Pan American Health Organization

Health Status of the Population

Noncommunicable Disease Prevention and Control

Introduction

Every year in the Americas, noncommunicable diseases (NCDs) are responsible for nearly four of every five deaths (79%). This figure is only expected to increase in the next decades as a consequence of population growth and aging, urbanization, and exposure to risk factors. Cardiovascular diseases (38%), cancer (25%), respiratory diseases (9%), and diabetes (6%) are the four leading causes of NCD deaths ().

As people age, they face longer exposure to potential risk factors such as tobacco use, harmful use of alcohol, insufficient physical activity, and unhealthy eating patterns and diets. As a result, multiple chronic conditions emerge in the elderly. An overview of the population trends and projections in the Americas by age group from 1970 to 2030 shows a doubling of the overall population by 2030, with the greatest increases in groups aged 60–79 years (a 4.2-fold increase) and 80+ years (a remarkable 7.3-fold increase).

Demographic and epidemiologic shifts contributed to the rising NCD burden in the Americas. Moreover, NCDs are no longer considered exclusively a result of the natural life course, since NCDs are preventable and the cause of many premature deaths. Of all NCD deaths, 35% occurred prematurely in people from 30 to 70 years of age, of which cardiovascular diseases and cancer combined to account for 65% of total premature deaths ().

Four main NCDs and their common risk factors

The four leading NCDs (cardiovascular diseases, cancer, respiratory diseases, and diabetes) share four risk factors: tobacco use, harmful use of alcohol, unhealthy diet, and physical inactivity. These in turn lead to other key metabolic/physiological changes such as raised blood pressure, overweight/obesity, raised blood glucose, and higher cholesterol levels (). The status of the key modifiable and biological risk factors that contribute to NCDs in the Region is presented in the following.

Harmful use of alcohol

The harmful use of alcohol contributes to over 200 health conditions, the majority of which are NCDs, including cancers, cardiovascular diseases, and liver cirrhosis. For most diseases and injuries caused by alcohol, there is a dose-response relationship: the higher the consumption, the larger the risk for a negative consequence ().

In the Americas, alcohol is a significant public health problem. It is the WHO Region with the second highest levels of alcohol per capita consumption (APC) and heavy episodic drinking (HED) in the world. Average APC among those aged 15 years and older in the Americas is 8.4 L, compared to 6.2 L globally. APC among all drinkers is 18.0 L for males and 8.0 L for females, indicating that those who drink do so at high levels ().

At the same time, certain patterns of consumption are particularly significant in determining many of the harmful effects of alcohol: the volume of alcohol consumed in a single occasion is linked to acute consequences such as alcohol poisoning, violence, and injuries. The prevalence of HED (60 g of pure alcohol at least once a month) is estimated to be 13.7% in the Americas and 22% among drinkers (1 in 5 drinkers); each occasion is associated with a high risk for an acute consequence, and the higher the frequency of these occasions, the higher the risk of chronic disease including cancers, liver cirrhosis, and alcohol use disorders (AUD). The prevalence of HED among the general adult population is especially high in Paraguay and Dominica (Figure 1) ().

Figure 1. Heavy episodic drinking among those 15+ years old, Region of the Americas

Source: Population (15+ years old) – WHO. Global status report on noncommunicable diseases, 2014; Population (15–19 years old) – Global information system on alcohol and health.
Note: Percent of population that consumed at least 60 g or more of pure alcohol on at least one occasion in the past 30 days. Heavy episodic drinking is defined as the proportion of the population who have had at least 60 g or more of pure alcohol on at least one occasion in the past 30 days. Consumption of 60 g of pure alcohol corresponds to approximately six standard alcoholic drinks. Numerator: the (appropriately weighted) number of respondents who reported drinking 60 g or more of pure alcohol on at least one occasion in the past 30 days. Denominator: the total number of participants responding to the corresponding question(s) in the survey plus abstainers.

