بسم الله الرحمن الرحيمبسم الله الرحمن الرحيم

الحمد لله رب العالمين الحمد لله رب العالمين والصالة والسالم على والصالة والسالم على

نبينا محمد خاتم األنبياء نبينا محمد خاتم األنبياء وسيد المرسلين وعلى وسيد المرسلين وعلى

آله وصحبه أجمعين آله وصحبه أجمعين وبعدوبعد

Epidemiology of Chronic Epidemiology of Chronic diseasesdiseases

Non communicable Non communicable diseasesdiseases

Chronic diseases have been Chronic diseases have been defined as :defined as :

Chronic illnesses. Chronic illnesses. Non-Communicable. Non-Communicable. Degenerative. Degenerative.

Characteristics: Characteristics:

Uncertain etiology.Uncertain etiology. multiple risk factors.multiple risk factors. long latency period .long latency period . Prolonged course of illness.Prolonged course of illness. non- contagious origin.non- contagious origin. functional disability and sometimes functional disability and sometimes

incurability . incurability .

Latency periodLatency period is the period between contact of is the period between contact of the causative agent with susceptible host to the the causative agent with susceptible host to the onset of first sign a symptoms.onset of first sign a symptoms.

The cause of many chronic diseases remains The cause of many chronic diseases remains obscure, but risk factors identified for some of obscure, but risk factors identified for some of the leading chronic diseases. The most the leading chronic diseases. The most important among these risk factor is Tobacco important among these risk factor is Tobacco use especially in COPD .use especially in COPD .

Strategies for the preventionStrategies for the prevention

Approach to prevention of chronic Approach to prevention of chronic diseases can be considered diseases can be considered under three headings :under three headings :

1-Primordial prevention: prevention or 1-Primordial prevention: prevention or avoiding the development of risk factors avoiding the development of risk factors in the community to prevent the disease in the community to prevent the disease in the population and as such protects in the population and as such protects the individuals. This involves the the individuals. This involves the avoidance of risk behaviors.avoidance of risk behaviors.

prevention of disease occurrence by prevention of disease occurrence by altering susceptibility of the host or altering susceptibility of the host or reducing exposure of susceptible reducing exposure of susceptible persons to the risk factors persons to the risk factors

Examples : immunization , good Examples : immunization , good nutrition , health education , nutrition , health education ,

counseling, environmental sanitation, counseling, environmental sanitation, purification of water , protection against purification of water , protection against accidents at work place and seat belts.accidents at work place and seat belts.

Requires : accurate knowledge of Requires : accurate knowledge of causative agent and process of disease.causative agent and process of disease.

2-Primary prevention : Modifying or 2-Primary prevention : Modifying or reducing the risk factors associated with reducing the risk factors associated with the development of a disease in the development of a disease in individuals with or without the use of individuals with or without the use of interventions, It involves modification of interventions, It involves modification of established risk behavior and risk factors established risk behavior and risk factors with specific interventions to prevent with specific interventions to prevent clinically manifest disease clinically manifest disease

That is by early detection , screening by That is by early detection , screening by examinations altering the course of examinations altering the course of disease disease

Examples : high blood pressure , T.B. Examples : high blood pressure , T.B. Diabetes , Cancer of the breast , Cancer Diabetes , Cancer of the breast , Cancer of the cervix colo-rectal cancers, lung of the cervix colo-rectal cancers, lung cancer etc. cancer etc.

3- Secondary prevention : Modifying the 3- Secondary prevention : Modifying the risk factors in the presence of the risk factors in the presence of the manifested disease by changes in manifested disease by changes in lifestyle and/or use of drugs.lifestyle and/or use of drugs.

4- Tertiary Prevention : alleviation 4- Tertiary Prevention : alleviation and limitation of disability and limitation of disability improvement of quality of life , improvement of quality of life , RehabilitationRehabilitation and follow up. and follow up.

What would be the top 10 causes What would be the top 10 causes of their deaths? of their deaths?

99

The major non communicable The major non communicable diseases are :diseases are :

Cardiovascular Diseases.Cardiovascular Diseases. Chronic Obstructive Pulmonary DiseaseChronic Obstructive Pulmonary Disease DiabetesDiabetes HypertensionHypertension CancersCancers

• Accidents in its different typesAccidents in its different types

Non communicable diseases also include Non communicable diseases also include injuries, which have an acute onset, but injuries, which have an acute onset, but may be followed by prolonged may be followed by prolonged convalescence and impaired function, as convalescence and impaired function, as well as chronic mental diseases.well as chronic mental diseases.

Out of all non-communicable illnesses, Out of all non-communicable illnesses, cardiovascular diseases stay as the cardiovascular diseases stay as the leading cause of morbidity and mortality , leading cause of morbidity and mortality , especially in developed and rich countries. especially in developed and rich countries. All over the world, almost 1.5 million All over the world, almost 1.5 million adults and elderly died in 1995 from heart adults and elderly died in 1995 from heart disease, stroke or other forms of disease, stroke or other forms of circulatory disease. circulatory disease.

Cancer is a growing health problem in Cancer is a growing health problem in developing countries, where more than developing countries, where more than half of the global total of six million deaths half of the global total of six million deaths occur.occur.

Noncommunicable diseases (NCDs) are a Noncommunicable diseases (NCDs) are a global challenge. During the next several global challenge. During the next several decades, NCDs will govern the health care decades, NCDs will govern the health care needs of populations in most low- and needs of populations in most low- and middle-income countries because of middle-income countries because of declines in communicable diseases, declines in communicable diseases, conditions related to childbirth and conditions related to childbirth and nutrition, changes in lifestyle factors (eg, nutrition, changes in lifestyle factors (eg, smoking), and population aging (1). smoking), and population aging (1).

We examined the burden of NCDs in the We examined the burden of NCDs in the Hashemite Kingdom of Jordan. We Hashemite Kingdom of Jordan. We computed the projected prevalence of computed the projected prevalence of diabetes, hypertension, and high blood diabetes, hypertension, and high blood cholesterol. All of these risk factors are cholesterol. All of these risk factors are associated with an increased risk of associated with an increased risk of cardiovascular disease (CVD) — the cardiovascular disease (CVD) — the leading cause of death in Jordan — and leading cause of death in Jordan — and increased health care use.increased health care use.

In 2005, Jordan’s population was In 2005, Jordan’s population was approximately 5.5 million. By 2050, the approximately 5.5 million. By 2050, the population is expected to increase to population is expected to increase to between 8.5 and 14.8 million people. (2) between 8.5 and 14.8 million people. (2) The proportion of older people (aged 60 The proportion of older people (aged 60 years or older) is expected to be 15.6% (or years or older) is expected to be 15.6% (or approximately 1.8 million people) in 2050, approximately 1.8 million people) in 2050, more than 3 times that in 2000 (2).more than 3 times that in 2000 (2).

During 2005, NCDs accounted for more During 2005, NCDs accounted for more than 50% of all deaths in Jordan. Heart than 50% of all deaths in Jordan. Heart disease and stroke (International disease and stroke (International Statistical Classification of Diseases, 10th Statistical Classification of Diseases, 10th Revision, codes I00-I99) accounted for Revision, codes I00-I99) accounted for 35% of all deaths; malignant neoplasms 35% of all deaths; malignant neoplasms (C00-C97) were responsible for 13% of (C00-C97) were responsible for 13% of deaths (3). deaths (3).

Nearly 60% of deaths from malignant Nearly 60% of deaths from malignant neoplasms occurred among people neoplasms occurred among people younger than 65 years, and approximately younger than 65 years, and approximately one-third of those who died from CVD one-third of those who died from CVD were aged 65 or youngerwere aged 65 or younger

During 2004, approximately 400,000 During 2004, approximately 400,000 (15%) Jordanian adults had diabetes (an (15%) Jordanian adults had diabetes (an increase from 7% in 1996), and an increase from 7% in 1996), and an estimated 350,000 (12%) had impaired estimated 350,000 (12%) had impaired fasting glucose (4,5). Approximately 15% fasting glucose (4,5). Approximately 15% of adults reported hypertension, and of adults reported hypertension, and roughly 23% had high blood cholesterol — roughly 23% had high blood cholesterol — an increase from 9% in 1996 (4,5). an increase from 9% in 1996 (4,5).

The proportion of all deaths attributable to The proportion of all deaths attributable to NCDs in the World Health Organization's NCDs in the World Health Organization's Eastern Mediterranean Region is Eastern Mediterranean Region is projected to increase from 51% during projected to increase from 51% during 2005 to 66% by 2030 (6). 2005 to 66% by 2030 (6). 

Assuming prevalences are similar to that Assuming prevalences are similar to that in Jordan, diabetes may affect nearly 10 in Jordan, diabetes may affect nearly 10 million people in Egypt, one of the region’s million people in Egypt, one of the region’s largest countries, and 3 million people in largest countries, and 3 million people in Saudi Arabia. Hypertension may affect 18 Saudi Arabia. Hypertension may affect 18 million Egyptians and 6.5 million people in million Egyptians and 6.5 million people in Saudi Arabia by 2050. Saudi Arabia by 2050.

Programs to monitor and control risk Programs to monitor and control risk factors, clinical services, and a robust factors, clinical services, and a robust health care system will be important to health care system will be important to successfully improve NCD outcomes and successfully improve NCD outcomes and reduce the burden of disease. reduce the burden of disease.

Reducing the prevalence of NCDs will Reducing the prevalence of NCDs will require a renewed commitment by require a renewed commitment by governmental and nongovernmental governmental and nongovernmental institutions, by public health professionals institutions, by public health professionals and clinical practitioners, and by and clinical practitioners, and by communities and individuals to communities and individuals to acknowledge the burden of NCDs and the acknowledge the burden of NCDs and the need for timely action. need for timely action.

Moreover, stimulating, strengthening, and Moreover, stimulating, strengthening, and sustaining regional efforts and programs sustaining regional efforts and programs are necessary to reduce the prevalence of are necessary to reduce the prevalence of NCDs through coordinated and integrated NCDs through coordinated and integrated programs of health promotion and disease programs of health promotion and disease prevention. prevention.

These programs should involve networks These programs should involve networks for risk factor surveillance, information for risk factor surveillance, information sharing, capacity building, advocacy, sharing, capacity building, advocacy, policy development, and collaboration in policy development, and collaboration in generating, disseminating, and applying generating, disseminating, and applying knowledge.knowledge.

Common CVD Common CVD Risk FactorsRisk Factors

1-Tobacco use.1-Tobacco use. 2-Physical inactivity.2-Physical inactivity. 3- Unhealthy diet. 3- Unhealthy diet. Life expectancy in developing countries is Life expectancy in developing countries is

rising sharply and people are exposed to rising sharply and people are exposed to these risk factors for longer periods. these risk factors for longer periods.

Newly merging CVD risk Newly merging CVD risk factors: factors:

Like low birth weight.Like low birth weight. folate deficiency.folate deficiency. Infections.Infections. Social class: more frequent among the Social class: more frequent among the

poorest in low and middle income poorest in low and middle income countries.countries.

