Authors

• Verica Kralj — Croatian National Institute for Public Health, Zagreb, Croatia — ORCID: 0000-0002-4623-828X
• Ivana Brkic Bilos — Croatian National Institute for Public Health, Zagreb, Croatia — ORCID: 0000-0001-9088-8960
• Tanja Coric — Croatian National Institute for Public Health, Zagreb, Croatia — ORCID: 0000-0001-5084-287X
• Maja Silobrcic Radic — Croatian National Institute for Public Health, Zagreb, Croatia — ORCID: 0000-0002-8247-9881
• Mario Sekerija — Croatian National Institute for Public Health, Zagreb, Croatia — ORCID: 0000-0001-7508-1501

Abstract

Today, the world faces an epidemic of chronic noncommunicable diseases. They are the main cause of death in almost all countries of the world, endangering both the life and health of the people and economic development in general. They are characterized by shared risk factors, shared determinant causes, and shared prevention strategies. Particularly dangerous are cardiovascular and malignant diseases, diabetes, and chronic respiratory diseases associated with the four main shared risk factors – smoking, improper diet, lack of physical activity, and harmful alcohol consumption. However, it is important to also emphasize the association between noncommunicable diseases and shared risk factors with mental disorders and injuries, which requires special attention when discussing chronic diseases. All of this places a significant strain on the health care system, causes a large financial burden, and consequently influences the social and economic development of a country.

