Chronic diseases and their risk factors in the Kingdom of Saudi Arabia

Chronic diseases and their risk factors in the Kingdom of Saudi Arabia

October 15, 2014

Ali H. Mokdad, PhDDirector of Middle Eastern InitiativesProfessor of Global Health

Outline

Changing burden of disease in the Kingdom of Saudi Arabia

Saudi Health Interview Survey (SHIS)• Weighting methodology• Summary of findings• Chronic health problems• Risk factors and health behaviors• Conclusions and recommendations• Dissemination of findings

Next steps

2

3

4

5

6

7

Change in causes of premature death and disability

1990 2010

8

Leading risk factors, 1990 versus 2010

9

Outline



Next steps

10

Saudi Health Interview Survey (SHIS)

• Combines a health questionnaire with anthropometric measures and blood sample analysis

• Computer-assisted personal interviewing with near real-time data monitoring

• Survey conducted by ~240 interviewers (358 total personnel) from April to June 2013

• All adults were administered a questionnaire and invited to visit a clinic for further measurements

11

Sample design

• Multistage representative sample of Saudi households

• Conducted in all regions using probability proportional to size

• Total sample size 12,000 households

• Selection of a random adult 15 years of age or older

12

Survey tools

• Household interview− Household roster

− Random adult selection

− Socioeconomic information

− Health behavior

− Access to and utilization of health care

− History of chronic conditions

− Health problems

− Anthropometry

− Blood pressure

• Blood draw and analysis at local clinic− Blood glucose (HbA1c)

− Blood lipid profile (HDL, LDL, TRIG)

− Vitamin D

13

Response rate to household interview

• 12,000 households contacted

• 10,735 respondents completed the household interviewo Response rate of 89.5%

14

SHIS age and sex distribution

Age Sex Sample percent Census 2013

15 - 24 Males 11.08 15.77

Females 11.11 15.39

25 - 34 Males 11.68 12.81

Females 14.00 12.67

35 - 44 Males 10.54 9.31

Females 11.24 9.25

45 - 54 Males 6.73 6.20

Females 7.43 6.05

55 - 64 Males 4.09 3.58

Females 3.94 3.48

65+ Males 4.82 2.73

Females 3.33 2.76

15+ Males 48.93 50.40

Females 51.07 49.60

Total 100.00 100.00

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Outline



Next steps

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Household interview weight: WHI

• Two stepso Probability of selection

o Post-stratification

WHI

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Age Sex Sample percent WHI

15 - 24 Males 11.08 20.66

Females 11.11 19.65

25 - 34 Males 11.68 11.00

Females 14.00 10.50

35 - 44 Males 10.54 6.88

Females 11.24 8.29

45 - 54 Males 6.73 6.06

Females 7.43 6.32

55 - 64 Males 4.09 3.58

Females 3.94 2.88

65+ Males 4.82 2.47

Females 3.33 1.71

15+ Males 48.93 50.64

Females 51.07 49.36

Total 100.00 100.00

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Response rate to clinic visit

• 10,735 respondents completed the household interview

• 5,590 visited a local clinic for blood analysiso Response rate of 52.1%

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Predictors of clinical visits following the survey

Participated in the lab exam

Independent variables Categories No % Yes % AOR

95% CI

Last routine medical visit

Never 54.1 45.9 REF

Within 2013 54.0 46.0 0.9 0.8 – 1.1

Within 2012 52.0 48.0 1.04 0.8 – 1.3

2005 – 2011 61.6 38.4 0.7 0.6 – 0.9

Smoking status

Nonsmoker 52.7 47.3 REF

Smoker 64.9 35.1 0.90 0.8 – 1.0

Self-rated health Excellent/very good

56.5 43.5 REF

Good 46.9 53.1 1.3 1.2 – 1.5

Fair/poor 45.4 54.6 1.4 1.2 – 1.7

BMI (kg/m2) < 25 57.6 42.4 REF

25.00 – 29.99 55.7 44.3 1.1 0.9 – 1.2

30.00 – 34.99 48.0 52.0 1.4 1.2 – 1.5

≥ 35 44.8 55.2 1.5 1.2 – 2.0

Pre-diabetes diagnosis

No 56.6 43.4 REF

Yes 40.7 59.3 1.7 1.2 – 2.4

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Laboratory weight: WLab

• Two stepso Non-post-stratified laboratory weight

o Adjusted post-stratified laboratory weight

WLab

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Age Sex Laboratory sample percent WLab

