gov/pubmed/19769235 (accessed on 21 September 2011).

22. Mihardja L et al. Prevalence and determinants of diabetes mellitus and impaired glucose tolerance in

Indonesia (a part of basic health research/Riskesdas). Acta Medica Indonesia 2009;41:169-74.

http://www.inaactamedica.org/archives/2009/20124611.pdf (accessed on 21 September 2011).

23. Rahim MA et al. Rising prevalence of type 2 diabetes in rural Bangladesh: A population based study. DiabetesResearch and Clinical Practice 2007;77:3005.

24. Illangasekera U et al. Temporal trends in the prevalence of diabetes mellitus in a rural community in Sri

Lanka. Journal of the Royal Society for the Promotion of Health 2004;24:92.

25. Ramachandran A. Epidemiology of diabetes in Indiathree decades of research [review]. Journal of the

Association of Physicians India 2005;53:348.

26. Pradeepa R, Mohan V. The changing scenario of the diabetes epidemic: implications for India [review]. Indian

Journal of Medical Research 2002;116:12132.

27. Ramachandran A et al. Temporal changes in prevalence of diabetes and impaired glucose tolerance

associated with lifestyle transition occurring in the rural population in India. Diabetologia 2004;47:8605.

Epub 2004 Apr 28.

8/2/2019 sde_rep-2011-dec

29/104

2011

21

28. Porapakkham Y et al. Prevalence, awareness, treatment and control of hypertension and diabetes mellitus among

the elderly: The 2004 National Health Examination Survey III, Thailand. Singapore Medical Journal 2008;49:86873.

29. Liwsrisakun CC, Pothirat C. Actual implementation of the Thai Asthma Guideline. Journal of the Medical Association

of Thailand 2005;88:898-902.

30. Report on Result of National Basic Health Research (RISKESDAS) 2007. The National Institute of Health Research

and Development, Republic of Indonesia, 2008.

http://www.litbang.depkes.go.id/ccount/?http://www.litbang.depkes.go.id/LaporanRKD/Indonesia/Riskesdas_2007_English.zip / (accessed on 21 September 2011).

31. Murthy KJR, Sastry JG. Economic burden of asthma. Burden of Diseases in India. Background papers: National

Commission on Macroeconomics and Health. New Delhi: WHO India, 2005

http://www.whoindia.org/LinkFiles/Commision_on_Macroeconomic_and_Health_Bg_P2_Economic_burden_of_asth

ma.pdf (accessed on 21 September 2011).

32. Rahman MM et al. Detection of chronic kidney disease (CKD) in adult disadvantageous population in Bangladesh.

Chronic Kidney Disease 2006, MP281, iv393. http://ndt.oxfordjournals.org/cgi/reprint/21/suppl_4/iv390.pdf

(accessed on 21 September 2011).

33. Varma PP et al. Prevalence of early stages of chronic kidney disease in apparently healthy central government

employees in India. Nephrology Dialysis Transplantation 2010;9: 3011-7; Epub 2010 Mar 15.

34. Prodjosudjadi W. Incidence, prevalence, treatment and cost of end-stage renal disease in Indonesia. Ethnicity &

Disease 2006;16 (Suppl 2):S2-14-16. http://www.ncbi.nlm.nih.gov/pubmed/16774003 (accessed on 22 September2011).

35. Ong-ajyooth L et al. Prevalence of chronic kidney disease in Thai adults: a national health survey. BMC Nephrology

2009;10:35. http://www.biomedcentral.com/content/pdf/1471-2369-10-35.pdf (accessed on 22 September 2011).

36. Maldives. New Delhi: United Nations Office on Drugs and Crime, 2005.

http://www.unodc.org/pdf/india/publications/south_Asia_Regional_Profile_Sept_2005/11_maldives.pdf (accessed

on 22 September 2011).

37. Colah R et al. Epidemiology of beta-thalassaemia in Western India: mapping the frequencies and mutations in sub-

regions of Maharashtra and Gujarat. British Journal of Haematology 2010;149:739-47.

38. Timan IS et al. Some hematological problems in Indonesia. International Journal of Hematology2002;76 (Suppl

1):286-90.

