LIFESTYLE DISEASES IN

KERALA-BURDEN

Dr Aslesh OP,

Assistant Professor community medicine, Pariyaram medical College

Proportion of global deaths under the age

70 years, by cause of death, comparable estimates, 2012

Age-standardized NCD death rates by WHO

region

Probability of dying from the four main noncommunicable

diseases between the ages of 30 and 70 years

comparable estimates, 2012

NCD and risk factors

Status of risk factors in Kerala

Tobacco use in Kerala

21

13 11

34

14

26

0

5

10

15

20

25

30

35

40

Tobacco Smoked Smokeless

Kerala

India

International Institute for Population Sciences.Ministry of Health and Family Welfare. Government of India. Global adult tobacco

survey India 2009 2010. Global adult tobacco survey India 2009-10. Mumbai: International Institute for Population Sciences;

2010.

Tobacco use in Kerala

35

28

13

8.5

0

8.5

0

5

10

15

20

25

30

35

40

Tobacco Smoked Smokeless

Males

Females

International Institute for Population Sciences.Ministry of Health and Family Welfare. Government of India. Global adult tobacco

survey India 2009 2010. Global adult tobacco survey India 2009-10. Mumbai: International Institute for Population Sciences;

2010.

Smoking in Kerala over past 30 years

17.8

21.9

13.3

13

17.8

y = -0.5286x + 1075.2 R² = 0.9748

0

5

10

15

20

25

1990 2000 2010 2020

%

year

Current smoking

38.7

50

28 28

43 38.7

y = -0.9053x + 1848.3 R² = 0.7959 0

10

20

30

40

50

60

1980 1990 2000 2010 2020

%

Year

Current smoking in males

Alcohol use in Kerala

Current use of alcohol ( within one month ) was seen

in 20-23% of males aged above 15 years in

Kerala.

Annual Per capita alcohol consumption was 10.2 L

which is comparable to national average (11.4 L)

ICMR. NON-COMMUNICABLE DISEASE RISK FACTORS SURVEY India Phase -

I 2008-09. 2007.

Obesity

The prevalence of overweight and obese (BMI>=25) in the state was estimated to around 30 % and is showing an upward trend.

Central obesity (based on waste circumference, WC) is more prevalent affecting as much as 40% of the population.

Obesity/overweight was more common in females (BMI-38%, WC-52%) when compared to males (BMI-24%,WC-26%).

Hyper-cholestrolemia

57

37

13.9

51

30

62

41

0

10

20

30

40

50

60

70

Thankappan et al Vijayakumar etal INDIAB study

all

males

females

Dietary practice in Kerala

87.9

9.9 3.5

0

10

20

30

40

50

60

70

80

90

100

Coconut oil palm oil Oil rich in unsaturated fatty acid

Major cooking oil

Dietary practice in Kerala

Physical inactivity

Low level of physical activity was seen in 75% of

the population as per the STEPS survey report.

Lack of physical activity was more common in

women when compared to men.

The low level of physical activity was same in both

urban and rural areas as well as across different

age groups

Diabetes

Age-standardized prevalence of

diabetes, 2014

Comparison of current age standardized

prevalence of diabetes in above 18 years

14.8

9.5 9

0

2

4

6

8

10

12

14

16

Kerala India world

Age standardized prevalence of diabetes among >18 years

Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, et al. Risk factor profile for chronic non-communicable

diseases: Results of a community-based study in Kerala, India. Indian J Med Res. 2010;131(1):53–63.

World Health Organization. Global Status Report On Noncommunicable Diseases 2014. 2014.

Diabetes in Kerala over last 25 year

27.3

16.214.6

19.6

5.9

16.3

4

y = 1.0179x - 2023.9R² = 0.6882

0

5

10

15

20

25

30

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

%

Year

Prevalence of diabetes

14.8

20.6

0

5

10

15

20

25

Urban Rural

Prevalence of diabetes (%)

14.3

17.8

0

5

10

15

20

25

Males Females

Prevalence of diabetes (%)

Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, et al. Risk factor profile for chronic non-communicable diseases: Results

of a community-based study in Kerala, India. Indian J Med Res. 2010;131(1):53–63.

3.4

13.1

0

2

4

6

8

10

12

14

1999 2010

Prevalence of diabetes in age group 30-40 years

Kutty VR, Soman CR, Joseph A, Pisharody R, Vijayakumar K. Type 2 diabetes in southern Kerala: variation in prevalence among geographic

divisions within a region. Natl Med J India [Internet]. Jan [cited 2015 Apr 23];13(6):287–92

Jose R, Manojan KK, Augustine P, Nujum ZT, Althaf A, Haran JC, et al. Prevalence of Type 2 Diabetes and Prediabetes in Neyyattinkara

Taluk of South Kerala [Internet]. Academic Medical Journal of India. 2013 [cited 2015 Apr 23]. Available from:

http://medicaljournal.in/prevalence-of-type-2-diabetes-prediabetes

Detection , treatment and control of

diabetes in Kerala

72 68

22

73

65

31

71 70

15

0

10

20

30

40

50

60

70

80

Aware Treated Controled

All

males

females

Hypertension

Age standardized prevalence of

hypertension in above 18 years

28

23 22

0

5

10

15

20

25

30

Kerala India World

%

Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, et al. Risk factor profile for chronic non-communicable

diseases: Results of a community-based study in Kerala, India. Indian J Med Res. 2010;131(1):53–63.

