Lifestyle and Non-Communicable

Diseases
Prof. Martin CS Wong
MBChB, MD, MPH, FHKAM
School of Public Health & Primary Care
Faculty of Medicine,
Chinese University of Hong Kong

November 2015
 Content Outline

1. Definition and characteristics of Non-Communicable

Diseases (NCD)
– The rising threat of NCDs

2. Association between lifestyles and NCD

3. What strategies are controversial in reduction of NCDs

4. What is effective to reduce NCDs (Guest speaker)

 (1). Definition and
Characteristics of
Non-Communicable Diseases
(NCD) – the Rising Threat
 What is NCD?

• “…an illness that is caused by something other than

a pathogen. It might result from hereditary factors,
improper diet, smoking, or other factors. Those
resulting from lifestyle factors are sometimes called
diseases of affluence.”
– http://www.scribd.com/doc/46165607/Non-Communicable-
Disease
• Characteristics
– Rarely cured completely
– May have fluctuations in disease course
– May need add-on therapy with time
– Lifestyle factors usually play a major role
Some Important Examples

Cancer
Cardiovascular diseases
Hypertension
Diabetes
Lipid disorders
Gout
Asthma/allergy
Osteoporosis
Osteoarthritis
Depression
The 10 leading causes of death in the world, 2000 and 2011

Source: WHO. http://www.who.int/mediacentre/factsheets/fs310/en/index.html

 Globally
• NCDs
– were responsible for 2/3 of all deaths globally in 2011(↑ from
60% in 2000)
• Four main NCDs
– cardiovascular diseases, cancers, diabetes and chronic lung
diseases
• Cardiovascular Disease: (no. 1 killer)
– Killed 17 million people in 2011 (3/10 deaths)
– 7 million died of ischemic heart disease and 6.2 million from
stroke

Source: WHO. http://www.who.int/mediacentre/factsheets/fs310/en/index.html

 • What is the difference between high- & low-income
countries??

Source: WHO. http://www.who.int/mediacentre/factsheets/fs310/en/index.html

 Main causes of death, WHO region, 2000

% Chronic diseases
75
Injuries

Communicable
50 diseases,
maternal &
perinatal
conditions, &
nutritional
25 deficiencies

Eastern South- Western Americas

Africa Medi- East Europe 9
terranean Asia Pacific
Source: WHO report 2001
Age-adjusted incidence of colorectal cancer
Female Male

Japan, Nagasaki City

Japan, Miyagi Prefecture
Japan, Yamagata Prefecture
Singapore: Chinese
Japan, Osaka Prefecture
China, Hong Kong
Philippines, Manila
China, Shanghai
Singapore: Malay
China, Tianjin
Singapore: Indian Colon
Thailand, Chiang Mai Rectum
India, Bombay

UK, South Thames Region

USA, SEER: White
Canada
UK, Scotland
USA, SEER: Black

40 20 0 20 40 60 80

Age-standardized rate (per 100,000)

Sung et al. Lancet Oncology 2005
 Bowel cancer in hong kong

4500 10 most common cancers 3500

4000
10 major causes of cancer deaths
3000
3500
2500
3000
2500 2000
2000 1500
1500
1000
1000
500 500
0 0

*Non-Hodgkin's lymphoma ^Non-melanoma skin

*Hong Kong Cancer Registry, Hospital Authority. (2009)

Leading Cancer Sites in Hong Kong in 2008.
 Time trends of common cancers:
no. of new cases
5000
4500 4365
4000 4335
3500 Lung
3000
2500
Bowel
2000 Breast
1500
Liver
1000
500 Prostate
0
2001 2002 2003 2004 2005 2006 2007 2008 2009
Hong Kong Cancer Registry, Hospital Authority, 2009
 Depression

18 17.1%

16 Lifetime
14 13.3% 12-month
Prevalence (%)*

12
10.3%
10
7.9%
8
6 5.1%

3.1% 3.5%
4
2.3%
2
0
Depression Social phobia GAD Phobic
disorders

MDD=major depressive disorder.

*Data for MDD, SAD, GAD, and panic disorder are from the National Comorbidity Survey (NCS),
part 1 (N=8,098).

Kessler RC, et al. Arch Gen Psychiatry. 1994;51:8-19.

 The complex relationship between
different disorders
56% (panic disorder + depression1)

42% 特殊 驚恐症 48%

(specific phobia + 恐懼症 創傷後遺症 (PTSD +
depression2) depression3)

廣泛焦 社交恐懼症 37%

62% 慮症 抑鬱症
(SAD +
(GAD + depression2)
depression4)

27%
強迫症 (OCD + depression5)

*Lifetime prevalence of MDD among individuals with lifetime diagnoses of each anxiety disorder.