The prevalence of AUD is one reflection of the negative health harms attributable to alcohol consumption. This indicator is commonly used as a proxy for alcohol-related morbidity and mortality. The prevalence of AUD among women in the Region is the highest in the world (). Men and women, across all age groups, show differences in the prevalence of HED. As with total consumption, men are much more likely than women to engage in HED. Youth, too, are generally much more likely than adults to engage in risky alcohol-consumption patterns, following the same gender pattern. HED prevalence among all adolescents 15–19 years of age is the second largest in the world (29.3% of males and 7.1% of females), after Europe. In the Region of the Americas, Canada and Chile have the highest prevalence (Figure 1). In addition, the majority of adolescents aged 13–15 years, boys and girls, report alcohol consumption starting before the age of 14 years, which places them at a higher risk of escalating their drinking as they age and of developing an alcohol use disorder later in life ().

Insufficient physical activity

Regular physical activity (RPA) in adults reduces the risk of ischemic heart disease, stroke, diabetes, and breast and colon cancer. RPA is a determinant of energy expenditure and, along with health eating, can impact one’s weight control and prevention of obesity (). The evidence available also shows that physical activity is positively related to cardiorespiratory and metabolic health in children and youth. There are health benefits expected in most children and youth who accumulate 60 or more minutes of moderate to vigorous physical activity daily (). Unfortunately, obesity has reached epidemic proportions in the Americas, and efforts focusing on healthy eating and promoting physical activities play an important preventive role (). Estimates reported on insufficient physical activity for 2010 in adolescents and adult populations are similar to the global level. Approximately 81% of school-going adolescents (11–17 years) were insufficiently physically active in the Americas, with girls (87.1%) being less active than boys (75.3%) (). The age-standardized prevalence estimates for 2010 in adults (18+) show that the Americas had the highest prevalence of insufficient physical activity (32%) within WHO Regions, with an absolute difference between females (36.6%) and males (26.3%) of 10% ().

Salt/sodium intake

Hypertension and cardiovascular diseases are associated with increased consumption of dietary salt/sodium. High levels of salt/sodium consumption contribute to approximately 30% of hypertension cases (). WHO recommends reducing salt intake to less than 5 g/day (equivalent to 2 g/day of sodium) to reduce blood pressure and the risk of coronary heart disease and stroke ().

Current estimates suggest that the global mean intake of salt is around 10 g of salt daily (4 g/day of sodium) (). Among countries in the Americas where data are available, the salt intake was found to vary but be very high. In the United States and Canada, the average daily salt intakes per person are 8.7 and 8.5 g, respectively. In Latin America, Argentina’s average salt intake per day per person is 12 g, Brazil’s is 11 g, and Chile’s is 9 g ().

Studies have shown that in developed countries, processed foods contribute the most to salt consumption, while in some countries like Brazil, the evidence shows that salt added at the table or while cooking largely contributes to the amount of salt intake for that population ().

Tobacco use

Tobacco use is a common risk factor for cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes. It also has a causality link to many other diseases and adverse health effects (). Implementing tobacco control policies will have a positive impact in lessening the burden of NCDs.

In 2013, the age-standardized prevalence estimate for current tobacco smoking among persons aged 15 and older in the Americas was 17.5%, with males smoking more than females (). Although the gender gap varies widely between countries, there are countries such as Canada, Chile, and United States of America where this gap is narrowed with an absolute difference in the prevalence of current tobacco smoking among males and females of just 4% to 5% () (Figure 2).

Figure 2. Prevalence of current tobacco smoking among persons 15+ years old and current tobacco use among adolescents (13–15 years old), Region of the Americas

Source: PAHO. Report on tobacco control for the Region of the Americas, 2016.
Note: Age-standardized prevalence of current tobacco smoking among persons aged 15+ years old, 2013: percentage of the population of 15 years or more that smoked any tobacco product during the 30 days previous to the survey. This includes daily and occasional smokers. The data were standardized by age for the year 2013 for the countries with available information. These data should be used strictly in order to make comparisons between countries, not to calculate the absolute number of smokers in a given country. Data are not available or could not be standardized for: Antigua and Barbuda, Bahamas, Belize, Dominica, El Salvador, Grenada, Guatemala, Guyana, Nicaragua, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, and Venezuela (Bolivarian Republic of).