World Health Organization. Global Status Report On Noncommunicable Diseases 2014. 2014.

Trend in prevalence of hypertension in

Kerala (above 30 year of age)

Burden of hypertension

The prevalence was almost same in both genders

as well as in urban and rural areas.

The burden of hypertension increases with age

studies reports that 60-80% of people above age of

60 were hypertensive

proportion of people in pre-hypertension stage is

also very high (upto 40%).

Detection , treatment and control of

hypertension in Kerala

37

27

9

30

21

6

44

33

11

0

5

10

15

20

25

30

35

40

45

50

Aware Treated Controlled

All

males

females

Cardiovascular diseases

Cardiovascular diseases

Cardiovascular diseases is the leading cause of

mortality in Kerala contributing to as much as 40%

of all deaths.

The age adjusted death rate due to cardiovascular

in the state is 490 per lakh for men and 231 per

lakh for women every year

Coronary artery diseases

State reports a higher prevalence of coronary artery diseases when compared to other states in India

7.4% in rural (in 1991)

13.5% in urban(in 1995)

The estimated prevalence of coronary artery disease in the age group 20-69 years for 2015 is 10.1 %.(31)

*Kutty VR, Balakrishnan KG, Jayasree AK, Thomas J. Prevalence of coronary heart disease in the rural population of Thiruvananthapuram district,

Kerala, India. Int J Cardiol [Internet]. 1993 Apr [cited 2015 Apr 24];39(1):59–70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8407009

**Begom R, Singh RB. Prevalence of coronary artery disease and its risk factors in the urban population of South and North India. Acta Cardiol

[Internet]. 1995 Jan [cited 2015 May 7];50(3):227–40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7676762

***National Commission on Macroeconomics and Health. NCMH Background Papers·Burden of Disease in India. New delhi; 2005. p. 1–388.

Available from: http://www.who.int/macrohealth/action/NCMH_Burden of disease_(29 Sep 2005).pdf

Death due to coronary artery disease

in kerala

382

64 50

170

128

41 15

70

0

50

100

150

200

250

300

350

400

450

Kerala China Japan United states

Per

10

0,0

00

males

females

Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al. Presentation, management, and outcomes of 25

748 acute coronary syndrome admissions in Kerala, India: results from the Kerala ACS Registry. Eur Heart J [Internet]. 2013 Jan 7

[cited 2015 May 8];34(2):121–9. Available from:

http://eurheartj.oxfordjournals.org/content/early/2012/09/06/eurheartj.ehs219

Acute coronary event in Kerala

CAD in Kerala is both premature and malignant

Average age is 60 years (56 in males and 69 in

females)

60% of CAD deaths in men and 40% of CAD deaths in

women occur before the age of 65 (USA-18%)

1 month case fatality rate following STEMI- 8.5%

( around 4 in developed countries) Soman CR, Kutty VR, Safraj S, Vijayakumar K, Rajamohanan K, Ajayan K. All-cause mortality and cardiovascular mortality in Kerala state of India:

results from a 5-year follow-up of 161,942 rural community dwelling adults. Asia Pac J Public Health [Internet]. 2011 Nov [cited 2015 Apr

23];23(6):896–903. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20460280

Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al. Presentation, management, and outcomes of 25 748 acute

coronary syndrome admissions in Kerala, India: results from the Kerala ACS Registry. Eur Heart J [Internet]. 2013 Jan 7 [cited 2015 May

8];34(2):121–9. Available from: http://eurheartj.oxfordjournals.org/content/early/2012/09/06/eurheartj.ehs219

Stroke

Prevalence stroke among adults (>18 years ) in the state was 0.3%

The age adjusted annual incidence of stroke in Kerala in 2010 was

135 per 100,000

were more in males (143 )compared to females (128)

Ischemic stroke was the most common type of stroke ( 73 per

100000)

#Menon J, Joseph J, Thachil A, Attacheril T V, Banerjee A. Surveillance of noncommunicable diseases by community health workers in Kerala:

the epidemiology of noncommunicable diseases in rural areas (ENDIRA) study. Glob Heart [Internet]. 2014 Dec [cited 2015 Apr

1];9(4):409–17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25592794

##Soman CR, Kutty VR, Safraj S, Vijayakumar K, Rajamohanan K, Ajayan K. All-cause mortality and cardiovascular mortality in Kerala

state of India: results from a 5-year follow-up of 161,942 rural community dwelling adults. Asia Pac J Public Health [Internet]. 2011 Nov

[cited 2015 Apr 23];23(6):896–903. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20460280

