Non-Communicable Diseases
– A race against time
Debbie Bradshaw,1 Krisela Steyn,2 Naomi Levitt,2 and Beatrice Nojilana1
1. Burden of Disease Research Unit, South African Medical Research Council
2. Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town
South Africa faces a race against time to reduce the risk factor
profile and rapidly improve the detection and management of
the NCDs in those who already have these conditions. With the
exception of tobacco use, South African data shows that the pattern
of risk factors for NCDs has deteriorated substantially during the
last two decades, and that detection, management and outcomes
of care for those with NCDs are still non-optimal.1 The reduction in
smoking can be ascribed to the effective comprehensive tobacco
why is the un holding a summit on
non-communicable disease in September 2011?
Global health agencies have recognized the rising threat of noncommunicable diseases (NCDs) as a major contributor to preventable
disease and premature mortality in low and middle-income countries. They
have emphasized that NCDs are not addressed in the Millennium
Development Goals (MDG) and that they should be, if the objectives of the
MDG are to be achieved. These activities have culminated in the United
Nations (UN) resolution on the 13 May 2010 calling for a UN Head of State
Summit on NCDs in September 2011.3 This special session will place NCDs
firmly on the global development agenda, secure the commitment of
Heads of State to focus governments’ efforts to address the common risk
factors and reverse the epidemic, mobilize the international community to
take action, and send a clear message to donors and funders to significantly
support funding for NCDs.
non-communicable diseases
Non-communicable diseases (NCDs) are chronic medical conditions or
diseases which are non-infectious. Common examples include stroke, heart
attacks, diabetes, cancer, asthma and depression. Some of the major NCDs
are preceded by unhealthy behaviours followed by the emergence of
legislation that has been promulgated and amended since the early
1990s,2 while little attention has been focused on other risk factors
associated with NCDs as well as improving management of NCDs.
South Africa needs to support the UN Summit on NCDs and take
bold steps to prevent and control NCDs. A national policy and
strategy must be developed incorporating population wide
interventions. The health system must be strengthened to manage
NCDs and their risk factors.
metabolic risk factors and disease. The risk factors associated with NCDs are
overweight and obesity, raised blood pressure, increased blood glucose
levels and non-optimal blood cholesterol levels (particularly raised LDL
cholesterol). Most of these risk factors are considered modifiable through
changes in behaviours or medications. The key behaviours that would
reduce risk factors for NCDs are eating a healthy diet, participating in
regular physical activity, not using tobacco, and avoiding harmful use
of alcohol.4
what is the extent of ncds in south africa?
South Africa is experiencing a quadruple burden of disease.5 Not only is
there an AIDS pandemic that set in during the 1990’s, and high rates of
injury and other infectious diseases, but there is also a rising tide of NCDs
affecting the quality of life and increasing health-care expenses both at a
personal level and at a country level. NCDs affect large numbers of the
working-age population, impacting on the workforce and productivity of
the country. The major NCDs in South Africa are cardiovascular diseases,
diabetes, cancers, chronic respiratory diseases and mental illness.1
Moreover, national surveillance suggests that these patterns of unhealthy
lifestyle are already present in our children and youth.5,6 These NCD risk
factors must be addressed urgently to reduce the NCD burden.
asthma and chronic obstructive
pulmonary disease (copd)
mental illness
Asthma is the commonest chronic disease in children, affecting up to 13%
the course of their lifetime. Mental illness, however, will not be considered by
before the age of 14 years and occurs in more than 7% of adults. Unlike asthma,
the up-coming UN Summit for NCDs as it is focussed on the common conditions
in which modification of risk factors is difficult, COPD is a preventable disease
which have shared risk factors.
Internationally, 1 in 4 people suffer from a diagnosable mental disorder during
resulting chiefly from exposure to tobacco smoke (both active and passive
The South African Stress and Health (SASH) survey found that 16.5% of South
smoking), domestic and industrial atmospheric pollution, with the high rates of
Africans reported having suffered from a common mental disorder in the last
TB in South Africa playing a part. It is responsible for considerable disability and
year.7 There is evidence that: depression can be effectively treated with low-
mortality in South Africa. There is an urgent need to increase public awareness
cost antidepressants or psychotherapy; antipsychotic drugs are cost effective
about this disease and reduce risk factors.
interventions for people with schizophrenia; hazardous and harmful alcohol
use can be effectively dealt with by providing brief interventions by trained
primary-care workers; and for adults and children with chronic mental
disabilities, community-based rehabilitative models provide low-cost care.8
what are the
patterns of tobacco and
Tobacco use (Daily)
harmful alcohol60use,
Women diet intake and
physical inactivity?