39. Bangladesh Thalassemia Foundation. http://www.thals.org/ (accessed on 22 September 2011).

40. The world health report 2006. Geneva: World Health Organization, 2006. www.who.int/whr/2006/en/ (accessed on22 September 2011).

8/2/2019 sde_rep-2011-dec

30/104

8/2/2019 sde_rep-2011-dec

31/104

Risk Factors

I Four behavioural risk factors (tobacco use, unhealthy diet, physical

inactivity and harmful use of alcohol) are largely responsible for

majority of the NCDs.

I Behavioural risk factors lead to four key metabolic changes:

overweight/obesity; raised blood pressure; raised blood glucose; and

raised blood cholesterol.

I Behavioural and metabolic risk factors are highly prevalent in the

Region and on the rise.

I Hypertension, raised blood glucose and tobacco use are the top three

risk factors responsible for 3.5 million deaths in the Region every

year.

followed by raised blood glucose (6.8%),

tobacco use (6.8%), physical inactivity (5.1%)

and raised cholesterol (4.9%) (1) (Figure 3.2).

High blood pressure, tobacco use and high

blood sugar together account for approximately

3.5 million deaths each year in the Region.

This chapter provides evidence that NCD

risk factors are widely prevalent in this Region.

Data on risk factors are generated from WHO-

STEPS surveys (2) and reported as age

standardized rates in WHOs Global status

report on noncommunicable diseases 2010 (3).

2011

23

The four major NCDs namely CVDs,

diabetes, cancers and CRDs share four

common behavioural risk factors that account

for the majority of NCD deaths (Figure 3.1) (1).

These modifiable behavioural risk factors are

tobacco use, unhealthy diets, physical inactivity

and harmful use of alcohol. These behaviours in

turn lead to four key metabolic changes:

overweight/obesity, raised blood pressure,

raised blood sugar and raised blood cholesterol

(hyper-lipidaemia). The highest number of

deaths in SEAR are attributed to raised blood

pressure accounting for 9.4% of all deaths,

8/2/2019 sde_rep-2011-dec

32/104

Num

berofattributabledeaths(000s)

0

500

1000

1500

2000

Overweight

andobesity

Harmfuluse

ofalcohol

Suboptimal

breastfeeding

Low

fruitand

vegetableintake

Unsafewater,

sanitation,

hygiene

Indoorsmoke

from

solidfuels

Highcholesterol

Physicalactivity

Tobaccouse

Highbloodglucose

Highbloodpressure

Childhoodand

maternalunderweight

Risk factors

Behavioural Risk Factors

Tobacco use

Tobacco use is the single-most preventable

cause of death in the world today. Tobacco is the

only legal consumer product that kills up to half

of those who use it (4). Tobacco use causes a

wide range of diseases that impact nearly every

organ of the body. Second-hand smoke also has

serious and often fatal health consequences; it

has many different chemicals, 50 of which are

known to be associated with cancer (5).

Tobacco use is a serious public health

concern in the Region where about 1 million

2011

24

Tobacco Unhealthy Physical Harmful useuse diet inactivity of alcohol

Cardiovascular

diseasesDiabates (Type II)

Cancers

Chronicrespiratory diseasesN

oncommunicabledisea

ses

Fig 3.1: Shared risk factors for major noncommunicable diseases

Fig 3.2: Estimated number of attributable deaths by risk factor, South-East AsiaRegion, 2004

Source: Global health risks: mortality and burden of diseases attributable to selected major risks.Geneva: World Health Organization, 2009.

4 modifiableshared risk

factors cause4 major NCDs

which accountfor 80% of allNCD deaths

Hypertension,high blood

glucose andtobacco use are

top three riskfactors for death

8/2/2019 sde_rep-2011-dec

33/104

tobacco-related deaths occur every year (1). It is

estimated that by 2030 tobacco use will account

for more deaths than total deaths from malaria,

maternal conditions and injuries combined (6).