HypertensionHypertension

Prevalence:Prevalence: Hypertension is estimated to cause Hypertension is estimated to cause 4.5% of 4.5% of

current global disease burdencurrent global disease burden and is as and is as prevalent in many developing countries, as in prevalent in many developing countries, as in the developed world. Blood pressure-induced the developed world. Blood pressure-induced cardiovascular risk rises continuously across the cardiovascular risk rises continuously across the whole blood pressure range. Countries vary whole blood pressure range. Countries vary widely in capacity for management of widely in capacity for management of hypertension, but worldwide the majority of hypertension, but worldwide the majority of diagnosed hypertensive are inadequately diagnosed hypertensive are inadequately controlled. controlled.

Hypertension affects Hypertension affects one in four adults,one in four adults, putting them at higher risk for heartputting them at higher risk for heart

attacks, kidney disease, atherosclerosis, attacks, kidney disease, atherosclerosis, macular degeneration and stroke. It ismacular degeneration and stroke. It is

often termed the often termed the "silent killer" "silent killer" because because as many as 35% of those who haveas many as 35% of those who have

hypertension do not realize it. hypertension do not realize it.

More than 60% More than 60% of all women over age 65 of all women over age 65 have hypertension. Women over age 75 have hypertension. Women over age 75 are much moreare much more likely to develop the likely to develop the disease than men.disease than men...

HTN is a major public health problem of HTN is a major public health problem of worldwide distribution and is the most worldwide distribution and is the most common cardiovascular disease (CVD) common cardiovascular disease (CVD) risk factor . It is responsible for one half of risk factor . It is responsible for one half of coronary heart disease (CHD) and about coronary heart disease (CHD) and about two thirds of cerebrovascular accidents. two thirds of cerebrovascular accidents. By 2030, 23 million cardiovascular deaths By 2030, 23 million cardiovascular deaths are projected to have HTN, with about are projected to have HTN, with about 85% occurring in low and middle-income 85% occurring in low and middle-income countries . countries .

Research published between 1980 and Research published between 1980 and 2002 indicate the prevalence of HTN in 2002 indicate the prevalence of HTN in developing countries increased at a higher developing countries increased at a higher rate than in developed countries . rate than in developed countries . Prevention of HTN is possible, and early Prevention of HTN is possible, and early detection and treatment can reduce the detection and treatment can reduce the incidence of complications including incidence of complications including stroke, CHD, heart failure, and kidney stroke, CHD, heart failure, and kidney disease , and yet the levels of control of disease , and yet the levels of control of hypertension are low worldwide. hypertension are low worldwide.

Economically developed countries have Economically developed countries have higher rates of HTN than in developing higher rates of HTN than in developing countries . However, data reported in the countries . However, data reported in the last decade indicate that the prevalence, last decade indicate that the prevalence, awareness, treatment, and control of awareness, treatment, and control of hypertension in economically developing hypertension in economically developing countries are coming closer to those in countries are coming closer to those in economically developed countries .economically developed countries .

Recent epidemiological studies on Recent epidemiological studies on prevalence, awareness, treatment, and prevalence, awareness, treatment, and control of HTN in Jordan are scarce. The control of HTN in Jordan are scarce. The few community-based studies conducted few community-based studies conducted between 1994 and 1996 in Jordan between 1994 and 1996 in Jordan demonstrated a 16.1 and 16.3% demonstrated a 16.1 and 16.3% prevalence rates of HTN (cut-off point prevalence rates of HTN (cut-off point 160/90 mm Hg) with concomitant low 160/90 mm Hg) with concomitant low levels of awareness, treatment, and levels of awareness, treatment, and control. control.

Since that time, several activities have Since that time, several activities have been implemented to face this challenge in been implemented to face this challenge in HTN which have not been evaluated. HTN which have not been evaluated. Moreover, the last decades showed a Moreover, the last decades showed a remarkable improvement in treatment of remarkable improvement in treatment of hypertension due to introduction of new hypertension due to introduction of new antihypertensive medications and the antihypertensive medications and the development of international guidelines for development of international guidelines for detection and management . detection and management .

Meyasser Zindah, head of the Health Meyasser Zindah, head of the Health Ministry's cardiovascular disease Ministry's cardiovascular disease department, warned of the high department, warned of the high prevalence of heart disease, noting that prevalence of heart disease, noting that 662,527 citizens over the age of 18 662,527 citizens over the age of 18 suffered from high blood pressure in 2007. suffered from high blood pressure in 2007.

Risk FactorsRisk Factors

Uncontrollable risk factors: Uncontrollable risk factors: Increasing age. Increasing age. Family history.Family history. Race, African-Americans are at higher risk Race, African-Americans are at higher risk

than Caucasians).than Caucasians). Sodium sensitivity.Sodium sensitivity.. .

Controllable risk factors: Controllable risk factors:

Overweight or obesity.Overweight or obesity. Physical inactivity. Physical inactivity. Heavy alcohol consumption.Heavy alcohol consumption. Use of oral contraceptives.Use of oral contraceptives. Excessive sodium intake.Excessive sodium intake.. .

Diet:Diet:

Dairy, Fruits & Vegetables, and low fat, Dairy, Fruits & Vegetables, and low fat, high Fibers food may Lower Blood high Fibers food may Lower Blood Pressure Pressure

a recent study suggests that adding a recent study suggests that adding certain foods to the diet may also help. certain foods to the diet may also help. The dairy products act in lowering blood The dairy products act in lowering blood pressure in mildly hypertensive adults.pressure in mildly hypertensive adults.

Fat: Fatty food increases the risk.Fat: Fatty food increases the risk.

Coronary heart disease ( CHD)Coronary heart disease ( CHD)

is the leading cause of death in is the leading cause of death in Industrialized countries Industrialized countries

CHD is also called Ischemic heart disease CHD is also called Ischemic heart disease or coronary artery disease . These are or coronary artery disease . These are several disorders that reduce the blood several disorders that reduce the blood supply to the heart muscle . The supply to the heart muscle . The underlying impairment is the underlying impairment is the atherosclerosis which remains sub atherosclerosis which remains sub clinical . clinical .

Heart Disease Leading Cause of Heart Disease Leading Cause of Death in Jordan     2008Death in Jordan     2008

Heart disease has become a leading Heart disease has become a leading threat to the health of the Jordanian threat to the health of the Jordanian population, with 40.5 percent of population, with 40.5 percent of deaths last year found to be related deaths last year found to be related with heart ailments .with heart ailments .

High risk groupsHigh risk groups::

Gender: Men have a higher CHD mortality rates Gender: Men have a higher CHD mortality rates than women twice for men than women , never than women twice for men than women , never the less, CHD is the single greatest mortality risk the less, CHD is the single greatest mortality risk in women : 3 times the risk of breast cancer.in women : 3 times the risk of breast cancer.

Age : CHD is the leading cause of death for men Age : CHD is the leading cause of death for men and women over 65 years of age.and women over 65 years of age.

For men- major increases in CHD begin in 35-44 For men- major increases in CHD begin in 35-44 year age group.year age group.

For women – marked increase is delayed until For women – marked increase is delayed until after menopause after menopause

Sub- clinical CHD is more prevalent in Sub- clinical CHD is more prevalent in older than younger persons.older than younger persons.

Black women die at a higher rate than Black women die at a higher rate than white women from CHDwhite women from CHD

The Asians in American have The Asians in American have approximately half( ½) the CHD mortality approximately half( ½) the CHD mortality than white Americans.than white Americans.

Risk factors:Risk factors:

Coronary risk factors are modifiable and non-Coronary risk factors are modifiable and non-modifiable .modifiable .

Modifiable :Modifiable : Most important factors are :Most important factors are : high blood cholesterolhigh blood cholesterol elevated blood cholesterolelevated blood cholesterol physical inactivityphysical inactivity smokingsmoking

Other modifiable include :Other modifiable include :

diabetesdiabetes obesityobesity

dietary factors dietary factors alcohol use alcohol use stressstress

Non- modifiable risk factors Non- modifiable risk factors are :are :

Ethnicity.Ethnicity. age.age. gender.gender. socioeconomic status socioeconomic status

Classification of risk factors by Classification of risk factors by magnitude of the riskmagnitude of the risk

moderate relative risk :moderate relative risk : high B.P high B.P 140/90 140/90 : cigarette smoking: cigarette smoking : elevated cholesterol (: elevated cholesterol ( 200mg) 200mg) : diabetes FBS : diabetes FBS 140 mg 140 mg

Weak relative riskWeak relative risk

obesity obesity physical inactivity physical inactivity environmental tobaccoenvironmental tobacco smoke exposuresmoke exposure

Possible relative risk :Possible relative risk :

Excessive alcohol useExcessive alcohol use Elevated plasma homocysteineElevated plasma homocysteine Infectious agents Infectious agents

Selected Risk factors:Selected Risk factors:

Cigarette smoking is a major cause of Cigarette smoking is a major cause of

CHD among men and womenCHD among men and women Smokers have twice the risk of heart Smokers have twice the risk of heart

attack than non-smokers.attack than non-smokers. Risk of sudden death from heart attack 2-Risk of sudden death from heart attack 2-

4 times higher than the risk of non-4 times higher than the risk of non-smokers Heavy smokers , CHD death is 2-smokers Heavy smokers , CHD death is 2-3 times than non-smokers 3 times than non-smokers

Stop smoking : rapid reduction of CHD Stop smoking : rapid reduction of CHD mortality it takes 10 years to become mortality it takes 10 years to become normal.normal.

Passive smoking – increased risk of CHD Passive smoking – increased risk of CHD than non-exposed.than non-exposed.

Arteriography of non-smoking exposed Arteriography of non-smoking exposed women with CHD showed number of women with CHD showed number of stenotic arteries correlated with exposure.stenotic arteries correlated with exposure.

Importance of this health problem.Importance of this health problem.

Cholesterol : CHD increases steadily Cholesterol : CHD increases steadily with increase of cholesterol blood level.with increase of cholesterol blood level.

< 200 mg : low risk of CHD< 200 mg : low risk of CHD 240 mg : risk doubles.240 mg : risk doubles.

Excess CHD occurs with levels 220-310 Excess CHD occurs with levels 220-310 mg for people with cholesterol levels 250-mg for people with cholesterol levels 250-300 mg range. Each 1% reduction in 300 mg range. Each 1% reduction in cholesterol level results in about a 2% cholesterol level results in about a 2% reduction in CHD morbidity and mortality .reduction in CHD morbidity and mortality .

High levels of LDL are leading factor in High levels of LDL are leading factor in progression of atherosclorosis and progression of atherosclorosis and development of CHD.development of CHD.

Evidence supporting the association of Evidence supporting the association of elevated blood triglycerides and CHD has elevated blood triglycerides and CHD has been mounting in recent years. The level been mounting in recent years. The level of HDL is inversely related to CHD of HDL is inversely related to CHD however the lower level of HDL < 35mg however the lower level of HDL < 35mg increases the risk of CHD.increases the risk of CHD.