15 - 24 Males 9.96 22.48

Females 10.84 19.85

25 - 34 Males 9.45 11.81

Females 13.79 10.24

35 - 44 Males 9.62 6.91

Females 12.58 7.44

45 - 54 Males 6.78 6.06

Females 8.60 5.45

55 - 64 Males 4.31 3.28

Females 4.36 2.75

65+ Males 5.96 2.33

Females 3.74 1.41

15+ Males 46.08 52.86

Females 53.92 47.14

Total 100.00 100.00

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Conclusions

• Fewer respondents complete a clinic visit following a household interview o Respondents present a self-selection bias

• Non-response and self-selection biases lead to over- or underestimation of national burden of disease

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Lessons learned• Correcting for non-response and self-selection is possible

o Sample design

─ Probability of selection

o Census information

─ Post-stratification

» Educational level if available

o Respondents’ characteristics

─ Behavioral

─ Health

• Weighting methodology documentationo Comparability and reliability

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Outline



Next steps

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Summary of findings for Saudis ages 15 or older

15.1%are hypertensive

40.5%are borderline hypertensive

8.5%are hypercholesterolemic

20%are borderline hypercholesterolemic

13.4%are diabetic

16.3%are borderline diabetic

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Summary of findings for Saudis ages 15 or older

28.7% are obese

51%are vitamin D deficient

12.2%currently smoke cigarettes

11.3%consume shisha daily

75.5%have never gone for a routine checkup

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Outline



Next steps

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Body mass index (BMI)

< 25.0 kg/m2 25-<30 30+0

5

10

15

20

25

30

35

40

4542.5

33.4

24.1

38.6

28.0

33.5

40.6

30.728.7

Males Females Total

%

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Body mass index (BMI)

< 18.5 kg/m2 18.5-<25 25-<30 30-<40 40+0

5

10

15

20

25

30

35

40

7.1

35.4

33.4

21.6

2.5

6.3

32.3

28.028.8

4.7

Males Females

%

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Hypertension

Males Females Total0

5

10

15

20

25

30

35

40

45

50

7.76.5 7.1

17.7

12.515.115.3

9.912.6

46.5

34.3

40.5

Self reported Total Measured Borderline

%

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Hypertension by age

15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+ 0

10

20

30

40

50

60

70

3.4

7.3

16.9

31.0

48.4

65.2

%

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Hypertension diagnoses and control

Males Females Total0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

61.252.9

57.8

5.8

4.95.4

13.9

20.516.6

19.1 21.7 20.2

Undiagnosed Not treated Controled Not controled

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Hypertension status in numbers

Borderline Total Measured Diagnosed Medication Uncontrolled0

500000

1000000

1500000

2000000

2500000

3000000

3500000

3041271

1161787998358

501409

383417 219988

2180043

795404630309

415779335444

170350

Males Females

co

un

ts

34

Hypercholesterolemia


5

10

15

20

25

6.2

3.2

4.8

9.5

7.38.5

7.06.1 6.6

19.520.6

20.0


%

35

Hypercholesterolemia by age

15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+ 0

5

10

15

20

25

30

35

3.5

5.7

10.9

16.3

20.2

28.7

%

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Hypercholesterolemia diagnoses and control

Males Females Total0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

62.668.9 65.1

4.1

4.64.3

31.923.0 28.3

1.4 3.5 2.3

Undiagnosed Not treated Controled Not controled

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Cholesterol status in numbers