Tobacco-related illnesses, such as cancers as

well as cardiovascular and respiratory diseases

are already major problems in most Member

countries of the Region. Four countries of SEAR

Bangladesh, India, Indonesia and Thailand

are among the top 20 tobacco-producing

countries in the world (7). The Region also has

some of the highest tobacco consuming

countries in the world India and Indonesia

are among the top ten tobacco consuming

countries in the world (8).

Types of tobacco products consumed

in the Region

Both smoking and smokeless types of

tobacco products are used in the Region. The

poorer sections of the population in this Region

smoke low-cost indigenous products, such as

bidis (Bangladesh, India, Nepal and Sri Lanka),

cheroots (Myanmar) and roll-your-own

cigarettes (Thailand). Manufactured cigarettesare the preferred choice of the upper class in the

Region. Clove cigarettes called kreteks are

popular in Indonesia. Other forms of smoking

products used in Region are dhumti, chuttas,

chillums, hookah, pipes and cigars (8).

Smokeless tobacco products are used in

various ways chewing, sucking and applying

tobacco preparations to the teeth and gums. The

commonly used smokeless form of tobacco inthe Region is tobacco with betel quid (known as

paan in India, Bangladesh and Nepal; kwanya

in Myanmar and sirih in Indonesia). Tobacco

and lime mixture (known as khainior surtiin

India and khoinee in Bangladesh) is another

common tobacco product that is either

manufactured or prepared by the users

themselves. Gutkha, a manufactured tobacco

mixed with betel nut and other additives, is

popular among youth in India and gutkha

2011

consumption is now prevalent throughout the

Region. The misconception about tobacco being

good for oral health, has been used as an

advantage by the tobacco industry, which has

produced tobacco products, such as dentifrice,

most common in India and Bangladesh in

different forms such as gul, gudaku, bajjar,

tapkir, lal dantmanjan.

The use of smokeless tobacco products

among children, youth and women has

increased in recent times in the Region, mainly

because of lack of adequate knowledge about

the addictive and harmful effects of smokeless

tobacco. Additionally, aggressive marketing by

the tobacco industry, easy accessibility to and

lower prices of smokeless tobacco products have

contributed to their widespread use in the

Region (8).

Tobacco use among adults

The prevalence of tobacco use varies

significantly across the Member countries of the

Region. Smoking is higher among men while

women usually take to chewing tobacco. Theprevalence of current use of any smoked

tobacco ranges from 26% (India) to 61%

(Indonesia) in males and from less than 1% (Sri

Lanka) to 29% (Nepal) among females. The

prevalence of daily cigarette smoking among

males ranges from 7% (India) to 53% (DPR

Korea). The prevalence of smokeless tobacco

product use among males ranges from 1.3%

(Thailand) to 51.4% (Myanmar); in females

prevalence of smokeless tobacco product use

ranges from 4.6% (Nepal) to 27.9%

(Bangladesh) (Table 3.1). Overall, tobacco use

among males is higher than among their female

counterparts in all Member countries of the

Region.

Tobacco use among students aged 1315

years

The findings of the Global Youth Tobacco

Survey (GYTS) reveal a high prevalence of

25

8/2/2019 sde_rep-2011-dec

34/104

8/2/2019 sde_rep-2011-dec

35/104

Boys

Percent

Girls

0

10

20

30

40

50

60

2007

Myanmar

2207

SriLanka

2009

Indonesia

2006

Timor-Leste

2007

B

angladesh

2009

Thailand

2007

Nepal

2009

Bhutan

2006

India

2007

Maldives

Country and year of survey

Fig 3.3: Prevalence of current tobacco use among students aged 1315 years by sex, South-East Asia Region, 20062009

Source: Global Youth Tobacco Surveys in Member countries of South-East Asia Region

1995

Boys

Percent

Girls

2001 20040

5

10

15

20

25

30

35

40

Both sexes

Fig 3.4: Prevalence of smoking among students aged 1519 years, by sex, Indonesia,19952004

Sources: National Socio-Economic Survey 1995, 2001, 2004. Ministry of Health Indonesia

schooling (68% in males; 33% in females) and

lowest prevalence among those who had

secondary education and above (31% in males;