DiabetesDiabetes is considered a major CHD risk is considered a major CHD risk factor CHD is the most common cause of factor CHD is the most common cause of morbidity and mortality among diabetics – 2-4 morbidity and mortality among diabetics – 2-4 times higher than non-diabetics.times higher than non-diabetics.

Risk is higher in diabetic women than diabetic Risk is higher in diabetic women than diabetic men.men.

Homocysteine , increased attention as a Homocysteine , increased attention as a potential modifiable risk factor for acute CHD.potential modifiable risk factor for acute CHD.

Plasma levels of homocysteine , positively Plasma levels of homocysteine , positively associated with risk of CHD.associated with risk of CHD.

Homocysteine : an inborn metabolic error Homocysteine : an inborn metabolic error leads to extremely high levels of leads to extremely high levels of homocysteine people with this error, have homocysteine people with this error, have strokes before age 30 years .strokes before age 30 years .

People with moderately high People with moderately high homocysteine levels have not been shown homocysteine levels have not been shown to be at increased risk of CHD.to be at increased risk of CHD.

Obesity :Obesity :

. Body mass index (kg/m2) BMI . Body mass index (kg/m2) BMI ( ( weightweight) )

ratio of weight to height > ratio of weight to height > (height ) 2(height ) 2

Overweight : BMI > 27.8 kg/m2 in Overweight : BMI > 27.8 kg/m2 in males males

: BMI > 27.3 kg /m2 in : BMI > 27.3 kg /m2 in females females

prevalence of overweight increased dramatically prevalence of overweight increased dramatically in the USAin the USA

Poverty is related to obesity in womenPoverty is related to obesity in women Death from CHD is associated with obesity at Death from CHD is associated with obesity at

the upper range of body weight BMI the upper range of body weight BMI 30 kg/m2 30 kg/m2 ..

Under the age of 50 years, men and women with Under the age of 50 years, men and women with relative weight of 130% or more – associated relative weight of 130% or more – associated with two fold increase in risk of CHD.with two fold increase in risk of CHD.

Recent studies suggest that the Recent studies suggest that the distribution of fat is the body may effect distribution of fat is the body may effect CHD riskCHD risk

Central obesity – upper body and Central obesity – upper body and abdominal fat increases risk more than abdominal fat increases risk more than lower body fat.lower body fat.

Physical ActivityPhysical Activity

6) Physical in-activity is recognized as a 6) Physical in-activity is recognized as a major risk factor for CHD.major risk factor for CHD.

Physical activity decreases body weight Physical activity decreases body weight blood pressure and improves insulin blood pressure and improves insulin sensitivity .sensitivity .

The greatest benefits appear to occur with The greatest benefits appear to occur with very moderate level of activity.very moderate level of activity.

7) Alcohol consumption:7) Alcohol consumption:

Moderate to heavy increases blood Moderate to heavy increases blood pressure levels and CHD mortality , pressure levels and CHD mortality , however , light regular drinking has been however , light regular drinking has been associated with modest reduction of CHD associated with modest reduction of CHD risk through increasing HDL.risk through increasing HDL.

8) Psychological factors and stress : 8) Psychological factors and stress : especially type A behavior pattern especially type A behavior pattern characterized by excessive characterized by excessive competitiveness, hostility , impatience, fast competitiveness, hostility , impatience, fast

speech and quick motor movements speech and quick motor movements have been studied along with anger, job have been studied along with anger, job stress, anxiety and social support.stress, anxiety and social support.

9) Risk factors for CHD tend to work in 9) Risk factors for CHD tend to work in cluster than individual the patient likely to cluster than individual the patient likely to have more than one risk factor.have more than one risk factor.

CHD increases markedly when risk CHD increases markedly when risk factors manifest simultaneously there is an factors manifest simultaneously there is an additive contribution to CHD risk factors .additive contribution to CHD risk factors .

"This number is much higher than 10 "This number is much higher than 10 years ago," The prevalence of years ago," The prevalence of cardiovascular disease in Jordan is mostly cardiovascular disease in Jordan is mostly due to diet, smoking and pollution, due to diet, smoking and pollution, according to Bassam Hijjawi, director of according to Bassam Hijjawi, director of the ministry's disease control department. the ministry's disease control department.

He also tied the prevalence of the chronic He also tied the prevalence of the chronic disease to a lack of exercise, noting that disease to a lack of exercise, noting that over 60 percent of Jordanians suffering over 60 percent of Jordanians suffering from heart conditions do not participate in from heart conditions do not participate in physical exercises.physical exercises.

In Jordan, the average life expectancy in In Jordan, the average life expectancy in 2002 was 72 years, and chronic diseases 2002 was 72 years, and chronic diseases are becoming increasingly prevalent. are becoming increasingly prevalent. Because personal behavior can influence Because personal behavior can influence the occurrence and progression of many the occurrence and progression of many chronic diseases. chronic diseases.

the Jordan Ministry of Health (JMOH) the Jordan Ministry of Health (JMOH) established surveillance for behavioral risk established surveillance for behavioral risk factors, particularly those related to factors, particularly those related to cardiovascular diseases and diabetes.cardiovascular diseases and diabetes.

This report summarizes the key findings of This report summarizes the key findings of the 2002 Behavioral Risk Factor Survey, the 2002 Behavioral Risk Factor Survey, the first reporting segment in Jordan's the first reporting segment in Jordan's surveillance program for chronic diseases.surveillance program for chronic diseases.

The findings indicate that:The findings indicate that: A- A- SmokingSmoking B- Physical inactivityB- Physical inactivity C- ObesityC- Obesity

contribute substantially to the burden of contribute substantially to the burden of chronic disease in Jordan and chronic disease in Jordan and underscores the need for effective public underscores the need for effective public health interventions. health interventions.

Reported by:Reported by:  F Shehab, MD, Field F Shehab, MD, Field Epidemiology Training Program; A Epidemiology Training Program; A Belbeisi, MD, Jordan Ministry of Health. H Belbeisi, MD, Jordan Ministry of Health. H Walke, MD, Div of International Health, Walke, MD, Div of International Health, Epidemiology Program Office, CDC.Epidemiology Program Office, CDC.

بسم الله الرحمن الرحيمبسم الله الرحمن الرحيم

الحمد لله رب العالمين الحمد لله رب العالمين والصالة والسالم على والصالة والسالم على

نبينا محمد خاتم األنبياء نبينا محمد خاتم األنبياء وسيد المرسلين وعلى وسيد المرسلين وعلى

آله وصحبه أجمعين آله وصحبه أجمعين وبعدوبعد

What is diabetes?What is diabetes?

Diabetes mellitus is a group of diseases Diabetes mellitus is a group of diseases characterized by high levels of blood characterized by high levels of blood glucose resulting from defects in insulin glucose resulting from defects in insulin production, insulin action, or both. production, insulin action, or both. Diabetes can be associated with serious Diabetes can be associated with serious complications and premature death, but complications and premature death, but people with diabetes can take steps to people with diabetes can take steps to control the disease and lower the risk of control the disease and lower the risk of complications.complications.

Types of diabetesTypes of diabetes

Type 1 diabetesType 1 diabetes was previously called was previously called insulin-dependent diabetes mellitus (IDDM) insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes.(5-10%).or juvenile-onset diabetes.(5-10%).

Type 2 diabetesType 2 diabetes was previously called was previously called non-insulin-dependent diabetes mellitus non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes. Type 2 (NIDDM) or adult-onset diabetes. Type 2 diabetes may account for about 90 percent diabetes may account for about 90 percent to 95 percent of all diagnosed cases. to 95 percent of all diagnosed cases.

Gestational diabetes: Gestational diabetes: After pregnancy, 5 After pregnancy, 5 percent to 10 percent of women with percent to 10 percent of women with gestational diabetes are found to have gestational diabetes are found to have type 2 diabetes. Women who have had type 2 diabetes. Women who have had gestational diabetes have a 20 percent to gestational diabetes have a 20 percent to 50 percent chance of developing diabetes 50 percent chance of developing diabetes in the next 5-10 years. in the next 5-10 years.

Other specific typesOther specific types of diabetes result of diabetes result from specific genetic conditions (such as from specific genetic conditions (such as maturity-onset diabetes of youth), surgery, maturity-onset diabetes of youth), surgery, drugs, malnutrition, infections, and other drugs, malnutrition, infections, and other illnesses. Such types of diabetes may illnesses. Such types of diabetes may account for 1 percent to 5 percent of all account for 1 percent to 5 percent of all diagnosed cases of diabetes.diagnosed cases of diabetes.

Risk Factors Risk Factors

The primary risk factor for type 1 The primary risk factor for type 1 diabetesdiabetes

Genetics and family historyGenetics and family history. Having family members . Having family members with diabetes is a major risk factor. The American with diabetes is a major risk factor. The American Diabetes Association recommends that anyone with Diabetes Association recommends that anyone with a first-degree relative with type 1 diabetes -- a a first-degree relative with type 1 diabetes -- a mother, father, sister, or brother -- should get mother, father, sister, or brother -- should get screened for diabetes. A simple blood test can screened for diabetes. A simple blood test can diagnose type 1 diabetes. diagnose type 1 diabetes.

  

Diseases of the pancreasDiseases of the pancreas. Injury or . Injury or diseases of the pancreas can inhibit its diseases of the pancreas can inhibit its ability to produce insulin and lead to ability to produce insulin and lead to type 1 diabetes. type 1 diabetes.

Infection or illness.Infection or illness. A range of relatively A range of relatively rare infections and illnesses can rare infections and illnesses can damage the pancreas and cause type 1 damage the pancreas and cause type 1 diabetes.diabetes.

Risk Factors for Type 2 DiabetesRisk Factors for Type 2 Diabetes

Type 2 diabetes occurs when the body can't Type 2 diabetes occurs when the body can't use the insulin that's produced, a condition use the insulin that's produced, a condition called insulin resistance. Though it typically called insulin resistance. Though it typically starts in adulthood, type 2 diabetes can starts in adulthood, type 2 diabetes can begin anytime in life. Because of the current begin anytime in life. Because of the current epidemic of obesity among U.S. children, epidemic of obesity among U.S. children, type 2 diabetes is increasingly found in type 2 diabetes is increasingly found in teenagers.teenagers.

. .

Obesity or being overweight is a major Obesity or being overweight is a major risk factor for Diabetes Type 2risk factor for Diabetes Type 2. . Diabetes has long been linked to Diabetes has long been linked to obesity and being overweight. obesity and being overweight. Research at the Harvard School of Research at the Harvard School of Public Health showed that the single Public Health showed that the single best predictor of type 2 diabetes is best predictor of type 2 diabetes is being obese or overweightbeing obese or overweight

Obesity and diabetes are both epidemic in the Obesity and diabetes are both epidemic in the U.S. The most-used measure for obesity is BMI, U.S. The most-used measure for obesity is BMI, which stands for body mass index. BMI is a which stands for body mass index. BMI is a ratio, and can be determined using standard ratio, and can be determined using standard tables of height and weight (kg/m2) . A BMI of 25 tables of height and weight (kg/m2) . A BMI of 25 to 29.9 is considered overweight. A BMI of 30 or to 29.9 is considered overweight. A BMI of 30 or higher defines obesity. higher defines obesity. BMI of 40 would be BMI of 40 would be diagnosed with "extreme obesity" or as diagnosed with "extreme obesity" or as having “clinically severe morbid obesity”. having “clinically severe morbid obesity”.