Prevalence of current tobacco use among adolescents (13–15 years old), most recent survey: percentage of youth 13–15 years old that used, at least once, any tobacco product, smoked or smokeless, during the past 30 days previous to the survey. Whenever possible, data correspond to the national area. In Colombia, Ecuador, Honduras, and Nicaragua, the data available were subnational. In all of the countries, except Brazil, Canada, Chile, and the United States of America, data were provided by GYTS. The data reported by Brazil correspond to the 9th grade and the data for Canada to the 7th–9th grades. The indicator reported by Canada was for current tobacco smoking, while the United States of America was for current cigarrete smoking. The fact that the surveys were conducted in different years needs to be taken into account. GYTS (Global Youth Tobacco Survey), GSHS (Global School-based Student Health Survey), PeNSE (Pesquisa Nacional de Saúde), YSS (Youth Smoking Survey).

Among students 13–15 years old, the prevalence of current tobacco use is especially worrying. In the Americas, 13.5% of this cohort currently use tobacco (14.7% male and 12.3% female). The highest prevalence was found in Non-Latin Caribbean countries (23.2%) and in the majority of countries from the Southern Cone (21.7%) subregion. There is a characteristic in the pattern of consumption in adolescents that needs to be highlighted. In this population, the gap among males and females is limited in most of the countries in the Region, with 5% or less absolute difference, but in some countries, such as Chile (male 19.8% and female 27.8%) and Uruguay (male 12.7% and female 12.5%), females are using more than males or have a similar pattern of tobacco use as males () (Figure 2).

The consumption of novel smoking methods such as electronic nicotine and non-nicotine delivery systems (ENDS/ENNDS) and other tobacco products such as water-pipes and smokeless tobacco is growing in the Region, where smoking manufactured cigarettes was most common in the past. Therefore, surveillance systems should include the monitoring of ENDS/ENNDS products, and more research is needed to understand the public health consequences of their use ().

Studies have shown that a decline of 50% by 2025 in the prevalence of tobacco use as defined by the Global Monitoring Framework (GMF) targets and indicators can avert many deaths and consequently improve health outcomes at the Regional and global level ().

Raised blood pressure

Raised or high blood pressure, commonly known as hypertension, continues to have a negative impact on mortality and on the development of cardiovascular diseases and other NCDs, both globally and in the Americas (). Uncontrolled raised blood pressure and/or hypertension can cause stroke, myocardial infarction, cardiac failure, dementia, renal failure, and blindness (). Among all of the diseases related with hypertension, the heaviest burden is on the cardiovascular diseases (CVDs). Tackling hypertension will avert many diseases, disabilities, and deaths.

In 2014, the age-standardized prevalence of raised blood pressure in the Americas was lower (18.7%) compared to the global prevalence of 22% (). Among countries in the Americas, the prevalence of raised blood pressure varied from 13.3% in Canada to 23.3% in Brazil, in 2014. In all countries of the Region, males have a higher prevalence than females, but there are subregions such as the Central American Isthmus (Male: 23.7%, Female: 21.0%), Latin Caribbean (Male: 25.1%, Female: 22.1%), and Non-Latin Caribbean male 23.7% and female 21.0%), Latin Caribbean (male 25.1% and female 22.1%), and Non-Latin Caribbean (male 24.7% and female 20.4%) where the gap between males and females is narrower ().

Hypertension assessment and management is critical for the prevention and control of CVDs (). Not addressing hypertension in a timely fashion will have significant economic and social impacts since the number of people affected by hypertension has been predicted to rise by 2025 ().