1. Roy-Byrne PP, et al. Br J Psychiatry. 2000;176:229-235.

2. Magee WJ, et al. Arch Gen Psychiatry. 1996;53:159-168.
3. Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-1060.
4. Wittchen HU, et al. Arch Gen Psychiatry. 1994;51:355-364.
5. Weissman MM, et al. J Clin Psychiatry. 1994;55(suppl):5-10.
 Metabolic syndrome

Gout
Diabetes
Metabolic Lipid disorder
Syndrome

Hypertension
Obesity
(2). Impacts of NCDs to our
society
 Impact of NCDs (1)

• (1). Highly Prevalent in clinical practice (e.g. HT

15-35%)

• (2). Complications

• (3). “Clustering effects”

– The presence of one disease
associated with another
 Importance of NCD (2): individual

• Disease complications
–Physical
–Psychological
–Social
–Spiritual
 Importance of NCD (3): societal

• Societal impact
– Productivity
– Job absenteeism & turnover
– Will our future leaders “sicker”?
• Huge Public health burden
– Health service utilization
– Health care expenditure
– Side effects of drugs
– Advanced technological equipments and
expertise sometimes required
 Examples of economic impact
• China:
– reducing cardiovascular mortality by 1% per year between 2010
and 2040 could generate an economic value equivalent to 68% of
China’s real GDP in 2010 or over PPP US$10.7 trillion (World
Bank 2011c)
• Egypt:
– NCDs could be leading to an overall production loss of 12% of
Egypt’s GDP (Rocco et al. 2011)
• Brazil
– : costs of NCDs between 2005 and 2009 could equal 10% of
Brazil’s 2003 GDP (World Bank 2005a)
• India:
– eliminating NCDs could have, in theory, increased India’s 2004
GDP by 4%-10% (Mahal et al. 2010)
Source: Chronic Emergency
(3). Association between
lifestyles and NCD
 Lifestyle factors <-> NCDs

Unhealthy Premature
diet deaths
Tobacco
Mortality
use

Harmful
use of Morbidity
alcohol

Physical
inactivity NCDs disabilities
 (4). What strategies are controversial in
reduction of NCDs?
1). Smoking: the use of e-cigarettes

2). Overweight: drinking low calorie soft drink

3). Body vibration for fat-burning

4). Surgery for obesity

 E-cigarettes

• Personal Vaporizer (PV), or Electronic Nicotine Delivery

System (ENDS)
• Battery-powered:
– simulates the feeling of smoking
– without tobacco combustion
• Activates the e-cigarette by taking a puff or pressing a button

https://en.wikipedia.org/wiki/Electronic_cigarette#/media/File:Electronic_cigarette_exploded.jpg
1. On some e-cigarettes, inhalation activates the battery-powered atomiser. Other
types are manually switched on
2. A heating coil inside the atomiser heats liquid nicotine contained in a cartridge
3. The mixture becomes vapour and is inhaled. Many e-cigarettes have an LED
light as a cosmetic feature to simulate traditional cigarette glow.
'Ban E-cigarette use indoors,' says WHO by Smitha Mundasad Health reporter, BBC
News. http://www.bbc.com/news/health-28937610
 Claimed health benefits

Source:
https://hk.images.search.yahoo.com/search/images;_ylt=A2oKmJhlt0VWTkIAZjOzygt.;_ylu=X3oDMTE1cnFmY2I5BGNvbG8Dc2czBHBvcwMxBHZ0a
WQDSEtDMDEwXzEEc2VjA3BpdnM-?p=e-cigarettes&fr=yfp-t-900-hk&fr2=piv-web#id=46&iurl=http%3A%2F%2Fwww.e-cigarettepedia.com%2Fwp-
content%2Fuploads%2F2009%2F06%2Fgeneral_health_benefits_of_e-cigarette21.jpg&action=click
Possible Perceived Benefits
might be useful to help tobacco smokers quit or reduce consumption

Replacing cigarettes and slowly dialing down nicotine levels, much as

other nicotine delivery devices (gum, patches, inhalers, and so on) do

might be used to maintain a tobacco habit by allowing smokers nicotine

intake in tobacco free areas, e.g. the workplace or home, as the vapor
emitted from e-cigarettes is odorless and presumed to be not toxic.

allowing e-cigarettes to compete with regular cigarettes might cut

tobacco-related deaths and illness

No evidence has shown that the vapor produced by e-cigarettes is

harmful to users or bystanders in contrast to cigarette smoke
Possible Harm
later-generation and "hotter" e-cigarettes (e.g. 5.0 volts) may generate
equal or higher levels of formaldehyde than smoking

Nicotine is associated with cardiovascular disease, potential birth

defects, and poisoning

E-cigarettes create vapor that consists of ultrafine particles. The

vapor contains similar chemicals to the e-liquid, together with tiny
amounts of toxicants and heavy metals

Not enough evidence to determine if electronic cigarettes can help

people quit smoking

Smokers should be encouraged to use approved methods for help

with quitting, such as Nicotine Replacement Therapy (NRT)
 Low calorie soft drinks

• Can we use low-calorie soft drinks to reduce

weight?
 Nature of these drinks

• low-calorie (0.3 kcal per 100ml)

• A taste that is indistinguishable from standard ones
• Artificial sweeteners are used
– In the U.S., this includes aspartame and acesulfame potassium
– Some contains Potassium benzoate
• Theoretically can reduce weight by replacing energy-
dense drinks…
 Further studies…