The CDC ( Centers for Disease Control and The CDC ( Centers for Disease Control and Prevention )estimates that more than one out of Prevention )estimates that more than one out of every four Americans is obese, having a BMI of every four Americans is obese, having a BMI of 30 to 39.9; 6% of Americans have clinically 30 to 39.9; 6% of Americans have clinically severe obesity. That means they have a BMI of severe obesity. That means they have a BMI of 40 or greater.40 or greater.

Impaired glucose tolerance or impaired Impaired glucose tolerance or impaired fasting glucose. Prediabetes is a milder form fasting glucose. Prediabetes is a milder form of diabetes that's sometimes called impaired of diabetes that's sometimes called impaired glucose tolerance. It can be diagnosed with a glucose tolerance. It can be diagnosed with a simple blood test. Prediabetes is a major risk simple blood test. Prediabetes is a major risk factor for developing type 2 diabetes. factor for developing type 2 diabetes.

Insulin resistance. Type 2 diabetes Insulin resistance. Type 2 diabetes often starts with cells that are resistant often starts with cells that are resistant to insulin. That means they are unable to insulin. That means they are unable to take in insulin as it moves glucose to take in insulin as it moves glucose from the blood into cells. With insulin from the blood into cells. With insulin resistance, the pancreas has to work resistance, the pancreas has to work overly hard to produce enough insulin overly hard to produce enough insulin so cells can get the energy they need. so cells can get the energy they need. This involves a complex process that This involves a complex process that eventually leads to type 2 diabetes. eventually leads to type 2 diabetes.

Ethnic background. Diabetes occurs Ethnic background. Diabetes occurs more often in Hispanic/Latino more often in Hispanic/Latino Americans, African-Americans, Native Americans, African-Americans, Native Americans, Asian-Americans, Pacific Americans, Asian-Americans, Pacific Islanders, and Alaska natives.Islanders, and Alaska natives.

High blood pressure . Hypertension, or High blood pressure . Hypertension, or high blood pressure, is a major risk high blood pressure, is a major risk factor for diabetes. High blood factor for diabetes. High blood pressure is generally defined as 140/90 pressure is generally defined as 140/90 mm Hg or higher. Low levels of HDL mm Hg or higher. Low levels of HDL "good" cholesterol and high "good" cholesterol and high triglyceride levels also put you at risk. triglyceride levels also put you at risk.

History of gestational diabetes. If you History of gestational diabetes. If you developed diabetes while you were developed diabetes while you were pregnant, you've had what is called pregnant, you've had what is called gestational diabetes. Having had gestational diabetes. Having had gestational diabetes puts you at higher gestational diabetes puts you at higher risk of developing type 2 diabetes later risk of developing type 2 diabetes later in life.in life.

Sedentary lifestyle. Being inactive -- Sedentary lifestyle. Being inactive -- exercising fewer than three times a exercising fewer than three times a week -- makes you more likely to week -- makes you more likely to develop diabetes. develop diabetes.

Family history. Having a family history Family history. Having a family history of diabetes -- a parent or sibling who's of diabetes -- a parent or sibling who's been diagnosed with this condition -- been diagnosed with this condition -- increases your risk of developing type increases your risk of developing type 2 diabetes. 2 diabetes.

Polycystic ovary syndrome. Women with Polycystic ovary syndrome. Women with polycystic ovary syndrome (PCOS) are at polycystic ovary syndrome (PCOS) are at higher risk of type 2 diabetes. higher risk of type 2 diabetes.

Age. Some doctors advise anyone over 45 to Age. Some doctors advise anyone over 45 to be screened for diabetes. That's because be screened for diabetes. That's because increasing age puts you at higher risk of increasing age puts you at higher risk of developing type 2 diabetes. It's important to developing type 2 diabetes. It's important to remember, though, that people at any age remember, though, that people at any age can develop diabetes. If you're over 45 and can develop diabetes. If you're over 45 and overweight or if you have symptoms of overweight or if you have symptoms of diabetes, talk to your doctor about a simple diabetes, talk to your doctor about a simple screening test. screening test.

Gestational Diabetes Risk FactorsGestational Diabetes Risk Factors

Obesity or being overweight. Being Obesity or being overweight. Being obese or overweight puts women at obese or overweight puts women at risk of gestational diabetes.risk of gestational diabetes.

Polycystic ovary syndromePolycystic ovary syndrome Previous glucose intolerance. A history Previous glucose intolerance. A history

of glucose intolerance or previous of glucose intolerance or previous gestational diabetes increases the risk gestational diabetes increases the risk of gestational diabetes in a current of gestational diabetes in a current pregnancy. pregnancy.

Family history. A family history of Family history. A family history of diabetes -- a parent or sibling who's diabetes -- a parent or sibling who's been diagnosed with diabetes -- been diagnosed with diabetes -- increases the risk of gestational increases the risk of gestational diabetes. diabetes.

Age. The older a woman is when she Age. The older a woman is when she becomes pregnant, the higher her risk becomes pregnant, the higher her risk of gestational diabetes.of gestational diabetes.

PreventionPrevention

Whatever your risk factors for diabetes Whatever your risk factors for diabetes may be, there's a lot you can do to delay may be, there's a lot you can do to delay or prevent diabetes. To manage your risk or prevent diabetes. To manage your risk of diabetes, you should:of diabetes, you should:

manage your blood pressure manage your blood pressure keep your weight within or near normal keep your weight within or near normal

ranges ranges get moderate exercise on most days get moderate exercise on most days eat a balanced diet eat a balanced diet

PreventionPrevention

Lifestyle interventions included diet and Lifestyle interventions included diet and moderate-intensity physical activity (such moderate-intensity physical activity (such as walking for 2 1/2 hours each week). In as walking for 2 1/2 hours each week). In the Diabetes Prevention Program, a large the Diabetes Prevention Program, a large prevention study of people at high risk for prevention study of people at high risk for diabetes, the development of diabetes was diabetes, the development of diabetes was reduced 58 percent over 3 years.reduced 58 percent over 3 years.

Prevention or Delay of DiabetesPrevention or Delay of Diabetes

Research studies have found that lifestyle Research studies have found that lifestyle changes can prevent or delay the onset of changes can prevent or delay the onset of type 2 diabetes among high-risk adults. type 2 diabetes among high-risk adults. These studies included people with IGT These studies included people with IGT and other high-risk characteristics for and other high-risk characteristics for developing diabetes. developing diabetes.

Prevention of Diabetes Prevention of Diabetes ComplicationsComplications

Diabetes can affect many parts of the body and Diabetes can affect many parts of the body and can lead to serious complications such as can lead to serious complications such as blindness, kidney damage, and lower-limb blindness, kidney damage, and lower-limb amputations. Working together, people with amputations. Working together, people with diabetes and their health care providers can diabetes and their health care providers can reduce the occurrence of these and other reduce the occurrence of these and other diabetes complications by controlling the levels diabetes complications by controlling the levels of blood glucose, blood pressure, and blood of blood glucose, blood pressure, and blood lipids and by receiving other preventive care lipids and by receiving other preventive care practices in a timely manner.practices in a timely manner.

Total Prevalence of Diabetes in Total Prevalence of Diabetes in the United States, All Ages, 2002the United States, All Ages, 2002

Total:Total: 18.2 million people--6.3 18.2 million people--6.3 percent of the population--have percent of the population--have diabetes.diabetes.

Diagnosed:Diagnosed: 13 million people 13 million peopleUndiagnosed:Undiagnosed: 5.2 million people 5.2 million people

Diabetes in JordanDiabetes in Jordan

An increase in prevalence of diabetes An increase in prevalence of diabetes mellitus in Jordan over 10 years.mellitus in Jordan over 10 years.

The age-standardized prevalence of diabetes and The age-standardized prevalence of diabetes and impaired fasting glycemia IFG was 17.1% and impaired fasting glycemia IFG was 17.1% and 7.8%, respectively, with no significant 7.8%, respectively, with no significant differences between women and men. Journal differences between women and men. Journal Diabetes Complications. 2008 Sep-Diabetes Complications. 2008 Sep-Oct;22(5):317-24. Epub 2008 Apr 16.Oct;22(5):317-24. Epub 2008 Apr 16.

Ajlouni K, Khader YS, Batieha A, Ajlouni H, El-Ajlouni K, Khader YS, Batieha A, Ajlouni H, El-Khateeb M.Khateeb M.

The prevalence of type 2 diabetes and impaired The prevalence of type 2 diabetes and impaired fasting glycemia (IFG) is high in Jordan and is fasting glycemia (IFG) is high in Jordan and is increasing. More than half of the patients with increasing. More than half of the patients with diabetes have unsatisfactory control. Therefore, diabetes have unsatisfactory control. Therefore, they are likely to benefit from programs aimed at they are likely to benefit from programs aimed at encouraging behaviors toward achieving encouraging behaviors toward achieving optimum weight as well as physical activity optimum weight as well as physical activity behaviors. Physicians caring for patients with behaviors. Physicians caring for patients with diabetes may need to adopt a more vigorous diabetes may need to adopt a more vigorous approach for diabetes control. approach for diabetes control.

CONCLUSION:CONCLUSION:

Diabetes mellitus and IGT are common Diabetes mellitus and IGT are common among adult Jordanians. Considering the among adult Jordanians. Considering the high prevalence of this sickness makes it high prevalence of this sickness makes it imperative to formulate a national plan to imperative to formulate a national plan to face this disease and its complications.face this disease and its complications.

Global Prevalence of DiabetesGlobal Prevalence of Diabetes

Estimates for the year 2000 and Estimates for the year 2000 and projections for 2030 projections for 2030

Sarah Wild, MB BCHIR, PHD1Sarah Wild, MB BCHIR, PHD1, , Gojka Roglic, MD2Gojka Roglic, MD2, , Anders Green, MD, PHD, DR MED SCI3Anders Green, MD, PHD, DR MED SCI3, , Richard Sicree, MBBS, MPH4Richard Sicree, MBBS, MPH4 and and Hilary King, MD, DSC2Hilary King, MD, DSC2

RESULTSRESULTS

The prevalence of diabetes for all age-The prevalence of diabetes for all age-groups worldwide was estimated to be groups worldwide was estimated to be 2.8% in 2000 and 4.4% in 2030. The total 2.8% in 2000 and 4.4% in 2030. The total number of people with diabetes is number of people with diabetes is projected to rise from 171 million in 2000 projected to rise from 171 million in 2000 to 366 million in 2030. The prevalence of to 366 million in 2030. The prevalence of diabetes is higher in men than women, but diabetes is higher in men than women, but there are more women with diabetes than there are more women with diabetes than men. men.