3.6% in females) (Figure 3.6) (13). Similarly,

2011

27

lowest among those who had secondary

education and above (10%). India GATS (2009)

revealed the highest prevalence of current use

of any tobacco among those who had no formal

Variable, buthigh tobacco

use among

youth in theRegion

Smoking amongIndonesian boys

has more than

doubled over adecade

8/2/2019 sde_rep-2011-dec

36/104

Boys

2001

Percent

2007

Girls Girls0

5

10

15

20

25

Boys

Current cigarette smoker Current user of other

tobacco products

Fig 3.5: Prevalence of current tobacco use among students aged 13-15 years, by sex,Myanmar, 2001 and 2007

Source: Global Youth Tobacco Survey 2001 and 2007, Myanmar

No formal

schooling

Male

Percent

Female

Less than

primary

Secondary

and above

0

10

20

30

40

50

60

70

80

Primary but

less than

secondary

Education

Fig 3.6: Percentage of adults, who are current users of tobacco products, by education,India, 2009

Source: India Global Adult Tobacco Survey 2009

2011

than in those who had university level education

(14%) (14). In Sri Lanka, least-educated males

were twice as likely to smoke as most-educated

males (15). In Indonesia, smoking prevalence

among men who had not completed elementary

28

Thailand GATS (2009) revealed a higher

prevalence of current use of any smoked

tobacco product among those who had less than

primary (24%) and primary (29%) education

The lesseducated aremore likely to

use tobacco

Reduction incigarette

smoking butincrease in use

of other tobacco

products

8/2/2019 sde_rep-2011-dec

37/104

school was 72% compared with 50% among

men who had completed a bachelors degree

(16).

Tobacco consumption and place of

residence

Bangladesh GATS (2009) revealed that a

much higher percentage of people in rural areas

(14%) smoke bidis than those in urban areas

(4.7%) while the prevalence of cigarette

smoking was higher in urban areas (18%) than

in rural areas (13%) (12). Another study from

Bangladesh revealed that 60% men living in

slums smoked compared with 46% men living

in non-slum areas (17). In India, the prevalence

of current tobacco use (smoking and smokeless)

is greater in rural areas (38%) than in urban

areas (25%). Similarly, the prevalence of current

smokeless tobacco use is much higher in rural

areas (23%) than urban areas (14%) (13). As per

Thailand GATS (2009), the prevalence of any

smoked tobacco product among the rural

population was slightly higher than that for the

urban population (25% and 22%) (14). The type

of smoked tobacco products used also differed

between urban and rural smokers; the results

showed a higher prevalence of manufactured

cigarettes use in urban areas than in rural areas

(18% and 14%, respectively) and a higher

prevalence of hand-rolled cigarettes use in rural

areas as against urban areas (18% and 6%

respectively) (14).

Tobacco consumption and poverty

As per Bangladesh GATS (2009), the

prevalence of current use of any smoked

tobacco product and any smokeless tobacco

product decreased with increasing wealth index,

with the highest prevalence in the lowest wealthindex (29% and 36%, respectively) and lowest

prevalence in the highest wealth index (14% and

17%, respectively) (Figure 3.7) (12). Studies

from other sources also revealed consistent

results. Tobacco consumption is now

universally more common among lower

socioeconomic groups (18). In a survey of 471

143 persons of age >10 years in India in the year

19951996, people below the poverty line had

Lowest

Any smoked tobacco product

Percent

Any smokeless tobacco product

Low High0

5

10

15

20

25

30

35

40

Middle

Wealth index

Highest

Fig 3.7: Percentage of adults, who are current users of tobacco products, by wealth index,Bangladesh, 2009

Source: Bangladesh Global Adult Tobacco Survey 2009

2011

29

Tobacco use ishighest

among the

poorest

8/2/2019 sde_rep-2011-dec

38/104

higher relative odds of chewing tobacco

compared to those above the poverty line, and

regular tobacco use significantly increased with

each diminishing income quintile (19). In

Indias National Family Health Survey (NFHS

II), prevalence among those in the richest

quintile was 16% compared to 40% among the

poorest quintile (20). Prevalence of tobacco

chewing among women labourers in Dharan,

Nepal (22%), was twice as much as the

prevalence among service class women (10%)

(21). The National Socio-Economic Survey 1995,

2001, 2004 for Indonesia revealed an increased

proportion of household expenditure spending

on tobacco products across all wealth quintiles(6.4% in 1995; 9.6% in 2001; 12% in 2004).