• Aspartame
– dangerous food additives
– associated with cancer, neurological disorders e.g. Parkinson’s
disease & Alzheimer’s disease
• Acesulfame Potassium
– promote cancer and ↑ insulin production in animals
• Potassium benozate
– a food preservative
– potential to form benzene when combined with vitamin C
– cancer, anemia, suppressed immunity, irregular menstruation,
and infertility
 • people who rely on artificially sweetened beverages
are more likely to gain weight

• ↑ appetite and ↑calorie consumption

[1. Fowler SP, Williams K, Resendez RG, Hunt KJ, Hazuda HP, Stern MP. "Fueling the Obesity Epidemic?
Artificially Sweetened Beverage Use and Long-term Weight Gain." Obesity. 2008. 16(8):1894-1900.]
[2. Tordoff MG, Alleva AM. "Oral stimulation with aspartame increases hunger." Physiology & Behavior. 1990.
47(3):555-559.]
[3. Lavin JH, French SJ, Read NW. "The effect of sucrose and aspartame sweetened drinks on energy intake,
hunger and food choice of female, moderately restrained eaters." International Journal of Obesity. 1997. 21:37-
42.]
 Surgery for obesity

• Can bariatric surgery reduce weight?

• reducing the size of the stomach with a gastric band
or through removal of a stomach portion
• Gastric bypass surgery
– and re-routing the small intestine to a small stomach pouch

https://en.wikipedia.org/wiki/Bariatric_surgery
 Long-term benefits

• May lead to:

– Significant long-term loss of weight

– Recovery from diabetes
– Improvement in cardiovascular risk factors
– ↓Sleep apnea
– ↓in mortality of 23% (from 40%)
– ↑psychological health

Robinson MK (July 2009). "Editorial: Surgical treatment of obesity—weighing the facts". N.

Engl. J. Med. 361 (5): 520–1. doi:10.1056/NEJMe0904837. PMID 19641209.
 Who receives it?

– for patients with a BMI ≥40 kg/m2 who instituted but failed
an adequate exercise and diet program

– Those with BMI ≥40 kg/m2 may be at higher risk of

depression (5-fold)

– and who present with obesity-related comorbid conditions,

• hypertension, impaired glucose tolerance, diabetes mellitus,
hyperlipidemia, and obstructive sleep apnea

Snow V, Barry P, Fitterman N, Qaseem A, Weiss K (2005). "Pharmacologic and Surgical Management of Obesity in Primary Care: A Clinical Practice
Guideline from the American College of Physicians". Annals of Internal Medicine 142 (7): 525–31. doi:10.7326/0003-4819-142-7-200504050-00011.
Maggard MA, Shugarman LR, Suttorp M; et al. (2005). "Meta-analysis: surgical treatment of obesity". Annals of Internal Medicine 142 (7): 547–59.
doi:10.7326/0003-4819-142-7-200504050-00013.
 Potential harms

• 22% complications during hospital stay

• 40% complications in the next 6 months
• Gastric dumping syndrome in about 20% (bloating
and diarrhea after eating, necessitating small meals or
medication),
• Leaks at the surgical site (12%), infections (6%),
leaking (5%) and pneumonia (4%) where the
mortality was 0.2%

Quinlan, J, Cost of Bariatric Surgery: 2014 Surgeon Survey & Key Findings, Bariatric
Surgery Source, retrieved 1 January 2015
 Challenges forward

• 1). Ageing population but affecting the younger subjects more

Life Expectancy at Birth (Male and Female), 1971 – 2010

Source: Centre for Health Protection website:
http://www.chp.gov.hk/en/data/4/10/27/111.html
 Challenges forward

• 2). Westernization & urbanization

Increased Rates of
Inflammatory Bowel Disease
in Hong Kong Blamed on
Westernization of Asian
Eating Practices

Source: MediterrAsian.com
http://mediterrasian.com/blog/?p=290
• Stress & sedentary lifestyle – behavior
modification is difficult
Around 500 randomly selected women
aged 45-64 years: prevalence of
depressive symptoms 37%
moderate
severe
mild

v. mild

normal
 Health seeking behavior
People at higher risk of chronic diseases
– less likely to undergo health check
“Ostrich phenomenon”
(5). Strategies to control NCDs
Emphasis on prevention
rather than curative care
 “Upstream” Parable

“Every so often a drowning person is swept alongside. The

lifesaver dives in to the rescue, retrieves the ‘patient’ and
resuscitates them. Just as they have finished another
casualty appears alongside. So busy and involved are the
lifesavers in all of this rescue work that they have no time
to walk upstream and see why it is that so many people
are falling into the river.” - Ashton and Seymour, 1988
 Responding to the Grand challenges
in Chronic NCD
• Raise public awareness
• Enhance economic, legal and
environmental policies
• Modify risk factors
• Engage businesses and community
• Mitigate health impacts of poverty and
urbanization
• Reorientate health systems
Daar et al. 2007. Nature 450:494
 Thank you!

http://www.sphpc.cuhk.edu.hk
School of Public Health and Primary Care,
CUHK

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