The urban population in developing The urban population in developing countries is projected to double between countries is projected to double between 2000 and 2030. The most important 2000 and 2030. The most important demographic change to diabetes demographic change to diabetes prevalence across the world appears to be prevalence across the world appears to be the increase in the proportion of people the increase in the proportion of people >65 years of age. >65 years of age.

CONCLUSIONSCONCLUSIONS

These findings indicate that the “diabetes These findings indicate that the “diabetes epidemic” will continue even if levels of epidemic” will continue even if levels of obesity remain constant. Given the obesity remain constant. Given the increasing prevalence of obesity, it is likely increasing prevalence of obesity, it is likely that these figures provide an that these figures provide an underestimate of future diabetes underestimate of future diabetes prevalence.prevalence.

Deaths Among People with Deaths Among People with Diabetes, United States, 2000Diabetes, United States, 2000

Diabetes was the sixth leading cause of Diabetes was the sixth leading cause of death listed on U.S. death certificates in death listed on U.S. death certificates in 2000. This ranking is based on the 69,301 2000. This ranking is based on the 69,301 death certificates in which diabetes was death certificates in which diabetes was listed as the underlying cause of death. listed as the underlying cause of death. Diabetes is likely to be underreported as a Diabetes is likely to be underreported as a cause of death. cause of death.

Risk for deathRisk for death

Studies have found that only about 35 percent to Studies have found that only about 35 percent to 40 percent of decedents with diabetes have 40 percent of decedents with diabetes have diabetes listed anywhere on the death certificate diabetes listed anywhere on the death certificate and only about 10 percent to 15 percent have it and only about 10 percent to 15 percent have it listed as the underlying cause of death. listed as the underlying cause of death.

Overall, the risk for death among people with Overall, the risk for death among people with diabetes is about two times that of people diabetes is about two times that of people without diabetes.without diabetes.

Complications of Diabetes Complications of Diabetes

Heart disease and strokeHeart disease and stroke Heart disease is the leading cause of diabetes-Heart disease is the leading cause of diabetes-

related deaths. Adults with diabetes have heart related deaths. Adults with diabetes have heart disease death rates about two to four times disease death rates about two to four times higher than adults without diabetes.higher than adults without diabetes.

The risk for stroke is two to four times higher The risk for stroke is two to four times higher among people with diabetes.among people with diabetes.

About 65 percent of deaths among people with About 65 percent of deaths among people with diabetes are due to heart disease and stroke. diabetes are due to heart disease and stroke.

High blood pressureHigh blood pressure About 73 percent of adults with diabetes have About 73 percent of adults with diabetes have

blood pressure greater than or equal to 130/80 blood pressure greater than or equal to 130/80 mm Hg or use prescription medications for mm Hg or use prescription medications for hypertension.hypertension.

BlindnessBlindness Diabetes is the leading cause of new cases of Diabetes is the leading cause of new cases of

blindness among adults aged 20-74 years.blindness among adults aged 20-74 years. Diabetic retinopathy causes 12,000 to 24,000 Diabetic retinopathy causes 12,000 to 24,000

new cases of blindness each year.new cases of blindness each year.

Kidney diseaseKidney disease

Diabetes is the leading cause of end-stage Diabetes is the leading cause of end-stage renal disease, accounting for 44 percent of renal disease, accounting for 44 percent of new cases.new cases.

In 2001, 42,813 people with diabetes In 2001, 42,813 people with diabetes began treatment for end-stage renal began treatment for end-stage renal disease. disease.

In 2001, a total of 142,963 people with In 2001, a total of 142,963 people with end-stage renal disease due to diabetes end-stage renal disease due to diabetes were living on chronic dialysis or with a were living on chronic dialysis or with a kidney transplant. kidney transplant.

Nervous system diseaseNervous system disease

About 60 percent to 70 percent of people About 60 percent to 70 percent of people with diabetes have mild to severe forms of with diabetes have mild to severe forms of nervous system damage. The results of nervous system damage. The results of such damage include impaired sensation such damage include impaired sensation or pain in the feet or hands, slowed or pain in the feet or hands, slowed digestion of food in the stomach, carpal digestion of food in the stomach, carpal tunnel syndrome, and other nerve tunnel syndrome, and other nerve problems.problems.

AmputationsAmputations

More than 60 percent of nontraumatic More than 60 percent of nontraumatic lower-limb amputations occur among lower-limb amputations occur among people with diabetes.people with diabetes.

In 2000-2001, about 82,000 nontraumatic In 2000-2001, about 82,000 nontraumatic lower-limb amputations were performed lower-limb amputations were performed annually among people with diabetes.annually among people with diabetes.

Dental diseaseDental disease Periodontal (gum) disease is more Periodontal (gum) disease is more

common among people with diabetes. common among people with diabetes. Among young adults, those with diabetes Among young adults, those with diabetes have about twice the risk of those without have about twice the risk of those without diabetes.diabetes.

Almost one-third of people with diabetes Almost one-third of people with diabetes have severe periodontal diseases with have severe periodontal diseases with loss of attachment of the gums to the teeth loss of attachment of the gums to the teeth measuring 5 millimeters or more.measuring 5 millimeters or more.

Complications of pregnancyComplications of pregnancy

Poorly controlled diabetes before conception Poorly controlled diabetes before conception and during the first trimester of pregnancy can and during the first trimester of pregnancy can cause major birth defects in 5 percent to 10 cause major birth defects in 5 percent to 10 percent of pregnancies and spontaneous percent of pregnancies and spontaneous abortions in 15 percent to 20 percent of abortions in 15 percent to 20 percent of pregnancies.pregnancies.

Poorly controlled diabetes during the second Poorly controlled diabetes during the second and third trimesters of pregnancy can result in and third trimesters of pregnancy can result in excessively large babies, posing a risk to the excessively large babies, posing a risk to the mother and the child.mother and the child.

Other complicationsOther complications

Uncontrolled diabetes often leads to biochemical Uncontrolled diabetes often leads to biochemical imbalances that can cause acute life-threatening imbalances that can cause acute life-threatening events, such as diabetic ketoacidosis and events, such as diabetic ketoacidosis and hyperosmolar (nonketotic) coma. hyperosmolar (nonketotic) coma.

People with diabetes are more susceptible to People with diabetes are more susceptible to many other illnesses and, once they acquire many other illnesses and, once they acquire these illnesses, often have worse prognoses. these illnesses, often have worse prognoses. For example, they are more likely to die with For example, they are more likely to die with pneumonia or influenza than people who do not pneumonia or influenza than people who do not have diabetes.have diabetes.

Cost of diabetes in the United States, 2002Cost of diabetes in the United States, 2002 Total (direct and indirect):Total (direct and indirect): $132 billion $132 billion

Prevalence of diabetes in Arab Prevalence of diabetes in Arab WorldWorld

Diabetes Risk FactorsDiabetes Risk Factors

Diabetes complicationsDiabetes complications

Diabetes ComplicationsDiabetes Complications

ReferencesReferences

1-Mathers CD, Loncar D. Projections of global mortality and burden of 1-Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2005;3(11):e442. disease from 2002 to 2030. PLoS Med 2005;3(11):e442.

2-Population Division of the Department of Economic and Social Affairs of 2-Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World population prospects: The 2006 the United Nations Secretariat. World population prospects: The 2006 revision. New York (NY): United Nations; 2007. revision. New York (NY): United Nations; 2007.

3-Directorate of Information Studies and Research, Ministry of Health, The 3-Directorate of Information Studies and Research, Ministry of Health, The Hashemite Kingdom of Jordan. Mortality in Jordan 2005. Amman (JO): Hashemite Kingdom of Jordan. Mortality in Jordan 2005. Amman (JO): Ministry of Health, The Hashemite Kingdom of Jordan; 2008. Ministry of Health, The Hashemite Kingdom of Jordan; 2008.

4-Mokdad AH. Health issues in the Arab American community. 4-Mokdad AH. Health issues in the Arab American community. Chronic diseases and the potential for prevention in the Arab world: the JordChronic diseases and the potential for prevention in the Arab world: the Jordanian experience.anian experience. Ethn Dis 2007;17(2 Suppl 3):S3-55-56. Ethn Dis 2007;17(2 Suppl 3):S3-55-56.

5-Zindah M, Belbeisi A, Walke H, Mokdad AH. Obesity and diabetes in 5-Zindah M, Belbeisi A, Walke H, Mokdad AH. Obesity and diabetes in Jordan: findings from the Behavioral Risk Factor Surveillance System, 2004. Jordan: findings from the Behavioral Risk Factor Surveillance System, 2004. Prev Chronic Dis 2008;5(1). Prev Chronic Dis 2008;5(1). http://www.cdc.gov/pcd/issues/2008/jan/06_0172.htm. http://www.cdc.gov/pcd/issues/2008/jan/06_0172.htm.

6-Projections of mortality and burden of disease to 2030. Geneva (CH):  6-Projections of mortality and burden of disease to 2030. Geneva (CH):  http://www.who.int/healthinfo/statistics/bodprojections2030/ en/index.html. http://www.who.int/healthinfo/statistics/bodprojections2030/ en/index.html. Accessed July 16, 2008.Accessed July 16, 2008.

بسم الله الرحمن الرحيمبسم الله الرحمن الرحيم

الحمد لله رب العالمين الحمد لله رب العالمين والصالة والسالم على والصالة والسالم على

نبينا محمد خاتم األنبياء نبينا محمد خاتم األنبياء وسيد المرسلين وعلى وسيد المرسلين وعلى

آله وصحبه أجمعين آله وصحبه أجمعين وبعدوبعد

Chronic Diseases 2Chronic Diseases 2

Disability or chronicity may be the Disability or chronicity may be the outcome of many of these chronic outcome of many of these chronic diseases and they will not be accounted diseases and they will not be accounted for by using the mortality indicators as the for by using the mortality indicators as the only indicators for these chronic and only indicators for these chronic and degenerative diseases is the resulting degenerative diseases is the resulting morbidities and disabilities rates.morbidities and disabilities rates.

Examples :Examples :

1- Musculo-sketelal problems1- Musculo-sketelal problems OsteoporosisOsteoporosis Artihritis and osteoarthritis which may reach in old age a Artihritis and osteoarthritis which may reach in old age a

prevalence of 600/1000 persons, and over 300/1000 prevalence of 600/1000 persons, and over 300/1000 persons in males.persons in males.

Rheumatoid arthritisRheumatoid arthritis Low back painLow back pain Foot problems in old ageFoot problems in old age Scoliosis in childrenScoliosis in children Congenital hip dislocationCongenital hip dislocation

2- Neurological disorders2- Neurological disorders

Cerebral palsyCerebral palsy Mental retardationMental retardation Epilepsy and oEpilepsy and o ther seizure disorders ther seizure disorders Headache and migraineHeadache and migraine Multiple sclerosisMultiple sclerosis Alzheimer and dementiaAlzheimer and dementia Parkinson diseaseParkinson disease..