200000

400000

600000

800000

1000000

1200000

14000001258505

658513

452563414292

215226

9276

1183613

448783

347854

196582116335

15405

Males Females

co

un

ts

38

Diabetes


2

4

6

8

10

12

14

16

18

9.2

6.5

7.9

14.8

11.7

13.4

9.7

8.59.1

17.0

15.516.3


%

39

Diabetes by age

15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+ 0

10

20

30

40

50

60

4.77.8

12.4

26.9

47.850.4

%

40

Diabetes diagnoses and control

41

Diabetes status in numbers


200000

400000

600000

800000

1000000

1200000

1400000

1172819

1024986

671754627145

583319

230088

956421

720546

521321

395549 366678

167453

Males Females

co

un

ts

42

Current status of past pre-diabetics

Males Females0

10

20

30

40

50

6056.0 54.9

23.3

19.820.7

25.3

Normal PreDiabetic Diabetic

%

43

Current status for diagnosed pre-diabetic by routine medical checkup

never this year in the past0

10

20

30

40

50

60

70

80

90

100

53.2

24.722.1

44.6

29.126.4

78.4

3.1

18.4

Normal PreDiabetic Diabetic

%

44

Vitamin D

Deficient Sufficient Toxic levels0

10

20

30

40

50

60

70

40.6

58.8

0.6

62.6

36.6

0.7

51.048.4

0.7

Males Females Total

%

45

Outline



Next steps

46

Last routine medical checkup

Never 2013 2012 2 – 6 years ago0

10

20

30

40

50

60

70

80

90

100

74.8

15.2

6.23.8

76.3

14.3

6.23.2

75.5

14.8

6.23.5

Males Females Total

%

47

Distance traveled for last routine medical checkup

within 5 km 5 – 10 km 10 – 50 km 50 – 100 km0

10

20

30

40

50

60

70

64.9

18.615.6

1.0

55.0

20.422.4

2.2

61.0

19.3 18.3

1.4

Males Females Total

%

48

Fruit and vegetable consumption, per day

< 1 serving 1 – 2 serving 2 – 5 servings 5+ servings 0

5

10

15

20

25

30

35

30.9

33.2

28.7

7.2

32.4 33.0

26.6

8.0

31.633.1

27.7

7.6

Males Females Total

%

49

Smoking status

Never smoked Ex-smoker Current daily Current non-daily0

10

20

30

40

50

60

70

80

90

100

70.5

6.9

21.5

1.2

97.9

0.6 1.1 0.4

84.0

3.8

11.4

0.8

Males Females Total

%

50

Prevalence of daily shisha consumption


5

10

15

20

25

20.9

1.4

11.3

19.9

1.1

10.6

Current Current Daily

%

51

Levels of physical activity

Inactive low Moderate High 0

5

10

15

20

25

30

35

40

45

50

22.9 23.1

16.3

37.8

46.5

28.6

9.4

15.5

34.5

25.8

12.9

26.8

Males Females Total

%

52

Time sitting, per day

No time sitting 0.5 – 2 hours 2 – 4 hours 4 – 6 hours >6 hours 0

5

10

15

20

25

30

35

40

45

0.8

9.8

38.8

25.5 25.1

1.0

10.2

35.8

26.6 26.3

0.9

10.0

37.4

26.0 25.7

Males Females Total

%

53

Time spent watching TV

Doesn't watch tv 0.5 – 2 hours 2 – 4 hours 4 – 6 hours >6 hours 0

5

10

15

20

25

30

35

40

45

5.5

18.3

42.0

20.3

13.9

6.7

19.7

40.4

19.2

14.0

6.1

19.0

41.2

19.8

13.9

Males Females Total

%

54

Difficulty walking a short distance

No difficulty Little or some High difficulty or Inability0

10

20

30

40

50

60

70

80

90

100

86.5

11.7

1.8

75.3

21.4

3.3

81.0

16.5

2.5

Males Females Total

%

55

Ability to do vigorous activities

Able Very little or somewhat able Inability0

10

20

30

40

50

60

70

80

71.9

18.0

10.1

57.7

26.5

15.8

65.0

22.1

12.9

Males Females Total

%

56

Self-rated health

Excellent or very good Good Fair or poor0

10

20

30

40

50

60

70

80

90

100

80.3

14.5

5.1

73.8

19.5

6.7

77.1

17.0

5.9

Males Females Total

%

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Outline



Next steps

58

Conclusions

1. A young population, hence the burden of NCDs will increase irrespective of changes in rates.

2. High risk factors such as lack of physical activity, poor diet, and smoking. Tackling these risk factors should be a priority.

3. High levels of pre-conditions is a concern.

4. Lack of control of conditions is a concern. Our results suggest that it is due to personal behaviors rather than a medical response.

5. Lack of preventive care is alarming in a free and accessible health care system.