Keywords

chronic noncommunicable diseases, disease burden, prevention

DOI

Full Text

## The global situation During recent decades, there has been an increase in the incidence of chronic noncommunicable diseases (NCDs) in almost every country in the world. According to World Health Organization (WHO) estimates, 68% of global deaths in 2012 were caused by chronic diseases. Out of the 56 million total deaths, 38 million died from chronic diseases (17.5 million from cardiovascular diseases (CVD) – 46.2%; 8.2 million from malignant diseases – 21.7%; 4 million from respiratory diseases – 10.7%; 1.5 from diabetes – 4%). Approximately three quarters of NCD-related deaths (28 million) happens in low or moderately-high income countries. Standardized mortality rates from NCDs are lowest in high-income countries – 397/100 000, and highest in low or moderately-high income countries – 625 and 673/100 000, respectively. Approximately 42% of deaths due to NCDs take place before 70 years of age and are considered to be premature deaths. Most premature deaths (82%) happen in in low or moderately-high income countries. The presence of these diseases and related risk factors is associated with poverty, lower levels of education, and other social determinants of health. While the number of deaths from infectious diseases is decreasing, it is estimated that deaths from NCDs will grow to 52 million annually by 2030. (1, 2) According to the study The Global Burden of Diseases 2010, NCDs mortality increased from 57% of total mortality in 1990 to 65% in 2010. (3, 4) The same study showed that 54% of disability adjusted life years (DALYs – which calculates years of life lost due to premature deaths and years disabled due to disease) in 2010 were caused by NCDs, whereas that ratio was 43% in 1990. The increase is primarily due to an increase in DALYs due to CVD (22.6%), diabetes (69%), and cancer (27.3%). (5) In Europe, according to WHO data, 86% of deaths and 77% of the disease burden is caused by chronic NCDs. (6) According to WHO estimates for 2012, the leading causes of death in Europe were ischemic heart disease, cerebrovascular disease, lung cancer, chronic obstructive pulmonary disease, and colon and rectal cancer. (7) Years of life lost (YLL) is an indicator of premature death, and the top five causes in Europe are ischemic heart disease, cerebrovascular disease, lung cancer, cirrhosis, and self-harm (Table 1). ### Table 1: 10 Leading Causes of YLL in European Region, 2012. | | | WHO European Region | WHO European Region | | --- | --- | --- | --- | | Rank | Cause | YLL (000s) | % YLL | | 0 | All Causes | 205.656 | 100.0 | | 1 | Ischemic heart disease | 41.809 | 20.3 | | 2 | Stroke | 21.971 | 10.7 | | 3 | Trachea, bronchus, lung cancers | 9.945 | 4.8 | | 4 | Cirrhosis of the liver | 6.325 | 3.1 | | 5 | Self-harm | 5.449 | 2.7 | | 6 | Lower respiratory infections | 5.254 | 2.6 | | 7 | Colon and rectum cancers | 5.237 | 2.6 | | 8 | Chronic obstructive pulmonary disease | 4.556 | 2.2 | | 9 | Road injury | 4.341 | 2.1 | | 10 | HIV/AIDS | 4.240 | 2.1 | [†] YLL = Years of life lost. Source: World Health Organization. Global Health Estimates. The leading causes of disease burden expressed in DALYs were ischemic heart disease, unipolar depression, back and neck pain, and lung cancer (Table 2). (7) In Europe, total mortality rates gradually increase towards the east, premature death indicators in particular. CVD mortality greatly contributes to the difference between Eastern and Western Europe in total mortality and life expectancy. (8) Chronic diseases are the main public health issue in European Union member countries as well, with a significant difference in life expectancy and mortality rates compared with the most common diseases. (9) ### Table 2: 10 Leading Causes of DALYs in European Region, 2012. | | | WHO European Region | WHO European Region | | --- | --- | --- | --- | | Rank | Cause | DALYs (000s) | % DALYs | | 0 | All Causes | 314.387 | 100.0 | | 1 | Ischemic heart disease | 44.088 | 14.0 | | 2 | Stroke | 23.033 | 7.3 | | 3 | Unipolar depressive disorders | 11.976 | 3.8 | | 4 | Back and neck pain | 10.353 | 3.3 | | 5 | Trachea, bronchus, lung cancers | 10.034 | 3.2 | | 6 | Alcohol use disorders | 9.005 | 2.9 | | 7 | Chronic obstructive pulmonary disease | 8.057 | 2.6 | | 8 | Falls | 7.270 | 2.3 | | 9 | Diabetes mellitus | 6.885 | 2.2 | | 10 | Road injury | 6.793 | 2.2 | [†] DALY = Disability-Adjusted Life Year. Source: World Health Organization. Global Health Estimates. ## Prevention and control of chronic noncommunicable diseases globally Due to the growing disease burden from NCDs and their negative influence on economic development, there has been growing interest in the international community during the last fifteen years for setting up and implementing coordinated initiatives to combat NCDs, which resulted in different political and strategic documents. An especially important turning point in the fight with NCDs was the meeting of the General Assembly of the United Nations (UN) with representatives of member states in September 2011 in New York to discuss global health, for the second time in the history of the UN. Heads of state met to bring the issue of preventing and combating NCD to the highest political level and agree on further activities towards that goal. The meeting resulted in the adoption of the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, which is the basis for further action at the national and international levels in combating NCDs. (10, 11) At the global level, the Global Strategy for the Prevention and Control of Noncommunicable Diseases was adopted in the year 2000, which covers monitoring, prevention, and treatment of NCDs, stressing the importance of a multi-sector approach to initiatives aimed at reducing risk factors. Other important documents included the Framework Convention on Tobacco Control in 2003, the Global Strategy on