Tobacco use (Daily)
Overweight and obesity (BMI ≥25)
0 SADHS 11
2003
1998 SADHS 10
15-24 25-34 35-44 45-54 55-64
15-24 25-34 35-44 45-54 55-64 65+
Age group
Hazardous/harmful alcohol use (Audit ≥8) Age group
1998 SADHS 10
15-24 25-34 35-44 45-54 55-64 65+
Age group
65+
Tobacco
Tobaccouse
use(Daily)
(Daily)
17
9
17
23
5
21
17
45
Hazardous/harmful
alcohol
use (Audit ≥8)
44
45
44
41
38
38
40
40 20
17
20
20
17
41
41
41
17
14
21
20
20 21
14
11
8
20
17
4
17
40
40
20
35
35
Women
303131
25
25
80
40
40
20
20
10
20
3 3
2
15
1513
13
99 6
6
3 3
535 377
4
2
15
1512
12
99
13
13
77 6
6
2 2
1
14
14
00
00
0
11
15-24
25-34
35-44
15-24
45-54
65+
9
15-24 45-54
25-34 55-64
35-44 45-54
45-54 55-64
55-64 65+
65+
15-24
25-34
35-44
45-54 55-64
55-6415-19
65+20-24 25-34 35-44
5-19
20-24 25-34 35-44
45-5425-34
55-6435-44
65+
10
8
Age
Age
5
Agegroup
group
Agegroup
group
Age
Age group
4 group
4
3 3
1 2
3 3
2
3 3
80
40
Women
2008 SABSSM 13
100
60
20
2 2
Percentage
Percentage
42
4
11
10
17
17
17
17
39
78
99
5560
2210
10
20
17
52
17
20
20
70
60
20
60
52
42
12 4
4
7
88 24
15
52
50
44
38
34
10
10
24
71
63
50 2
1 2
44
33 33
52 44
22
33 33
33 33
22 22
1
34 0 38
00 39
400
0
5-24 25-34 35-44 15-19
45-54 20-24
55-64 65+35-44 45-54 55-64
15-24
25-34
35-44
45-54
65+
15-19
20-24
65+
24
24
22
15-1955-64
20-24 25-34
25-34 35-44
35-44 45-54
45-54 55-64
55-64
15-19 20-2425-34
25-34 35-44 45-54 55-64
65+
20
15
Age group
Age group
Age
Age
11
10
Agegroup
group
Agegroup
group 20 7 12
0 NIDS 171212
13
13
2008
2005
SABSSM
2008
SABSSM
SADHS
2008
SABSSM
2005
SABSSM
5-24 25-34 35-44 45-54 1998
55-64
65+
15-24 25-34 35-44
45-54
55-64 65+
Diabetes
Town
Ekhasi
(Township)
Age group(>11.1 mmol/l ) Cape
Age
group
Hypertension
(BP
≥
140/90
or
BPmeds)
Hypertension (BP ≥ 140/90 or BPmeds)
10
Women
Men
Tobacco
use:
About 35%
of adult men
and 10% of adult women
Women
Men 1998
Women
50
2008 NIDS
100
SADHS
100
100
100
11
78
Diabetes
(>11.1
mmol/l
)
Cape
Town
Ekhasi
(Township)
smoke
tobacco.
The
promulgation
of
comprehensive
tobacco
78
40
80
80
80
35
80
70
71
70
71
29
63
29
60
60
Women
63
60
60
30
control
legislation has 5052resulted
in the
in tobacco
use,
60
60
60
52
24
60 reduction
52
50
52
50
21
44
17
17
42
44
39
42
20
38
39
34
38
34
40
particularly
for men
above
Behaviour
Survey
40
40 25 years. The
40 14
40
14 Youth Risk 35
1122
10
10
24
8
24 2924
24
20
22
29
20
15
10
20
15
6
20
30
5
20
20
(YRBS)
found
that
21%
of
grade
8-11
learners
smoke
tobacco
with
no
4
11
12
10
11
10
2
2
7 12 24
44
21 7
17
17
00
6200
7
00
change
between
2002
and
2008
indicating
that
further
efforts
to
14
14
45-54
55-64
65+
35-44 45-54
15-2455-64
25-34 65+
35-44 45-54 55-6425-34
65+
15-24
25-34
65+ 35-44
15-24
25-34 35-44
35-44 45-54
45-54 55-64
55-64 65+
65+
10
8 15-2410 25-34 1135-44 45-54 55-64
10
Age group
Age group
Age
group
6
Age
group
5
Age
group
reduce tobacco use in young
people
are needed. Age group
4
2
2
25-34
5
1990 18
65+
0
2009 19
10
1998
1998SADHS
SADHS
25-34 10 35-44
17
17
2008
2008NIDS
NIDS
45-54
55-64
25-34 35-44 45-54 55-64
Harmful
alcohol
use:
About
16% of
adult
men 65+
report
LDL blood
cholestrol (>3
mmol/l(>11.1
) Capemmol/l
Town Ekhasi
Age
group
Age group
Diabetes
))Cape
Town
Ekhasi
Diabetes
(>11.1
mmol/l
Cape(Township)
Town
Ekhasi(Township)
(Township)
hazardous/
harmful
use of alcohol with
an increaseWomen
in recent years.