Raised blood glucose/diabetes

Raised blood glucose is a common effect of uncontrolled diabetes and may, over time, lead to serious damage to blood vessels, eyes, kidneys, and nerves, and increase the risk of heart attack and stroke (). It was estimated that, in 2014, around 422 million adults aged over 18 years were living with diabetes worldwide, with 62 million (15.0%) of them living in the Americas. This number has tripled in the Region since 1980 ().

In 2014, 68% of the adult population with diabetes in the Americas lived in just three countries: the United States of America (22.4 million), Brazil (11.7 million), and Mexico (8.6 million). The largest rise in the number of people living with diabetes from 1980 to 2014 occurred in Mexico (five times higher) and Brazil (four times higher). In the the United States of America, the increase was almost three times higher during the same period, but still lower compared to the increases in Brazil and Mexico (). The overall prevalence of raised blood glucose in the Americas increased from 5.0% in 1980 to 8.3% in 2014 (8.6% males and 8.4% females) ().

The increase in the prevalence of diabetes may be explained as a result of the population growth and aging, the rise in age-specific prevalence, or a combination of these two aspects (). The associated risk factors of overweight and obesity, together with insufficient physical activity, are estimated to cause a large proportion of the diabetes burden ().

Overweight and obesity

Obesity increases the likelihood of diabetes, hypertension, coronary heart disease, stroke, certain cancers, obstructive apnea, and osteoarthritis. It also negatively affects reproductive performance. The link between obesity, poor health outcomes, and all-cause mortality is well established ().

In the Americas in 2014, the age-standardized estimate for the adult (18 years and over) prevalence of overweight and obesity (with a body mass index [BMI] ≥ 25 kg/m2) was 61.0% (62.8% for males and 59.8% for females). The Americas ranks as the WHO Region with the highest prevalence of overweight and obesity (). In the Region, the countries with the highest prevalence of overweight and obesity are the Bahamas (69.0%), the United States of America (67.3%), Canada and Mexico (64.4%), and Chile (63.1%) () (Figure 3).

Figure 3. Age-standardized prevalence of overweight and obesity among persons 18+ years old, Region of the Americas, 2014

Source: WHO. Global status report on noncommunicable diseases, 2014.
Note: Prevalence of overweight and obesity among persons 18+ years old (defined as body mass index [BMI] ≥ 25 kg/m2). This information is based on aggregated data obtained through a review of published and unpublished literature gathered by WHO and collaborating groups. The inclusion criteria for estimation analysis included data that had come from a random sample of the general population, with clearly indicated survey methods (including sample sizes) and definitions used for this indicator. Using regression modeling techniques, adjustments were made so that the same indicator could be reported for the year 2014 in all countries. Age-standardized comparable estimates were produced by adjusting the crude age-specific estimates to the WHO Standard Population that reflects the global age and sex structure.

Regarding obesity (BMI ≥ 30 kg/m2), the prevalence in the Americas in 2014 was more than double the global average (26.8% versus 12.9%), with females having a higher prevalence (29.6%) than males (24.0%). Obesity poses a major health problem throughout the Region. The highest prevalence of obesity was found in the Bahamas (36.2%), USA (33.7%), Canada and Mexico (28.0%), and Chile (27.8%) ().

A study on pooled population-based data to determine trends from 1975 to 2014 reported the 10 countries with the largest obesity populations worldwide. Among these top 10 countries, the USA, which ranked first in 1975, ranked second in 2014, with 87.8 million obese people (41.7 million males and 46.1 million females). Brazil ranks third (29.9 million total), and Mexico is sixth (22.8 million total) globally. In both countries, the number of obese females is almost double that of males ().

The prevalence of overweight and obesity in children has become a major problem in the Americas. The main reasons for this are changes in lifestyle and the lack of policies promoting healthy diet and physical activity. As a result, obesity among children and adolescents has reached epidemic proportions in the Americas ().