Diet, Physical Activity and Health in 2004, the Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases in 2008, and the new action plan in 2013 for the period between 2013 and 2020, which includes nine global goals and 25 indicators for monitoring and managing NCDs. At the European level, the Strategy for the Prevention and Control of Noncommunicable Diseases was adopted in 2006, and the Action plan for implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases 2012–2016 was adopted in 2011. (12) As a consequence of all these initiatives, the UN and WHO have called for countries to take more forceful action and reduce NCD mortality by 25% by 2025 in the age group between 30 and 70 in comparison with 2010, taking up the slogan 25 x 25. (13) ## Chronic noncommunicable diseases in Croatia Croatia has undergone “demographic transition” and is counted among countries with an “aging population”, with a high percentage of the population being older than 65. This was caused by many years of falling birthrates, an increase in mortality of the younger age groups during the war, negative migration, and reduced mortality, i.e. longer life expectancy. The life expectancy since the Republic of Croatia became independent increased from 71.0 years (66.1 for men, 76.2 for women) in 1991 to 77.2 (74.2 for men, 80.2 for women) in 2013. (14) The disease burden in the Croatian population indicates it has also undergone “epidemiological transition”, with NCDs becoming predominant, instead of infectious diseases. (15) According to mortality and morbidity indicators, chronic NCDs predominate in Croatia, primarily cardiovascular diseases, followed by malignant diseases, diabetes, mental disorders, chronic respiratory diseases, and injuries and their consequences (Figure 1). As much as 93% of the mortality in Croatia is estimated to be caused by NCDs. (16) Figure 1. Mortality by diseases group in Croatia, 2012, age-standardized death rate per 100 000. Source: WHO, European Detailed Mortality Database (DMDB), November 2014. CVD are the leading cause of the disease burden in Croatia in 2012, according to WHO estimates, accounting for 26% of all DALYs. The second place is taken by malignant diseases with 20.4%, followed by mental disorders (11.7%), non-intentional injuries (7.3%), and disease of the skeletomuscular system (6.7%). Regarding individual disease entities (Table 3), ischemic heart disease is the most common, followed by cerebrovascular diseases, unipolar depressive disorder, lung cancer, and diabetes. In the group of non-intentional injuries, most common are falls and traffic accidents, and in the skeletomuscular system diseases group most common as a cause of disease burden are back and neck pain. (7) ### Table 3: 10 Leading Causes of DALYs in Croatia, 2012. | | | Croatia | Croatia | | --- | --- | --- | --- | | Rank | Cause | DALYs (000s) | % DALYs | | 0 | All Causes | 1563.9 | 100.0 | | 1 | Ischemic heart disease | 204.2 | 13.1 | | 2 | Stroke | 117.0 | 7.5 | | 3 | Unipolar depressive disorders | 78.9 | 5.0 | | 4 | Trachea, bronchus, lung cancers | 71.0 | 4.5 | | 5 | Diabetes mellitus | 50.5 | 3.2 | | 6 | Falls | 50.4 | 3.2 | | 7 | Back and neck pain | 49.3 | 3.2 | | 8 | Chronic obstructive pulmonary disease | 48.1 | 3.1 | | 9 | Colon and rectum cancers | 44.9 | 2.9 | | 10 | Road injury | 37.2 | 2.4 | [†] DALY = Disability-Adjusted Life Year. Source: World Health Organization. Global Health Estimates. According to DALYs estimates for Croatia, unipolar depressive disorders are the third most common among all observed entities. An upward trend has been noted in depressive disorders in hospital morbidity, with a significant increase in hospitalization rates. Hospitalization rates in all age groups are higher in women, in which depressive disorders have been the leading cause of hospitalizations for mental disorders over the past several years. Mental disorders caused by alcohol, schizophrenia, depressive disorders, and severe stress reactions including post-traumatic stress disorder, as individual diagnostic categories, comprise almost two thirds of all hospital morbidity caused by mental disorders. (15) According to years of life lost (YLL), an indicator of premature mortality, the five top causes are ischemic heart disease, cerebrovascular disease, lung cancer, colon and rectal cancer, and cirrhosis of liver. Self-harm and traffic accidents are very common in the injury group (7) (Table 4). ### Table 4: 10 Leading Causes of YLL in Croatia, 2012. | | | Croatia | Croatia | | --- | --- | --- | --- | | Rank | Cause | YLL (000s) | % YLL | | 0 | All Causes | 984.6 | 100 | | 1 | Ischemic heart disease | 193.3 | 19.6 | | 2 | Stroke | 112.8 | 11.5 | | 3 | Trachea, bronchus, lung cancers | 70.4 | 7.2 | | 4 | Colon and rectum cancers | 43.6 | 4.4 | | 5 | Cirrhosis of the liver | 34.6 | 3.5 | | 6 | Chronic obstructive pulmonary disease | 26.6 | 2.7 | | 7 | Hypertensive heart disease | 25.5 | 2.6 | | 8 | Self-harm | 25.2 | 2.6 | | 9 | Diabetes mellitus | 23.6 | 2.4 | | 10 | Road injury | 20.8 | 2.1 | [†] YLL = Years of life lost. Source: World Health Organization. Global Health Estimates. ## Leading causes of death in Croatia In comparison with other European countries, Croatia is in the group of countries with moderately high mortality rates. (8) The leading cause of death in Croatia is CVD at 47.4% of total mortality in 2014, followed by malignant diseases at 27.9%, injuries (5.4%), respiratory system diseases (4.4%), and digestive tract diseases (4.2%). As an individual entity, diabetes is responsible for 2.6% of the total mortality (Figure 2 and Table 5). In 2014, 24 112 persons died from CVD, of which 13 800 women and 10 312 men. Leading diagnostic subgroups are ischemic heart disease at 21.3% and cerebrovascular diseases with 14.4% of total mortality. (17) Figure 2. Leading causes of death by diseases group in Croatia, 2014. Source: Croatian Central Bureau of Statistics, Croatian