However, a greater percentage of people in the

poorest quintile (6.1% in 1995; 9.1% in 2001;

11% in 2004) spent their household expenditure

on tobacco products than people in the

wealthiest quintile (4.9% in 1995; 7.5% in 2001;

9.7% in 2004).

Unhealthy diet

Due to globalization and urbanization,

there is a shift from a healthy traditional high-

fibre, low-fat, low-calorie diet containing whole

grains as well as fruits and vegetables, towards

calorie-dense foods that are high in saturated

fats, transfats, free sugars or salt. Foods that

are high in fats and sugars promote obesity, a

major risk factor for CVDs, diabetes and cancers

(22). Consumption of adequate servings of food

and vegetables on the other hand reduce the riskof heart disease and some cancers. With regards

to unhealthy diet, three areas of particular

concern in the Region are low intake of fruits

and vegetables, high consumption of salt and

widespread use of transfat by the food industry.

Half a million deaths in the Region are

attributed to low intake of fruits and vegetables

(1). In SEAR Member countries, the prevalence

of eating inadequate (less than five servings)

fruits and vegetables ranges from 60% to 97%

in males and 64% to 94% in females. In five of

eight Member countries for which data are

available, the prevalence of inadequate fruits

and vegetable consumption was higher among

females than males (Table 3.2). Considering the

low socioeconomic conditions and poor level of

awareness in a large segment of the population

in this Region, the findings that the vast

majority of the population eats less than five

servings of fruits and vegetables a day is not

surprising (Table 3.2). A major hindrance in

shifting to a healthy diet in this Region could be

the high cost of fruits and vegetables relative tothe income level of the population.

There is evidence of high consumption of

salt in many countries. High salt consumption is

associated with hypertension and adverse

cardiovascular events (23). According to the

National Heart Foundation Hospital and

Research Institute, Bangladesh, an average

Bangladeshi consumes around 16 g of salt per

day almost triple the recommended limit(24). In Thailand, the average consumption of

salt per day among adults is 10.8 g (25). The

Chennai Urban Rural Epidemiology Study

(CURES) conducted on 1902 subjects showed

that the mean dietary salt intake (8.5 g/d) in the

population (26) was higher than that

recommended by WHO for adults (5 g or less).

Subjects in the highest quintile (mean salt

intake=13.8 g/d) of salt intake had a

significantly higher prevalence of hypertension

than those in the lowest quintile (mean salt

intake = 4.9 g/d) of salt intake (48% vs 17%,

p

8/2/2019 sde_rep-2011-dec

39/104

Another area of concern is that partially

hydrogenated vegetable oils, which are

associated with coronary heart disease (27) are

commonly used in the preparation ofcommercially fried, processed, bakery, ready-

to-eat and street foods in the Region. In India,

vanaspati brands, widely available in the

market used in the food industry (28), have

512 times higher trans fatty acid (TFA) levels

than the 2% limit set by some developed

countries (29). In Thailand, samples collected

from supermarkets and popular bakery stores

showed that shortenings (2.4 g), butter cookies

(2.1 g) and margarine (1.7 g) contained highest

quantities of TFA per 100 g of food (30).

Available regional data confirm current

evidence that higher intake of TFA may be

associated with increased risk of coronary heart

disease. A case-control study (n=3575) carried

out in India (1996) showed that ghee (clarified

butter) plus TFA in both rural and urban areas

were significantly associated with coronary

artery disease (31).

Physical inactivity

Lack of physical activity contributes

significantly to overweight and obesity, which is

a risk factor for many NCDs. Participation in

150 minutes of moderate to vigourous physical

activity per week is estimated to reduce the risk

of ischaemic heart disease by 30%, the risk of

diabetes by 27%, and the risk of breast and

colon cancer by 21%25% (32).