Psychiatric DisordersPsychiatric Disorders

PsychosisPsychosis SchizophreniaSchizophrenia

6--Affective psychosis6--Affective psychosis 4--Unspecified psychosis4--Unspecified psychosis

3--Senile & pre-senile dementia3--Senile & pre-senile dementia 3--Psychosis associated with other 3--Psychosis associated with other

cerebral conditions1cerebral conditions1   

Neuroses.Neuroses.

PhobiasPhobias AnxietyAnxiety DepressionDepression Obsessive Compulsive Neuroses.Obsessive Compulsive Neuroses. Personality disorders & other Personality disorders & other

non- psychotic mental disordersnon- psychotic mental disorders

DepressionDepression

Depression, a mental illness in which a Depression, a mental illness in which a person experiences deep, unshakable person experiences deep, unshakable sadness and diminished interest in sadness and diminished interest in nearly all activities. nearly all activities. People also use the term depression to People also use the term depression to describe the temporary sadness, describe the temporary sadness, loneliness, or blues that everyone feels loneliness, or blues that everyone feels from time to time. from time to time.

In contrast to normal sadness, severe In contrast to normal sadness, severe depression, also called major depression, also called major depression, can dramatically impair a depression, can dramatically impair a person's ability to function in person's ability to function in social situations and at work. People social situations and at work. People with major depression often have with major depression often have feelings of despair, hopelessness, and feelings of despair, hopelessness, and worthlessness, as well as thoughts of worthlessness, as well as thoughts of committing suicidecommitting suicide

Surveys indicate that people commonly Surveys indicate that people commonly view depression as a sign of personal view depression as a sign of personal weakness, but psychiatrists and weakness, but psychiatrists and psychologists view it as a real psychologists view it as a real illness. In the United States, the National illness. In the United States, the National Institute of Mental Health has estimated Institute of Mental Health has estimated that depression costs society many billions that depression costs society many billions of dollars each year, mostly in lost work of dollars each year, mostly in lost work time.time.

Why is depression important?Why is depression important?

Projections are that by 2020, depression Projections are that by 2020, depression will be second only to heart disease in its will be second only to heart disease in its contribution to the global burden of contribution to the global burden of disease as measured disability-adjusted disease as measured disability-adjusted life yearslife years

PREVALENCEPREVALENCE

Depression is one of the most Depression is one of the most common mental illnesses. At least common mental illnesses. At least 8 percent of adults in the United 8 percent of adults in the United States experience serious States experience serious depression at some point during depression at some point during their lives, and estimates range their lives, and estimates range as high as 17 percent. as high as 17 percent.

Epidemiology of Depression Epidemiology of Depression Among Women Among Women

In U.S. twice as many women (12.3%) as In U.S. twice as many women (12.3%) as men (6.7%) are affected each year men (6.7%) are affected each year 12.4M women and 6.4M men12.4M women and 6.4M men

For low-income women, the estimated For low-income women, the estimated prevalence doubles to 25%prevalence doubles to 25%

Most prevalent among women of child-Most prevalent among women of child-bearing and child-rearing age (16 to 53)bearing and child-rearing age (16 to 53)

Epidemiology of Depression Epidemiology of Depression Among MothersAmong Mothers

Estimated rates of depression among Estimated rates of depression among pregnant and postpartum women range pregnant and postpartum women range from 8 to 20%.from 8 to 20%.

For low-income women with young For low-income women with young children, prevalence rates are commonly children, prevalence rates are commonly estimated at approximately 40%.estimated at approximately 40%.

PREVALENCEPREVALENCE Primary Health Care Physicians are the Primary Health Care Physicians are the

diagnosticians at the front line of the diagnosticians at the front line of the health services, and untreated depression health services, and untreated depression has come to be viewed as a major public has come to be viewed as a major public health problem.health problem.

In Arab worldIn Arab world

Communities in Arab world show Communities in Arab world show depression ranging from 13% to 32%.depression ranging from 13% to 32%.

Highest rate 32% was recorded in Highest rate 32% was recorded in Lebanese women after the civil war.Lebanese women after the civil war.

Urban population in Dubai and Cairo Urban population in Dubai and Cairo showed lower rates 12% and 16% showed lower rates 12% and 16% respectively.respectively.

The illness affects all people, regardless of The illness affects all people, regardless of sex, race, ethnicity, or socioeconomic sex, race, ethnicity, or socioeconomic standing. However, women are two to standing. However, women are two to three times more likely than men to suffer three times more likely than men to suffer from depression. Experts disagree on the from depression. Experts disagree on the reason for this difference. Some cite reason for this difference. Some cite differences in hormones, and others point differences in hormones, and others point to the stress caused by society's to the stress caused by society's expectations of women.expectations of women.

PrevalencePrevalence

Depression occurs in all parts of the world, Depression occurs in all parts of the world, although the pattern of symptoms can vary. although the pattern of symptoms can vary. The prevalence of depression in other The prevalence of depression in other countries varies widely, from countries varies widely, from 1.5 percent 1.5 percent of people in Taiwan to 19 percent of of people in Taiwan to 19 percent of people in Lebanonpeople in Lebanon. Some researchers . Some researchers believe methods of gathering data on believe methods of gathering data on depression account for different rates.depression account for different rates.

A number of large-scale studies A number of large-scale studies indicate that depression rates indicate that depression rates have increased worldwide over have increased worldwide over the past several decades. the past several decades. Furthermore, younger generations Furthermore, younger generations are experiencing depression at an are experiencing depression at an earlier age than did previous earlier age than did previous generations.generations...

Social scientists have proposed Social scientists have proposed many explanations, including many explanations, including changes in family structure, changes in family structure, urbanization, and reduced cultural urbanization, and reduced cultural and and religious influencesreligious influences

Prevalence of DepressionPrevalence of Depression

In JordanIn Jordan

• A study published last year, done A study published last year, done on Jordanian women reviewing on Jordanian women reviewing PHC centers for different reasons PHC centers for different reasons showed a rate of 37% scored showed a rate of 37% scored positively. positively.

OnsetOnset

Although it may appear anytime from Although it may appear anytime from childhood to old age, depression childhood to old age, depression usually begins during a person's 20s usually begins during a person's 20s or 30s. The illness may come on or 30s. The illness may come on slowly, then deepen gradually over slowly, then deepen gradually over months or years.months or years.

Symptoms.Symptoms.

A) Appetite and Sleep ChangesA) Appetite and Sleep Changes

B) Changes in Energy LevelB) Changes in Energy Level

C) Poor Self-EsteemC) Poor Self-Esteem

CAUSES/Risk FactorsCAUSES/Risk Factors

Some depressions seem to Some depressions seem to come out of the bluecome out of the blue, even when , even when things are going well. Others things are going well. Others seem to have an obvious cause: a seem to have an obvious cause: a marital conflict, financial difficulty, marital conflict, financial difficulty, or some personal failure.or some personal failure.

Yet many people with these problems do Yet many people with these problems do not become deeply depressed. Most not become deeply depressed. Most psychologists believe depression results psychologists believe depression results from an interaction between stressful life from an interaction between stressful life events and a person's biological and events and a person's biological and psychological vulnerabilities.psychological vulnerabilities.

A) Biological/Genetic FactorsA) Biological/Genetic Factors ..

Depression runs in families. By studying twins, Depression runs in families. By studying twins, researchers have found evidence of a strong researchers have found evidence of a strong genetic influence in depression. Genetically genetic influence in depression. Genetically identical twins raised in the same environment identical twins raised in the same environment are three times more likely to have depression in are three times more likely to have depression in common than fraternal twins, who have only common than fraternal twins, who have only about half of their genes in common. In addition, about half of their genes in common. In addition, identical twins are five times more likely to have identical twins are five times more likely to have bipolar disorder in common.bipolar disorder in common.

These findings suggest that vulnerability to These findings suggest that vulnerability to depression and bipolar disorder can be depression and bipolar disorder can be inherited. Adoption studies have provided inherited. Adoption studies have provided more evidence of a genetic role in more evidence of a genetic role in depression. These studies show that depression. These studies show that children of depressed people are children of depressed people are vulnerable to depression even when vulnerable to depression even when raised by adoptive parents.raised by adoptive parents.

Genetic/Biochemical FactorsGenetic/Biochemical Factors

Genes may influence depression by Genes may influence depression by causing abnormal activity in the brain. causing abnormal activity in the brain. Studies have shown that certain brain Studies have shown that certain brain chemicals called neurotransmitters play an chemicals called neurotransmitters play an important role in regulating moods and important role in regulating moods and emotions. emotions.

Neurotransmitters involved in depression Neurotransmitters involved in depression include norepinephrine, dopamine, and include norepinephrine, dopamine, and serotonin. Research in the 1960s serotonin. Research in the 1960s suggested that depression results from suggested that depression results from lower than normal levels of these lower than normal levels of these neurotransmitters in parts of the brain. neurotransmitters in parts of the brain.

Support for this theory came from the Support for this theory came from the effects of antidepressant drugs, which effects of antidepressant drugs, which work by increasing the levels of work by increasing the levels of neurotransmitters involved in depression. neurotransmitters involved in depression. However, later studies have discredited However, later studies have discredited this simple explanation and have this simple explanation and have suggested a more complex relationship suggested a more complex relationship between neurotransmitter levels and between neurotransmitter levels and depression.depression.

An imbalance of hormones may also play An imbalance of hormones may also play a role in depression. Many depressed a role in depression. Many depressed people have higher than normal levels of people have higher than normal levels of hydrocortisone (cortisol), a hormone hydrocortisone (cortisol), a hormone secreted by the adrenal gland in response secreted by the adrenal gland in response to stress. In addition, an under active or to stress. In addition, an under active or overactive thyroid gland can lead to overactive thyroid gland can lead to depression.depression.

Medical causesMedical causes

A variety of medical conditions can cause A variety of medical conditions can cause depression. These include dietary deficiencies in depression. These include dietary deficiencies in vitamin B6, vitamin B12, and folic acid (see vitamin B6, vitamin B12, and folic acid (see Vitamin); degenerative neurological disorders, Vitamin); degenerative neurological disorders, such as Alzheimer's disease and Parkinson's such as Alzheimer's disease and Parkinson's disease ; strokes in the frontal part of the brain; disease ; strokes in the frontal part of the brain; and certain viral infections, such as hepatitis and and certain viral infections, such as hepatitis and mononucleosis. mononucleosis.

Many chronic diseases:Many chronic diseases: CardiovascularCardiovascular DiabetesDiabetes EpilepsyEpilepsy Multiple SclerosesMultiple Scleroses Rheumatoid Arthritis and othersRheumatoid Arthritis and others

B) Psychological FactorsB) Psychological Factors

As a secondary to psychiatric illness As a secondary to psychiatric illness especially Neurotic (Obsessive especially Neurotic (Obsessive Compulsive Neurosis), or Affective Compulsive Neurosis), or Affective Schizophrenia. Schizophrenia.

C) Stressful C) Stressful Events/EnvironmentalEvents/Environmental

Psychologists agree that stressful Psychologists agree that stressful experiences can trigger depression in experiences can trigger depression in people who are predisposed to the illness. people who are predisposed to the illness. For example, the death of a loved one For example, the death of a loved one may trigger depression. Psychologists may trigger depression. Psychologists usually distinguish true depression from usually distinguish true depression from grief, a normal process of mourning a grief, a normal process of mourning a loved one who has died (Reactive loved one who has died (Reactive Depression).Depression).