The latest estimates produced for the Region (2012) show a prevalence of 7.2% for overweight in children aged less than 5 years (). For school-going adolescents (13-15 years), the prevalence of obesity ranges from 21.0% in the Bahamas to 4.1% in Guyana. The data presented for overweight and obesity show that this is a major public health problem that requires urgent actions.

NCDs in figures

In 2012, a 30-year-old individual living in the Americas had a 15.4% chance of dying from any of the four major NCDs (CVDs, cancer, diabetes, or chronic respiratory diseases) before reaching the age of 70. This probability is lower than the global-level estimate in 2012, where the same individual had a 19.4% chance of dying before reaching 70 years of age. Premature mortality in the Americas varied across the subregions from 18.6% in the Non-Latin Caribbean to 11.4% in the Andean Area, for an absolute difference of 7.2 percentage points. Premature mortality tends to be higher in men (18.5%) than in women (13.0%) in all subregions ().

Cardiovascular diseases

Cardiovascular diseases (CVDs) are the leading cause of death in the Region. The main risk factors are tobacco use, obesity, hypertension, and high cholesterol. Even so, CVD mortality has declined steadily in most countries in the Americas, with an overall reduction of 19% from 2000 to 2010 (20% in women and 18% in men). One-third of the 1.8 million annual deaths from CVDs in the Americas occur in people under 70 years of age; however, this figure declined by 21% during the period 2000-2010 ().

There are striking disparities among countries, with 56.7% and 20.6% excess CVD mortality in lower-middle and upper-middle income countries, respectively. Canada and the United States had the greatest decline in average annual percent change from 2000–2010. However, in 2010, the Bahamas, Brazil, the Dominican Republic, Guyana, and Trinidad and Tobago had a premature mortality rate from CVDs that surpassed the Regional average ().

Regional estimates for the unconditional probability of dying from CVDs from age 30 to 70 are higher for men than women, with men nearly twice as likely to die from CVDs as women (8.6% and 4.6%, respectively) ().

Cancer

Cancer affects almost 3 million people in the Americas each year, and in 2012, 1.3 million people died from cancer (). Approximately 45% of these cancer deaths are premature, occurring in persons under 70 years of age, including almost 9,000 children under 14 years of age (). In men, in Latin America and the Caribbean (LAC), prostate, lung, stomach, and colorectal cancers are the leading causes of cancer deaths; whereas in women, the leading causes are breast, stomach, lung, cervical, and colorectal cancers. In contrast, lung cancer is the leading cause of cancer death for both sexes in Canada and the United States ().

Cancer mortality is typically higher in men, driven by high rates of lung and prostate cancers. The exceptions are El Salvador and Nicaragua, where female cancer rates are higher owing to the high death rates from cervical and stomach cancers. Cancer mortality is relatively stable in the Region, yet overall cancer mortality for both sexes is decreasing in nine countries (Argentina, Brazil, Canada, Chile, Mexico, Nicaragua, Paraguay, USA, and Venezuela) and only slightly increasing in Cuba (). Although cancer incidence in Latin America is, in general, lower than the cancer incidence in more developed regions of the world, mortality is higher in LAC. This may be explained, in part, by the more advanced stages at cancer diagnosis and by poorer access to cancer diagnostic, screening, and treatment services ().

Diabetes

Diabetes is a chronic metabolic disease and one of the most prevalent chronic diseases globally (). It is estimated that, in 2012, there were 305,000 deaths directly caused by diabetes, representing 5% of all NCD deaths in the Americas ().

An analysis of premature mortality from diabetes revealed that a 30-year-old individual living in the Americas had a 1.7% chance of dying from diabetes before reaching the age of 70. In 61% of the countries, the premature mortality is higher than the Regional estimates (1.7%). Guyana, Belize, Trinidad and Tobago, Mexico, and Honduras ranked as the top five countries in this category, with a premature mortality over 5.4%. In contrast, Canada, the Cayman Islands, Martinique, Uruguay, and Cuba reported the least premature mortality, below 0.8% ().