Stroke

No urban rural difference in incidence

average age of stroke patients was 67 years

stroke in the young( <40 years,)only 4%

case fatality rate within one month was 24.5% for

urban and 37.1% for rural populations which is

comparable to national figures

Sridharan SE, Unnikrishnan JP, Sukumaran S, Sylaja PN, Nayak SD, Sarma PS, et al. Incidence, types, risk factors, and

outcome of stroke in a developing country: the Trivandrum Stroke Registry. Stroke [Internet]. 2009 Apr 1 [cited 2015

May 5];40(4):1212–8. Available from: http://stroke.ahajournals.org/content/40/4/1212.full

Cancer

Incidence of cancer in Kerala

132

97

204

123

92

167

0

50

100

150

200

250

Kerala (1) India (2) World (2)

Per

10

0,0

00

males

females

1.Three Year Report of PBCR 2009-2011 [Internet]. [cited 2015 Apr 28]. Available from:

http://www.ncrpindia.org/ALL_NCRP_REPORTS/PBCR_REPORT_2009_2011/ALL_CONTENT/Printed_Version.htm

2 GLOBOCAN :Fact Sheets by Population [Internet]. [cited 2015 Apr 27]. Available from:

http://globocan.iarc.fr/Pages/fact_sheets_population.aspx

Trend in incidence of cancer in Kerala

109.2

87.8

96.6

132.3 132.6

87.1 81.1 80

114.9 123.2

0

20

40

60

80

100

120

140

In 1

00,0

00

Thiruvananthapuram

males females

115.9 116.6

99.4 102.6

118.5

80.4 80.4 76 76.3

91.6

0

20

40

60

80

100

120

140

In 1

00,0

00

Kollam

Males Females

*CI5 - Home [Internet]. [cited 2015 Apr 27]. Available from: http://ci5.iarc.fr/Default.aspx

**Three Year Report of PBCR 2009-2011 [Internet]. [cited 2015 Apr 28]. Available from:

http://www.ncrpindia.org/ALL_NCRP_REPORTS/PBCR_REPORT_2009_2011/ALL_CONTENT/Printed_Version.htm

Among males lung cancer (14.5%) was the leading

site followed by cancer of oral cavity (14.2%).

Among females cancer of breast (29.8%) was the

leading site of cancer followed by cancer of

thyroid( 12.5%)

Children (0-14years) constituted 4.8% of all

cancers and leukemia was the predominant cancer

among them in both genders ( males 57.5% and

females 47.5%).

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Change in cancer incidence in females from 1991-92 to 2009-11

Chronic Lung diseases

Chronic lung diseases

Chronic obstructive pulmonary diseases (COPD)

accounted for 5.2% of the total NCD burden and

12.2% of the NCD related mortality.

In Kerala, 15.3% of the death were due to

respiratory causes of which COPD was the main

culprit

Prevalence of chronic respiratory

disease in Kerala

10.1

3.5 3.1

1.9

0

2

4

6

8

10

12

Kerala India

%

Chronic bronchitis

Asthma

Jindal SK. Indian Study on Epidemiology of Asthma , Respiratory Symptoms and Chronic Bronchitis (

INSEARCH ) A Multi ‐ Centre Study ( 2006 ‐ 2009 ) Department of Pulmonary Medicine [Internet].

2010. Available from: http://icmr.nic.in/final/INSEARCH_Full _Report.pdf

5

13.5

4.5

1.9

0

2

4

6

8

10

12

14

16

urban rural

Chronic bronchitis Asthma

11

9

2.5

3.7

0

2

4

6

8

10

12

Males Females

Chronic bronchitis Asthma

Prevalence of chronic bronchitis

6.2

9.4

14.6

18.7

27.0

37.5

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

35-44 45-54 55-64 65-74 75-84 >84

Kerala

Kerala

Chronic Kidney disease

Age-adjusted incidence rate of ESRD in India to be

22.9 per lakh population.

7500 new chronic kidney diseases every year in Kerala

Prevalence in hospitalized patients is 17 %

33 % in Kerala

Main causes are diabetes nephropathy and

hypertensive nephrosclerosis

*Modi GK, Jha V. The incidence of end-stage renal disease in India: a population-based study. Kidney Int [Internet]. 2006 Dec 25 [cited 2015

May 2];70(12):2131–3. Available from: http://dx.doi.org/10.1038/sj.ki.5001958

**Singh AK, Farag YMK, Mittal B V, Subramanian KK, Reddy SRK, Acharya VN, et al. Epidemiology and risk factors of chronic kidney disease in

India - results from the SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol [Internet]. 2013 Jan [cited 2015 Apr

22];14(1):114. Available from: http://www.biomedcentral.com/1471-2369/14/114

***Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK, Almeida AF, et al. What do we know about chronic kidney disease in India:

first report of the Indian CKD registry. BMC Nephrol [Internet]. 2012 Jan [cited 2015 Apr 17];13:10. Available from:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3350459&tool=pmcentrez&rendertype=abstract

Conclusion

The current data shows that prevalence of major

Non communicable diseases is showing an upward

trend in the state.

The high prevalence of these risk factors points to

the fact that NCD burden would continue to rise in

the coming years

there is an urgent need of intervention to overcome

these risk factors using life course approach in

order to contain these disease

Thank you