GenderGender

In the United States, women are about as twice In the United States, women are about as twice as likely as men to be diagnosed and treated for as likely as men to be diagnosed and treated for major depression. Approximately 20-25% of major depression. Approximately 20-25% of women and 12% of men will experience a women and 12% of men will experience a serious depression at least once in their serious depression at least once in their lifetimes. Among children, depression appears to lifetimes. Among children, depression appears to occur in equal numbers of girls and boys. occur in equal numbers of girls and boys. However, as girls reach adolescence, they tend However, as girls reach adolescence, they tend to become more depressed than boys do. This to become more depressed than boys do. This gender difference continues into older age.gender difference continues into older age.

Other stressful experiences may include Other stressful experiences may include divorce, pregnancy, the loss of a job, and divorce, pregnancy, the loss of a job, and even childbirth. About 20% of women even childbirth. About 20% of women experience an episode of depression, experience an episode of depression, known as postpartum depression, after known as postpartum depression, after having a baby. In addition, people with having a baby. In addition, people with serious physical illnesses or disabilities serious physical illnesses or disabilities often develop depression often develop depression

TREATMENTTREATMENT

Depression typically cannot be shaken or Depression typically cannot be shaken or willed away. An episode must therefore willed away. An episode must therefore run its course until it weakens either on its run its course until it weakens either on its own or with treatment. Depression can be own or with treatment. Depression can be treated effectively with treated effectively with antidepressant antidepressant drugs, psychotherapy, or a drugs, psychotherapy, or a combination of both.combination of both.

Other TreatmentsOther Treatments

Electroconvulsive therapy (ECT)Electroconvulsive therapy (ECT) can often can often relieve severe depression in people who fail to relieve severe depression in people who fail to respond to antidepressant medication and respond to antidepressant medication and psychotherapy. Regular aerobic exercise may psychotherapy. Regular aerobic exercise may improve mood as effectively as psychotherapy improve mood as effectively as psychotherapy or medication. In addition, some research or medication. In addition, some research indicates that dietary modifications can influence indicates that dietary modifications can influence one's mood by changing the level of serotonin in one's mood by changing the level of serotonin in the brain.the brain.

Despite the availability of effective Despite the availability of effective treatment, most depressive disorders go treatment, most depressive disorders go untreated and undiagnosed. Studies untreated and undiagnosed. Studies indicate that general physicians fail to indicate that general physicians fail to recognize depression in their patients at recognize depression in their patients at least half of the time. In addition, many least half of the time. In addition, many doctors and patients view depression in doctors and patients view depression in elderly people as a normal part of aging, elderly people as a normal part of aging, even though treatment for depression in even though treatment for depression in older people is usually very effective.older people is usually very effective.

ConclusionConclusion

Of the estimated 17.5 million Americans Of the estimated 17.5 million Americans who are affected by some form of who are affected by some form of depression, 9.2 million have major or depression, 9.2 million have major or clinical depressionclinical depression

Two thirds of people suffering from Two thirds of people suffering from depression do not seek necessary depression do not seek necessary treatment. treatment.

80%80% Of all people with clinical depression Of all people with clinical depression who have received treatment significantly who have received treatment significantly improve their lives.improve their lives.

The economic cost of depression is The economic cost of depression is estimated at $30.4 billion a year but the estimated at $30.4 billion a year but the cost in human suffering cannot be cost in human suffering cannot be estimatedestimated

Women experience depression about Women experience depression about twice as often as mentwice as often as men

By the year 2020, the World Health By the year 2020, the World Health Organization (WHO) estimates that Organization (WHO) estimates that depression will be the number two cause depression will be the number two cause of "lost years of healthy life" worldwideof "lost years of healthy life" worldwide

According to the U.S. Centers for Disease According to the U.S. Centers for Disease Control and Prevention (CDC) suicide was Control and Prevention (CDC) suicide was the ninth leading cause of death in the the ninth leading cause of death in the United States in 1996United States in 1996

RecommendationsRecommendations

Public education.Public education. Provision of relevant posters and leaflets Provision of relevant posters and leaflets

in waiting rooms at PHC centers helps in in waiting rooms at PHC centers helps in destigmatization of the disease.destigmatization of the disease.

Improvements in depression screening Improvements in depression screening have paralleled improvements in have paralleled improvements in depression treatment and reduced stigmadepression treatment and reduced stigma

Encourage patients to talk about their Encourage patients to talk about their symptoms with their Family doctors.symptoms with their Family doctors.

Recognition of depression by the patient Recognition of depression by the patient and his or her family.and his or her family.

PCPs have embraced responsibility for PCPs have embraced responsibility for screening ,recognition, and treating screening ,recognition, and treating depressiondepression

For additional efficiencies, we will needFor additional efficiencies, we will need Advances in technology (e.g,computerized Advances in technology (e.g,computerized

screening and scoring)screening and scoring) Improved Rx outcomesImproved Rx outcomes

Training courses for Primary Health physicians to improve their diagnostic skills in depression to improve the recognition rate of depression in Primary Health Care Settings in Jordan is also recommended

DementiaDementia

Dementia is defined as Dementia is defined as global impairment of global impairment of cognitive function which cognitive function which interferes with normal interferes with normal activities.activities.

Impaired short and long-term Impaired short and long-term memory and other cognitive memory and other cognitive functions (abstract thinking, functions (abstract thinking, judgment, speech, judgment, speech, coordination, planning or coordination, planning or organizationorganization

Alzheimer's accounts for most cases of Alzheimer's accounts for most cases of dementia.dementia.

10-20% cases are attributed to vascular 10-20% cases are attributed to vascular (multi-infarct) dementia (multi-infarct) dementia

Other causes-alcoholism, Parkinson, vit Other causes-alcoholism, Parkinson, vit B12 deficiency, hypothyroidism, CNS B12 deficiency, hypothyroidism, CNS infections, intracranial lesionsinfections, intracranial lesions

Prevalence of DementiaPrevalence of Dementia

Increases steadily with age, roughly Increases steadily with age, roughly doubling every 5 years doubling every 5 years

Common among institutionalized elderly Common among institutionalized elderly Present in ½ to 2/3 of nursing home Present in ½ to 2/3 of nursing home

residents residents Family history associated with an Family history associated with an

increased risk of Alzheimerincreased risk of Alzheimer

Prevalence of DementiaPrevalence of Dementia disease progresses over a period of 2-20 disease progresses over a period of 2-20

years, causing increasing functional years, causing increasing functional impairment and disability impairment and disability

Care of the demented patient imposes an Care of the demented patient imposes an enormous psychosocial and economical enormous psychosocial and economical factors.factors.

• Alzheimer’s burden on the familyAlzheimer’s burden on the family

Risk factorsRisk factors Age: Strongest risk factor particularly for Age: Strongest risk factor particularly for

ALZ dALZ d annual incidence 0.6% for age 65-69annual incidence 0.6% for age 65-69 1% for age 70-741% for age 70-74 2% for age 75-792% for age 75-79 3.3 % for age 80-84 and 8.4% for above 3.3 % for age 80-84 and 8.4% for above

8585 1/2-2/3 of nursing home residents1/2-2/3 of nursing home residents

Risk factorsRisk factors Family history : Especially in relation to Family history : Especially in relation to

ALZ DALZ D First degree relatives have 10-30% First degree relatives have 10-30%

increased risk for the diseaseincreased risk for the disease Apolipoprotein E epsilon 4 genotype Apolipoprotein E epsilon 4 genotype

predisposes to development of ALZDpredisposes to development of ALZD

Risk factorsRisk factors History of head trauma especially with the epsilon History of head trauma especially with the epsilon

4 allele4 allele History of low educational achievementHistory of low educational achievement Organic solvent exposureOrganic solvent exposure Female genderFemale gender 16%/6% 16%/6% Relationship to blood pressure : a U shape Relationship to blood pressure : a U shape

associationassociation Hypercholesterolemia /role of statinsHypercholesterolemia /role of statins

DiabetesDiabetes

Screening TestsScreening Tests

Dementia is easily recognized in advanced Dementia is easily recognized in advanced stages, often overlooked in early stagestages, often overlooked in early stage

Clinicians fail to detect 21-72% of patients Clinicians fail to detect 21-72% of patients with dementia esp. in early stageswith dementia esp. in early stages

Routing physical examination and patient Routing physical examination and patient history not sensitive for dementia, history not sensitive for dementia, especially if family members not present to especially if family members not present to corroborate patient self-reportcorroborate patient self-report

Alzheimer Warning SignsAlzheimer Warning SignsTop TenTop Ten

Alzheimer AssociationAlzheimer Association

1. Recent memory loss affecting job1. Recent memory loss affecting job 2. Difficulty performing familiar tasks2. Difficulty performing familiar tasks 3. Problems with language3. Problems with language 4. Disorientation to time or place4. Disorientation to time or place 5. Poor or decreased judgment5. Poor or decreased judgment 6. Problems with abstract thinking6. Problems with abstract thinking 7. Misplacing things7. Misplacing things 8. Changes in mood or behavior8. Changes in mood or behavior 9. Changes in personality 9. Changes in personality 10. Loss of initiative10. Loss of initiative

AD is Under-diagnosedAD is Under-diagnosed Early Alzheimer’s disease is subtle, the diagnosis Early Alzheimer’s disease is subtle, the diagnosis

continues to be missed continues to be missed it is easy for family members to avoid the problem it is easy for family members to avoid the problem

and compensate for the patient and compensate for the patient physicians tend to miss the initial signs and physicians tend to miss the initial signs and

symptomssymptoms Less than half of AD patients are diagnosedLess than half of AD patients are diagnosed

Estimates are that 25% to 50% of cases remain Estimates are that 25% to 50% of cases remain undiagnosedundiagnosed

Diagnoses are missed at all levels of severity: mild, Diagnoses are missed at all levels of severity: mild, moderate, severemoderate, severe

Evans DA. Milbank Quarterly. 1990; 68:267-289

Undiagnosed AD patients often face avoidable social, Undiagnosed AD patients often face avoidable social, financial, and medical problemsfinancial, and medical problems

Early diagnosis and appropriate intervention may lessen Early diagnosis and appropriate intervention may lessen disease burdendisease burden Early treatment may improve overall course Early treatment may improve overall course

substantiallysubstantially No definitive laboratory test for diagnosing AD existsNo definitive laboratory test for diagnosing AD exists

Efforts to develop biomarkers, early recognition by Efforts to develop biomarkers, early recognition by brain scanbrain scan

Prevalence of AlzheimerPrevalence of Alzheimer Alzheimer’s disease (AD) is the most Alzheimer’s disease (AD) is the most

common form of dementia. It represents a common form of dementia. It represents a worldwide medical challenge affecting worldwide medical challenge affecting more than 18 million people; estimated to more than 18 million people; estimated to reach 34 million by the year 2025reach 34 million by the year 2025. .