National Institute of Public Health. ### Table 5: Rank of the 10 leading causes of death in Croatia, 2014. | Rank | ICD Code | Diagnosis | No. | % | | --- | --- | --- | --- | --- | | 1 | I20-I25 | Ischemic heart diseases | 10.831 | 21.3 | | 2 | I60-I69 | Cerebrovascular diseases | 7.300 | 14.4 | | 3 | C33-C34 | Malignant neoplasms of trachea, bronchus and lung | 2.827 | 5.6 | | 4 | C18-C21 | Malignant neoplasms of colon, rectum and anus | 2.094 | 4.1 | | 5 | J40-J47 | Chronic lower respiratory diseases | 1.721 | 3.4 | | 6 | I10-I15 | Hypertensive diseases | 1.589 | 3.1 | | 7 | E10-E14 | Diabetes mellitus | 1.333 | 2.6 | | 8 | I50 | Heart failure | 1.311 | 2.6 | | 9 | C50 | Malignant neoplasm of breast | 1.086 | 2.1 | | 10 | K70, K73-K74 | Chronic liver diseases, fibrosis and cirrhosis | 1.020 | 2.0 | | | First 10 causes | | 31.112 | 61.2 | | | Total | | 50.839 | 100.0 | [†] Source: Croatian Central Bureau of Statistics, Croatian National Institute of Public Health. Malignant diseases are the second most common cause of death, with 14 206 deaths in 2014, of which 6143 women and 8063 men. According to data from the Croatian National Cancer Registry, 20 905 persons were newly diagnosed with cancer in 2013. Cancer incidence in women was 440.3/100 000, which translates to 9786 newly diagnosed women, and 538.9/100 000 in men, i.e. 11 136 newly diagnosed male patients. (18) In comparison with other European countries Croatia has a moderately high incidence and high mortality from cancer. Injuries are the third most common cause of death, with 2750 deaths, of which 1134 women and 1616 men. Leading external causes of the injuries are falls (35%), suicide (26%), and traffic accidents (15%). (17) Trend analysis in age-specific mortality from all causes in Croatia for the period from 1990 to 2010 shows that there has been an reduction in total mortality in all age groups and in both genders, with the greatest reduction in mortality taking place in the men in the age group of 25-29 years of age, at 63%. The lowest reduction in mortality was found in women of 80+ years of age, at only 17% (Figure 3). (19) Figure 3. Percent decline in age specific mortality rate by sex from 1990-2010 in Croatia. Adapted: Institute for Health Metrics and Evaluation. The Global Burden of Disease Study. GBD Profile: Croatia. Trends in standardized mortality rates for the most common diagnostic groups for the period from 2000 to 2012 show that there has been a significant reduction in CVD mortality in that period in both women and men (from 680 to 461/100 000 in men) and a somewhat lower reduction in mortality from injuries. For malignant and chronic respiratory diseases as well as diabetes, the mortality trends have been mostly stable in the observed period (Figure 4). (20) We can thus conclude that the reduction in total mortality is primarily due to a reduction in mortality from cardiovascular diseases. Figure 4. Mortality by diseases group in Croatia from 2000-2012, age standardized death rate per 100 000. Source: WHO, European Detailed Mortality Database (DMDB), November 2014. ## Chronic noncommunicable diseases – a priority for the Croatian public health system According to WHO estimates, about 50% of DALYs is caused by three main risk factors: improper diet, elevated blood pressure, and smoking, which are then followed by increased body mass index, harmful alcohol consumption, and inadequate physical activity. (19-21) Based on the above, it became obvious that NCDs are a priority for the Croatian public health system, so a number of political and strategic documents were introduced for the prevention of these diseases. (22) The most significant documents are: - Strategic Plan of Public Health Development 2012-2015 - National Strategy for Preventing Harmful Use of Alcohol and Alcohol Related Disorders 2011-2016 - Action Plan for Overweight Prevention 2010-2012 - National Strategy for Mental Health Care 2011-2016 - Act on the Restriction of the Use of Tobacco Products - The Adoption of the World Health Organization Framework Convention on Tobacco Control Act - Croatian Tobacco Control Action Plan (2013-2016) - Strategic Plan for the Reduction of Excessive salt Intake in Croatia 2015-2019. A number of national programs specifically targeted at primary and secondary prevention have been introduced as well: - Preventive checkups for insured persons over 50 years of age since 2004 - National Program for Interventional Cardiology (2005) - National Program for the Early Detection of Breast Cancer (2006) - National Program for the Early Detection of Colorectal Cancer (2007) - National Program for the Early Detection of Cervical Cancer (2012) - National Diabetes Prevention Program (2007) - The “Healthy Living” national program was introduced in July 2015 consisting of several components: health education, health tourism, health and diet, workplace health, and health and the environment - In preparation: Action Plan for the Prevention and Control of Chronic Noncommunicable Diseases 2015-2020. ## Conclusion It is known that chronic NCDs are largely preventable, that they share risk factors and determinant causes, and that effective, economical, and evidence-based interventions exist that can prevent and manage chronic NCDs in order to avoid early mortality and invalidity, reduce the disease burden, and improve quality of life. Important progress can be achieved if the necessary measures are introduced at the national level in three basic areas: monitoring and management, prevention, and treatment. Croatia has responded to the epidemiologic situation regarding NCDs with the introduction of a number of strategic and legal documents and measures. However, it is always a challenge to translate policies and measures into effective interventions in practice, which requires a firm political will, adequate institutional capacities, and financial support.

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