The 2014 age-standardized death rate for type 2 diabetes in the Americas shows a slight difference between males (35.6) and females (31.6) per 100,000 population (). Implementing population-based interventions to prevent diabetes, along with early detection, healthy lifestyles, and pharmacological interventions, can prevent or delay
complications from diabetes.

Chronic respiratory diseases

Chronic respiratory diseases (CRDs) are chronic diseases of the airways and other structures of the lung. The most common CRDs are asthma, chronic obstructive pulmonary disease, occupational lung diseases, and pulmonary hypertension (). Tobacco smoking, indoor and outdoor air pollution, allergens, occupational risks such as exposure to chemicals and dusts, and frequent lower respiratory infections are major risk factors for CRDs ().

CRDs pose a significant burden of disability and death in the population, causing around 413,000 of all NCD deaths (6.4%) in 2012 (). Premature mortality from CRDs in the Americas shows a slight downward trend from 1999 to 2013, which has stagnated in recent years. In 2013, a 30-year-old individual living in the Region had a 1.4% chance of dying from CRD before reaching the age of 70. The probability of dying prematurely from CRD is higher in men than in women. Out of 44 countries and territories with available data from the Region, only eight (18%) have premature mortality higher than the Regional estimate of 1.4%: French Guiana (2.8%), Argentina (2.1%), Belize (1.96%), the Dominican Republic (1.93%), Honduras (1.7%), Brazil (1.49%), Uruguay (1.46%), and the USA (1.45%) ().

CRDs constitute a major NCD group, with lower levels of premature mortality in the Americas; however, as drivers of NCDs, urbanization together with tobacco use and indoor and outdoor air pollution, mainly in urban areas, need to be monitored and controlled to prevent an increase of CRD morbidity and mortality ().

Chronic kidney disease

Chronic kidney disease (CKD) has been identified as an increasing public health issue worldwide and deserves focused attention in the Americas (). Over the past two decades, the Central American Isthmus has reported a growing number of cases of people suffering and dying from CKD. Among these cases, a significant number have a type of CKD whose etiology is not linked to the most frequent causes of this disease, such as diabetes and hypertension. This type of CKD is most common among young male agricultural workers in clusters of agricultural and traditionally socioeconomic-deprived communities. It has been associated mainly with various factors including environmental determinants like the misuse of agrochemicals, and occupational risks such as inadequate occupational health and insufficient water intake (). In 2013, this form of CKD was recognized as a serious public health problem affecting agricultural communities in Central America ().

A mortality analysis of CKD of non-traditional causes (CKDnT) showed that in El Salvador, mortality increased from 18.7 deaths in 1997 to 47.4 deaths (per 100,000 population) in 2012, a 2.5-fold increase. In Nicaragua, mortality increased from 23.9 deaths in 1997 to 36.7 (per 100,000 population) in 2013, a 1.5-fold increase. These two countries have the highest death rates and an upward exponential trend compared to the rest of the Region. The death rate is high for both men and women, with a disproportionate excess in men. Multisectoral efforts are urgently needed to improve the social, environmental, occupational, and economic conditions of the affected communities ().

NCDs affect all

The burden of death, diseases, and disabilities related to NCDs affects all but is heavily concentrated in low- and middle-income countries. NCDs act as key barriers to development and poverty alleviation and as such are part of the sustainable development agenda ().

Countries in the Americas have made commitments to address and effectively monitor NCDs (). The cost of inaction will negatively impact on the health and socioeconomic sectors. Some progress has been made in the Region (as discussed in Chapter 2), but the data presented in this section show that there is still a long way to go.

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Reference/Note:

Regional Office for the Americas of the World Health Organization
525 Twenty-third Street, N.W., Washington, D.C. 20037, United States of America