Limited
Women
en
Men
Women
Men
80
1990
2009
50
50
50
50
66
policy
action
(e.g.
increasing
excise
tax
on
alcohol)
has
not
yet
63
LDL blood
cholestrol (>3 mmol/l ) Cape Town Ekhasi (Township)
40
40
40
40
60
35
35
51
resulted
in
any
improvements
and
further
actions
are
needed.
29
29
Women
en
29
29
42 30
42
40
80
30
3930
30
24
40
24
33
21
66
21
These
should32include the
of32 a63 comprehensive
29
17
17
17 promulgation
17 alcohol
20
20
20
20
22
14
14
60
15
15
14
14
20
51
11
10
10
11
8
10
10
strategy,
including
on advertising
and decreasing
8 use (Daily) restrictions10
10control
10
10
10
42 10
6Tobacco
42
55
6
40
44 55
39
2
22
40 Women
14 322
33
en 29
00 32
availability.
00
600
18
Men
Men
80
80
Percentage
Percentage
39
39
40
40
1998
SADHS 10
29
29
Percentage
Percentage
0
51
51
40
40
40
40
11
32
32
2003 SADHS
21
17
20
17
17
17
14
14
11
9
8
Percentage
30
35-44
45-54
35-44
45-54
Age
Agegroup
group
20
25-34
25-34
23
Women
Women
80
80
0
-19 20-24 25-34 35-44 45-54 55-64 65+
Age group
2005 SABSSM 12
1 2
3 3
2
4
25-34
25-34
100
3 3
3 3
2 2
15-19 20-24 25-34 35-44 45-54 55-64
Age group
60
52
42
20
11
10
22
39
Women
80
Percentage
70
60
71
63
60
50
34
40
20
12
15
24
24
67
64
67
67
38
52
44
78.2
78.2
77
81.9
81.9
62
77
64
56
62
50
35-44
45-54
1992
1997
1992
1997
Age group
25-34
100
Women 100
35-44
55-64
65+
2002
2002
Year
Year
2007
2007
11
45-54
55-64 2003
Physical
inactivity
Physical
inactivitySADHS
SADHS
2003 11 65+
Age group
Women
Women
Age group
Overweight and obesity (BMI ≥25)
100
Men
100
80
Women
80
60
3841
40
0
42
42
35-44
45-54
35-44
45-54
Age
Agegroup
group
2008 SABSSM 13
78
69
Women
45
50
43
51
42 44
29 31
11 13
70 72
56 58
60
40
65+
1998 SADHS 10
55-64
55-64
72
75
72 72
72
60
38
30
20
0
15-24 25-34 35-44 45-54 55-64
Age group
32
32
Hypertension (BP ≥ 140/90 or BPmeds)
n
67
50
00
25-34
22
22
10
4
56
6471.6
what are the trends in modifiable ncd
risk factors?
20
42
42
19
2009
2009 19
20
1990
1990 20
40
40
64
15-24 25-34 35-44 45-54 55-64 65+
Age group
2008 NIDS 17
Fat supply
quantity
(FAO) women have extremely
Overweight and obesity:
South
African
100
high levels of overweight and obesity. More
than 70% of
81.9 women
78.2
80
71.6
69.0 old are overweight
above 35 years
or obese.17 In the past 10 years,
60
there has been a significant increase among men and more than
45%40of those above 35 years are overweight or obese.10,17 Body
20
weight
is considered normal when the body mass index (BMI,
0
calculated
by dividing weight by height squared) is between 18 and
1992
1997
2002
2007
25 kg/m2. A BMI between 25 and 30
Yearis considered overweight and
that of 30 or above Physical
is obese.