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Outline

Saudi Health Interview Survey

Key findings

Risk factors and health behaviors

Conclusions

Recommendations

Next steps

60

Early detection campaigns

1. Encourage individuals to know their numbers

2. Conduct early detection campaigns

3. Get out there and do not wait for them to come to the clinics (workplace, religious gathering, major events, etc…).

4. 525,600 and 350,400 ruleThere are 525,600 minutes a year; accounting for 8 hrs/day of sleep we have 350,400 minutes. If a person sees a physician 4 times a year for 30 minutes, this amounts to only 0.03% of his/her time interacting with the health care system. The rest of the time is spent in one’s community. Indeed, we need to get out there and reach people to prevent diseases and improve health.

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Focus on preventable risks

1. Focusing on preventable risks is likely to be more cost-effective: bigger potential benefits, neglected in many communities, and less costly than other strategies.

2. Increase in smoking levels and shisha use among males will have a severe impact on health and should be a priority in prevention activities

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Strategies on physical activity, diet, and obesity

1. Independent but interrelated risks of total caloric intake, composition of diet, and physical activity with obesity.

2. Patterns of change suggest optimism on the potential across the Kingdom to change physical activity. Changes in composition of diet may also be feasible through a mixture of promotion, subsidies, and regulation.

3. Strategies to decrease obesity or address the imbalance between total energy intake and expenditure with large-scale population effects are less clear. Estimated benefits of physical activity and diet composition are independent of obesity.

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Fund local innovative strategies to reduce risks

1. Given the diversity of risks and communities, no simple menu of effective programs for risk reduction.

2. Local experimentation to figure out what works in a given community is likely to be necessary.

3. Fund innovative strategies and document through independent evaluation whether they work or not.

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Use the power of incentives

1. Reward programs that demonstrate measured changes in risks in the community they are serving by extending or increasing funding.

2. Stop funding programs that do not demonstrate progress on risk reduction.

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Engage medical providers in accountable care

1. With many leading risks (tobacco, blood pressure, blood sugar, cholesterol, alcohol intake, physical inactivity, components of diet), there is an important role for primary health care.

2. Need to broaden the notion of accountability beyond providing high-quality care to encompass achieving risk reduction in partnership with patients.

3. Forging a connection between health care provision and progress for individuals and communities in health outcomes will be critical for the future.

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Outline



Next steps

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Press conference in KSA to release SHIS results

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Dissemination materials

- Adult obesity in the Kingdom of Saudi Arabia at a glance

- Hypercholesterolemia in the Kingdom of Saudi Arabia at a glance

- Diabetes in the Kingdom of Saudi Arabia at a glance

- Hypertension in the Kingdom of Saudi Arabia at a glance

- Smoking in the Kingdom of Saudi Arabia: Findings from the Saudi

Health Interview Survey

- Saudi Health Interview Survey Report of Results

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Publications Accepted manuscripts as of June 2015:

Burden of Disease, Injuries, and Risk Factors in the Kingdom of Saudi Arabia 1990-2010. Preventing Chronic Disease.