PREVALENCE of AD PREVALENCE of AD Estimated 4 million cases in US (2000)Estimated 4 million cases in US (2000)

• (2000 - 46 million individuals over 60 y/o)(2000 - 46 million individuals over 60 y/o)

Estimated 500,000 new cases per yearEstimated 500,000 new cases per year

Increase with age (prevalence)Increase with age (prevalence) 1% of 60 - 65 (10.7m) = 107,000 1% of 60 - 65 (10.7m) = 107,000 2% of 65 - 70 ( 9.4m) = 188,0002% of 65 - 70 ( 9.4m) = 188,000 4% of 70 - 75 ( 8.7m) = 350,0004% of 70 - 75 ( 8.7m) = 350,000 8% of 75 - 80 ( 7.4m) = 595,0008% of 75 - 80 ( 7.4m) = 595,000

• 16% of 80 - 85 ( 5.0m) = 800,00016% of 80 - 85 ( 5.0m) = 800,000

With over 1.5 million cases in the Arab With over 1.5 million cases in the Arab world.world.Alzheimer’s disease is a devastating Alzheimer’s disease is a devastating illness which can affect all members of illness which can affect all members of societysociety

Conclusions and Conclusions and RecommendationsRecommendations

Next to Cancer and AIDS, the highest Next to Cancer and AIDS, the highest medical budgets are allocated to medical budgets are allocated to Alzheimer’s research. The Arab Alzheimer’s research. The Arab Conference on AD 2005 seeks to develop Conference on AD 2005 seeks to develop a regional and national plan to raise the a regional and national plan to raise the level of awareness on AD and reach level of awareness on AD and reach patients, caregivers, specialists, doctors, patients, caregivers, specialists, doctors, nurses, specialized international agencies nurses, specialized international agencies and governmental and non-governmental and governmental and non-governmental organizationsorganizations

      

Multiple SclerosisMultiple Sclerosis Epidemiology and Epidemiology and

PrevalencePrevalence

OnsetOnsetGeographic DistributionGeographic Distribution

Population StudiesPopulation StudiesGenetic FactorsGenetic Factors

Who Has MSWho Has MS

In the United States, about 400,000 In the United States, about 400,000 people have the disease, which is twice as people have the disease, which is twice as common in women as men. common in women as men.

Approximately 2.5 million people may Approximately 2.5 million people may have MS worldwide. have MS worldwide.

Most people with MS are diagnosed Most people with MS are diagnosed between the ages of 20 and 40. between the ages of 20 and 40.

OnsetOnset Geographic DistributionGeographic Distribution Population StudiesPopulation Studies

Genetic FactorsGenetic Factors

OnsetOnset

There are about 300,000 patients suffering from There are about 300,000 patients suffering from Multiple Sclerosis in the North America today. Multiple Sclerosis in the North America today. The age of onset peaks between 20 and 30 The age of onset peaks between 20 and 30 years. Almost 70% of patients manifest years. Almost 70% of patients manifest symptoms between ages 21 and 40. Disease symptoms between ages 21 and 40. Disease rarely occurs prior to 10 or after 60 years of age. rarely occurs prior to 10 or after 60 years of age. However, patients as young as 3 and as old as However, patients as young as 3 and as old as 67 years of age have been described. 67 years of age have been described.

Like other immuno- mediated diseases, Like other immuno- mediated diseases, females are affected more frequently than females are affected more frequently than males (1.4 to 3.1 times as many women males (1.4 to 3.1 times as many women than men affected.)than men affected.)

Geographic DistributionGeographic Distribution

There is a very specific geographic There is a very specific geographic distribution of this disease around the distribution of this disease around the world. A significantly higher incidence of world. A significantly higher incidence of the disease is found in the northernmost the disease is found in the northernmost latitudes of the northern and the southern latitudes of the northern and the southern hemispheres compared to southernmost hemispheres compared to southernmost latitudes. latitudes.

This observation is based on the incidence This observation is based on the incidence of the disease in Scandinavia, northern of the disease in Scandinavia, northern United States and Canada, as well as United States and Canada, as well as Australia and New Zealand. The data from Australia and New Zealand. The data from migration studies shows that if the migration studies shows that if the exposure to a higher risk environment exposure to a higher risk environment occurs during adolescence (before 15 occurs during adolescence (before 15 years of age,) the migrant assumes the years of age,) the migrant assumes the higher risk of the environment..higher risk of the environment..

What Is MS?What Is MS?

Multiple sclerosis (MS) is a disease that Multiple sclerosis (MS) is a disease that attacks the central nervous system—the attacks the central nervous system—the brain and the spinal cord. Depending on brain and the spinal cord. Depending on which nerves are damaged, people with which nerves are damaged, people with MS may experience problems with MS may experience problems with balance, muscle coordination, vision, balance, muscle coordination, vision, speech, thinking, or other physical and speech, thinking, or other physical and mental abilities. mental abilities.

Population StudiesPopulation Studies

There are also population studies that show There are also population studies that show difference in susceptibility to MS between difference in susceptibility to MS between different populations. Lapps in Scandinavia different populations. Lapps in Scandinavia appear to be resistant to the disease, contrary appear to be resistant to the disease, contrary to the expectations based on their geographic to the expectations based on their geographic distribution. Native Americans and Hutterites distribution. Native Americans and Hutterites very infrequently suffer from MS, as opposed very infrequently suffer from MS, as opposed to other residents of the North America. MS is to other residents of the North America. MS is uncommon in Japan, China and South uncommon in Japan, China and South America. America.

It is practically unknown among the It is practically unknown among the indigenous people of equatorial Africa and indigenous people of equatorial Africa and among native Inuit in Alaska. When the among native Inuit in Alaska. When the racial differences are correlated, White racial differences are correlated, White populations are at greater risk than Asian or populations are at greater risk than Asian or African populations. We can not yet explain African populations. We can not yet explain these obvious inconsistencies in disease these obvious inconsistencies in disease distribution, but the knowledge of them may distribution, but the knowledge of them may be helpful in assessing specific patients.be helpful in assessing specific patients.

Prevalence of MSPrevalence of MS

Prevalence data imply that racial and Prevalence data imply that racial and ethnic differences are important in ethnic differences are important in influencing the worldwide distribution of MS influencing the worldwide distribution of MS and that its geography must be interpreted and that its geography must be interpreted in terms of the probable discontinuous in terms of the probable discontinuous distribution of genetic susceptibility alleles. distribution of genetic susceptibility alleles. Racially and ethnically influenced Racially and ethnically influenced differences in the risk of MS, however, can differences in the risk of MS, however, can be modified by environment. be modified by environment.

Genetic FactorsGenetic Factors

The incidence of MS in first degree relatives is 20 The incidence of MS in first degree relatives is 20 times higher than in general population, times higher than in general population, suggesting the influence of genetic factors on the suggesting the influence of genetic factors on the disease. Monozygotic twin studies show the disease. Monozygotic twin studies show the concordance rate of 30%. Dizygotic twins show concordance rate of 30%. Dizygotic twins show concordance rate of less than 5%. These results concordance rate of less than 5%. These results suggest that both the genetic factors and suggest that both the genetic factors and environmental exposure are important in disease environmental exposure are important in disease expression. expression.

SymptomsSymptoms

Symptoms associated with MS vary Symptoms associated with MS vary

widely. There is not yet a way to predict widely. There is not yet a way to predict what symptoms people with MS may what symptoms people with MS may experience. MS symptoms are divided into experience. MS symptoms are divided into three types: three types:

. .

Primary symptomsPrimary symptoms are those caused are those caused directly by the disease process including directly by the disease process including immune system activity, destruction of immune system activity, destruction of myelin or the ensuing nerve damage. myelin or the ensuing nerve damage.

The most common includeThe most common include

problems with walking or maintaining problems with walking or maintaining balance, visual impairment (optic neuritis), balance, visual impairment (optic neuritis),

lapses in memory,lapses in memory, inability to solve problems or pay attention inability to solve problems or pay attention

for long periods of time,for long periods of time, pain, pain,

sexual dysfunction,sexual dysfunction, dizziness, dizziness, depression or mood swings,depression or mood swings, and disturbances in bladder or bowel and disturbances in bladder or bowel

function. function. Less common symptoms include speech Less common symptoms include speech

and swallowing disorders, tremors and and swallowing disorders, tremors and seizuresseizures

Secondary symptomsSecondary symptoms are complications are complications that occur as a result of primary that occur as a result of primary symptoms. For instance, a person with MS symptoms. For instance, a person with MS may have urinary burning, which could be may have urinary burning, which could be a sign of a urinary tract infection, resulting a sign of a urinary tract infection, resulting from lack of bladder control caused by from lack of bladder control caused by nerve damage. nerve damage.

Tertiary symptomsTertiary symptoms may include lowered may include lowered self-esteem, which could affect a person's self-esteem, which could affect a person's family or social life.family or social life.

Multiple sclerosis in Arabs in Multiple sclerosis in Arabs in JordanJordan

. . Department of Biochemistry and Department of Biochemistry and

Microbiology, Faculty of Medicine, Jordan Microbiology, Faculty of Medicine, Jordan University, Amman.University, Amman.

In a 2-year hospital-based study (1992 In a 2-year hospital-based study (1992 and 1993), there were 131 multiple and 1993), there were 131 multiple sclerosis patients attending 2 large referral sclerosis patients attending 2 large referral hospitals in Jordan. There were 126 Arabs hospitals in Jordan. There were 126 Arabs of whom 84 were Palestinians and 36 of whom 84 were Palestinians and 36 indigenous Jordanians.indigenous Jordanians.

Comparison of these subgroups, which had a Comparison of these subgroups, which had a similar age distribution revealed that the disease similar age distribution revealed that the disease was twice as frequent in Palestinians (estimated was twice as frequent in Palestinians (estimated 42.0/100,000) among Jordanians (estimated 42.0/100,000) among Jordanians (estimated 20.0/100,000). Clinical presentation, pattern of 20.0/100,000). Clinical presentation, pattern of disease, disability associated with the disease disease, disability associated with the disease were similar to that in the disease reported in were similar to that in the disease reported in Caucasians in the West. All investigations Caucasians in the West. All investigations including neurophysiology and imaging were including neurophysiology and imaging were also very similar to Western reportsalso very similar to Western reports

6- Genetic disorders6- Genetic disorders

– – Down’s syndromeDown’s syndrome Autosomal recessive defect chromosome 7 Autosomal recessive defect chromosome 7

mutations are thought to be responsible for that mutations are thought to be responsible for that disease .disease .

Cystic fibrosis : is the most lethal in Northern Cystic fibrosis : is the most lethal in Northern European descent (1/3500 births) in European descent (1/3500 births) in USA( 1/14,000 births in Blocks) in Asian USA( 1/14,000 births in Blocks) in Asian Americans 1/25,500 births , Median survival age Americans 1/25,500 births , Median survival age for C.F. improved between 1938 and 1998 from for C.F. improved between 1938 and 1998 from 5 y to almost 30 y . 5 y to almost 30 y .

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