Obesity is associated with diabetes,
inactivity SADHS 2003 11
100
hypertension and other metabolic abnormalities that predisposes to
77
NCDs.
80 An improved low calorie diet and regular physical activity is
69
67 67
64
64
62
56
required
to reverse this trend.
60
16
00
Women
55-64
55-64
60
6047
Men
Men
66
66
63
63
65+
33
33
69.0
69.0
7
80
80
7 6
15
15
20
20
10
10
00
9
65+
65+
13
15-24 25-34 35-44 45-54 55-64
60
60
Age group
15
15
20
20Hazardous/harmful
10
alcohol use (Audit ≥8)
10
n
12
17
2008
2008NIDS
NIDS 17
69
Physical inactivity: South Africa has high
levels6464of physical
inactivity
67
69
67 67
67
64
64
56
56
60
52
50
52
– 48% of adult men60and 63%
of adult
women
were
categorised
as
50
47
47
36
36
40
40
inactive.11 Women have
higher
levels of physical inactivity than men.
The YRBS observed 2020
that in the week before the survey, about 40% of
school learners had 0participated
in insufficient physical activity, with
0
25-34
35-44
45-54
55-64
25-34
35-44
45-54
55-64
7
no change between 20026 and 2008.
Age group
Percentage
9 6
7
2009519
1990 20
5-24 25-34 35-44 45-54 55-64 65+
60
60
Age group
13
15-24
15-24 25-34
25-34 35-44
35-44 45-54
45-54 55-6
55-6
Age
Agegroup
group
2007
Year
g/capita/day
25-34
0 21
Percentage
Percentage
38
22
25-34
35-44
45-54 35-44
55-6445-54
35-44
45-54
55-64 45-54
15
51
15
25-34
25-34
35-44
65+
25-34
35-44
45-54 55-64
55-64
25-34
35-44
45-54 55-64
55-64
65+
20
10 Age group
44
Age group
Age
Age
Agegroup
group
Agegroup
group
41
41
40
40
35
0
31
18
19
2009 191990
1990 20
19
1990 18 35-442009
200945-54
25-34
55-64
35-44
45-54
55-64
25
Cape
Town
Age group
Age group LDL
20 (>3
LDLblood
bloodcholestrol
cholestrol
(>3mmol/l
mmol/l))15
Cape
TownEkhasi
Ekhasi(Township)
(Township)
15
Percentage
45
10
00
11
Physical inactivity
SADHS
2003
16
1997
2002quantity
Fat
Fatsupply
supply
quantity(FAO)
(FAO) 162007
20
2047
36
72
7272
7
20
20
12,13
19
PercentagePercentage
Percentage
Percentage
25-34
52
75
75
72
72
81.9
38
38
30
30
40
40
Percentage
Percentage
5
Percentage
Percentage
PercentagePercentage
Percentage
Percentage
en
36
Men
17
10
Percentage
en
52
20
Men
0
4
44
42
44
42
78.2
71.6
11
80
inactivity SADHS 2003
80 Physical
69
71.6
60
20
40
0
41
38
3841
72
70
70 72
58
56
56 58
60
60
15-24
15-24 25-34
25-34 35-44
35-44 45-54
45-54 55-64
55-64 65+
65+
Age
Agegroup
group
1997
2002
Year
10
1998
1998SADHS
SADHS 10
100
100
100
60
80
40
51
51
43
43
50
50
45
45
81.9
80
80
13
11
11 13
1992
80
63
20
20
Women
60
17
100
17
14
14
14
14
40 1111
80
20
20
1992
100
71
Percentage
Percentage
20
20
en
21
21
60
PercentagePercentage
23
60
31
29
29 31
0
Women
Women
30
30
78
Hypertension
(BP ≥ 140/90
80 or BPmeds)
2370
40
40
00
20
16
Fat supply
71.6 quantity (FAO)
60
60
40
0
PercentagePercentage
Men
Men 2005 SABSSM 12
30
30
69.0
Women
Women
100
100
2008 NIDS 17
78.2
80
80
69.0
100
60
11
10
10
2003
1998
0 SADHS
2003SADHS
SADHS 11
1998
SADHS
2008
SABSSM 13
2005 SABSSM 12
15-19 20-24 25-34 35-44 45-54 55-64
5-19 20-24 25-34 35-44 45-54 55-64 65+
Hypertension (BPHazardous/harmful
≥ 140/90 or BPmeds)
Age use
group
Age group
alcohol
Hazardous/harmful
alcohol
use(Audit
(Audit≥8)
≥8)
en
Men
Men 1998 SADHS 10
100
100
100
Percentage
Percentage
Percentage
Percentage
en
21
PercentagePercentage
23
Women
Women
60
60
2003Women
SADHS 11
30
51
51
g/capita/day
g/capita/day
Men
Men 1998 SADHS 10
60
60
en
2008 NIDS 17
15-24 25-34 35-44 45-54 55-64 65+
Age group
Overweight
(BMI
Overweight
andobesity
obesity
(BMI≥25)
≥25)
Fat supply quantity
(FAO) 16 and
Percentage
Percentage
20 21
15-24
PercentagePercentage
20 21
Percentage
40
Percentage
Percentage
41
40 Women
South Africa has
information that can be used to track
35 considerable
31
60
25
51
the prevalence
of the behaviours and risk factors for NCDs among adults
45
44
20
15
15
41
41
40
38
13
13
12
9
9 6show the information
35
15 years and 31older.