In SEAR, 5.1% of deaths are the

attributable to physical inactivity (Annex 4) (1).

This translates to nearly 800 000 deaths in the

Region per year (1). In SEAR countries, the

prevalence of insufficient physical activity

varied from 3% to 41% among males and from

6.6% to 64% among females. The highest

prevalence in both males and females was in

Bhutan (41% and 64%, respectively), followed

by Maldives (37% and 42%, respectively). In

eight of nine SEAR countries for which data are

available, prevalence of insufficient physical

activity was higher among females than males.

Table 3.2 Percentage of male and female adults eating less than fiveservings of fruits and vegetables, South-East Asia Region, 20042010

Member countries Male (%) Female (%) Both sexes (%) Year of survey

Bangladesh 94 93 93 2010

Bhutan 65 69 67 2007

India NR NR 86 2007-08

Indonesia 94 94 94 2007

Maldives 97 93 97 2004

Myanmar 90 91 90 2009

Nepal 61 64 62 2007

Sri Lanka 81 83 82 2007

Thailand 83 82 82 2005

Total (Range) 6597 6493 6297

Source: National NCD risk-factor surveys in Member countries

2011

31

8/2/2019 sde_rep-2011-dec

40/104

Bangladesh

Males

Percent

Females

Bhutan I ndia Indonesia

0

10

20

30

40

50

60

70

Maldives Myanmar Nepal Sri Lanka Thailand

Indonesia was the only exception. No data were

available for DPR Korea and Timor-Leste

(Figure 3.8)

Harmful use of alcohol

Alcohol is a psychoactive and potentially

dependence-producing substance with severe

health and social consequences when taken in

excess. Harmful use of alcohol caused

2.5 million deaths each year globally in 2004

and an estimated 350 000 people died in SEAR

of alcohol-related causes in 2004 (1).

Across countries and cultures men are

consistently more likely to consume alcoholfrequently and in larger amounts than women

(33). The results of the STEPS survey confirm

this sex differential. In SEAR Member countries,

the prevalence of alcohol consumption varied

from 2% to 44% among males and from 0.1% to

26% among females. The highest prevalence

among males was in DPR Korea (44%), followed

by Nepal (40%) and Bhutan (35%). The highest

prevalence among females was in Bhutan (26%),

followed by Nepal (17%). In eight countries for

which data were available, prevalence of alcohol

consumption was higher among males than

females. No data were available for Maldives,

Thailand and Timor-Leste (Figure 3.9).

Evidence suggests that low socioeconomic

groups often experience a higher burden of

alcohol-attributable diseases despite lower

overall consumption levels (34).

A recent study from Sri Lanka found that

two lowest income categories spent 40% of their

income on alcohol and smoking (35). Many

poor people in this Region indulged in binge

drinking, so much so that almost nothing wasleft from household expenditure to meet the

necessities of life such as food and shelter.

Health, particularly the preventive and

promotive aspects, always receives low priority

in this segment of the population.

In Bhutan, little stigma is attached to

alcohol use (36) and thus the usual barriers and

deterrents to alcohol use inherent in some

Fig 3.8: Percentage of adults with insufficient physical activity*, South-East Asia Region,2008

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.

Data adjusted for 2008 based for comparability

* Less than 30 minutes of moderate-to-vigorous activity at least five days a week.

Many peopleare not

sufficientlyphysically

active

2011

32

8/2/2019 sde_rep-2011-dec

41/104

societies are not as apparent here. Until recently

it was not taboo for Bhutanese children to drink

at an early age and many women drink beer and

wine. Studies in the country have shown that

50% of the grain harvests of households are

used to brew alcohol; homemade alcohol

production exceeds industrial production.

Alcohol production and sale has become a

livelihood for a large number of people in

Bhutan. In certain areas, homemade alcohol is

the only source of cash income to farmers.

Alcohol is one of the five leading causes of death

in Bhutan (36).

Relatively few people in Bangladesh and

Indonesia drink alcohol. This may be a due to

the cultural setup in these countries.

Metabolic Risk Factors

Overweight and obesity

Overweight and ob

sde_rep-2011-dec

Documents