Obesity and associated factors – Kingdom of Saudi Arabia, 2013. Preventing Chronic Disease.

Hypertension and its associated risk factors in the Kingdom of Saudi Arabia, 2013: a national survey. International Journal of Hypertension.

Hypercholesterolemia and its associated risk factors – Kingdom of Saudi Arabia, 2013. Annals of Epidemiology.

Status of the diabetes epidemic in the Kingdom of Saudi Arabia, 2013. International Journal of Public Health.

Reported stroke symptoms and their associated risk factors in the Kingdom of Saudi Arabia, 2013. Journal of Hypertension - Open Access.

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Publications

Accepted manuscripts as of June 2015:

Breast cancer screening in Saudi Arabia: free but almost no takers (PLOS ONE)

Tobacco consumption in the Kingdom of Saudi Arabia, 2013: findings from a national survey (BMC Public Health)

Fruit and vegetable consumption among adults in Saudi Arabia, 2013 (Journal of Nutrition and Dietary Supplements)

Get a license, buckle up, and slow down: risky driving patterns among Saudis (Traffic Injury Prevention)

Low uptake of periodic health examinations in the Kingdom of Saudi Arabia, 2013 (Journal of Family Medicine and Primary Care)

Self-rated health among Saudi adults: findings from a national survey, 2013 (The Journal of Community Health)

Access and barriers to health care in the Kingdom of Saudi Arabia, 2013: Findings from a National Multistage Survey (BMJ open)

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Publications

Manuscripts in review as of June 2015:

On your mark, get set, go: levels of physical activity in the Kingdom of Saudi Arabia, 2013

The health status of Saudi Women: Findings from a national survey

Asthma in the Kingdom of Saudi Arabia: Findings from a national household survey, 2013

Deficiencies under plenty of sun: Vitamin D status among adults in the Kingdom of Saudi Arabia, 2013

The health of Saudi youth: Current challenges and future opportunities

Use of dental clinics and practices of oral hygiene in the Kingdom of Saudi Arabia, 2013

Cost of diabetes in the Kingdom of Saudi Arabia, 2014

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Outline



Next steps

73

Next steps

• Based on IHME’s preliminary analysis of MOH spending on diabetes treatment, the Minister created a MOH committee to work with IHME to analyze MOH spending on hypercholesterolemia and hypertension

• This analysis will also aim to project how much the MOH will spend in the future on borderline patients if they do not take action and end up fully developing the condition.

• Household interview: aims to capture indicators on wealth index, functional health, maternal and child health, chronic and infectious diseases, mortality, and health facility access and satisfaction

• Health facility survey: aims to capture indicators related to a facility’s capabilities as well as patient accessibility and satisfaction

• Exit interview: at select health facilities, patients will be interviewed to get feedback on how to improve services and reduce bottlenecks

5 million households

Saudi health census

Saudi health expenditure

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The importance of the Saudi Health Census

• It will provide the MOH with a better understanding of health needs at the regional and sub-regional levels.

• It will help inform the design and implementation of adequate interventions and policies tailored to communities’ needs.

• It will be used as an early detection program to identify persons at risk or with undiagnosed or uncontrolled conditions.

• It will allow the linkage of data from households to health facilities. This will inform the MOH of bottlenecks in health services and programs.

Next steps

1. Establish a burden of disease unit under Public Health Directorate linked to Saudi CDCo Health statistics

o Survey and surveillance team

o Local burden

o Data linkage

o Training

2. Training on burden of disease at IHME and in the Kingdom o MDs or MOH/regional managers for using the findings

o Data methodologies (preferably non-MDs)

o Communication

3. KSA regional burden of disease

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Acknowledgments

The Institute for Health Metrics and Evaluation would like to thank the Saudi Ministry of Health and all who have participated and supported this ongoing collaboration.

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Health & Medicine

Chronic diseases and their risk factors in the Kingdom of Saudi Arabia