These40 graphs
for the latest
7 6
5 7
25
0
available
year.
They
also
contrast
the
prevalence
to
an
earlier
year for each
45-54
55-64 65+
25-34 35-44 45-54 55-64 65+
20 15-24 25-34 35-44
15
15
13
13
12
9
Age
group
group The prevalence for men
9
age Age
group.
and
women
are
shown
separately.
6
7 6
5 7
Men
g/capita/day
g/capita/day
44
41
38
PercentagePercentage
51
45
Unhealthy diet: South Africans are increasingly eating a typical
Women
Men
100
100
Western
diet comprising increased calorie
intake, fat (particularly
75
Overweight
and
obesity
(BMI
≥25)
80
80
72
72
72 72
72
saturated fat), animal protein and sugar, but a 70lower
intake
of
60
Women 56 58
Men
60
60
15 100
100
51
50
unrefined carbohydrate
and
fibre. There is38 low intake of fruit and
45
43
42 44
3841
40
75
40
80
30
15
29 31
72
72 72
72
70 72
vegetables
and salt intake has also been80 increasing
over
this
period.
58
60
20
20
56
60
60 11 13
51
50
Data
from the 38Food
Organisation
show a steady
45 and
43 Agriculture
42 44
41
38
400
400
30
15-24 25-34
65+
29 31 35-44 45-54 55-64
15-24
25-34
35-44
55-64 65+
increase in the amount of fat supply in the country, 45-54
indicative
of
20
20 11 13
Age group
Age group
16
this0 change.
0
PercentagePercentage
Men
52
40
36
47
50
62
62
65+
65
•Population-wide interventions to promote healthy
diet, physical activity, healthy environment and no
smoking or harmful alcohol use
• S trengthen tobacco control, particularly among young people and
decrease passive smoke exposure of children in the home
• Support smoking quitting programmes
• Promote healthy eating patterns that are low in fat and sugar and high
in fruit and vegetables, in part, by addressing access, through intersectoral programmes involving the agricultural sector
• Reduce salt in foods
• Reduce trans-fat in foods
• Restrict access to alcohol (through addressing physical availability and
pricing) and extend alcohol control legislation (particularly in the areas
of alcohol marketing, and drinking and driving)
• Promotion of physical activity in schools and workplaces, and through
urban planning for active commuting and access to safe public
green space
• Reduce exposure to biomass pollutants through electrification
of households
• Control air pollution including review and enforcing legislation related
to polluted places of work
• Media and communication strategies to prevent NCDs
• Strengthen primary health care
• S trengthen district-based primary health care by implementing the
integrated World Health Organization chronic disease model of care
• Use the absolute risk approach to identify those at highest risk
for NCDs
• Develop community-based care to support primary health-care centres
and people with NCDs
• Introduce realistic guidelines for managing and treating NCDs and their
risk factors
• Train health-care providers and managers in optimal NCD care
• Train health-care providers in patient-centred communication styles
• Implement appropriate referral systems
• Ensure constant supply of medications needed for NCDs and their
risk factors
• Ensure cost-effective interventions are fully implemented
• Foster collaboration between public and private sector
• Strengthen quality assurance
• D
evelop an NCD surveillance system including information to monitor
quality of care
• Develop evaluation capacity
• Develop capacity to review evidence and identify best-buy options
• Strengthen health research focused on identifying effective interventions
for prevention and management of NCDs
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Investing in intensive NCD prevention and treatment programmes
NOW will have tremendous payoffs for the future of our country