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Chronic diseases and their risk factors in
the Kingdom of Saudi Arabia
October 15, 2014
Ali H. Mokdad, PhD
Director of Middle Eastern Initiatives
Professor 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
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
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 interview
o 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
15
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
16
Household interview weight: WHI
• Two steps
o Probability of selection
─ 𝐩 𝐬𝐞𝐥𝐞𝐜𝐭𝐢𝐨𝐧 =
𝐍 𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝𝐬,𝐬𝐚𝐦𝐩𝐥𝐞𝐝,𝐫𝐞𝐠𝐢𝐨𝐧
𝐍 𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝𝐬,𝐭𝐨𝐭𝐚𝐥,𝐫𝐞𝐠𝐢𝐨𝐧 ∗ 𝐍𝐢𝐧𝐝𝐢𝐯𝐢𝐝𝐮𝐚𝐥𝐬,𝐭𝐨𝐭𝐚𝐥,𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝
─ 𝐰 𝐩𝐞𝐫𝐬𝐨𝐧 =
𝟏
𝐩 𝐬𝐞𝐥𝐞𝐜𝐭𝐢𝐨𝐧
o Post-stratification
─ 𝒘 𝒑𝒆𝒓𝒔𝒐𝒏,𝒑𝒐𝒔𝒕−𝒔𝒕𝒓𝒂𝒕𝒊𝒇𝒊𝒆𝒅 = 𝐰 𝐩𝐞𝐫𝐬𝐨𝐧 ∗
% 𝐩𝐨𝐩 𝐒𝐚𝐮𝐝𝐢,𝐚𝐠𝐞,𝐬𝐞𝐱
% 𝐩𝐨𝐩 𝐬𝐚𝐦𝐩𝐥𝐞,𝐚𝐠𝐞,𝐬𝐞𝐱
WHI
17
SHIS age and sex distribution
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
18
Response rate to clinic visit
• 10,735 respondents completed the household interview
• 5,590 visited a local clinic for blood analysis
o Response rate of 52.1%
19
Predictors of clinical visits following the survey
Participated in the lab exam
Independent variables Categories No % Yes % AO
R
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
20
Laboratory weight: WLab
• Two steps
o Non-post-stratified laboratory weight
─ 𝐰𝐥𝐚𝐛 =
𝐍𝐢𝐧𝐝𝐢𝐯𝐢𝐝𝐮𝐚𝐥,𝐬𝐚𝐦𝐩𝐥𝐞𝐝,𝐫𝐞𝐠𝐢𝐨𝐧
𝐍𝐢𝐧𝐝𝐢𝐯𝐢𝐝𝐮𝐚𝐥𝐬,𝑳𝒂𝒃,𝐫𝐞𝐠𝐢𝐨𝐧
𝐰 𝐩𝐞𝐫𝐬𝐨𝐧
o Adjusted post-stratified laboratory weight
─ 𝐰𝐥𝐚𝐛,𝐩𝐨𝐬𝐭−𝐬𝐭𝐫𝐚𝐭𝐢𝐟𝐢𝐞𝐝 = 𝐰𝐥𝐚𝐛 𝐩𝐥𝐨𝐠𝐢𝐬𝐭𝐢𝐜 𝐅
% 𝐩𝐨𝐩 𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝𝐒𝐚𝐦𝐩𝐥𝐞𝐯𝐚𝐫𝐢𝐚𝐛𝐥𝐞𝐬
% 𝐩𝐨𝐩 𝒄𝒍𝒊𝒏𝒊𝒄 𝒗𝒊𝒔𝒊𝒕,𝐯𝐚𝐫𝐢𝐚𝐛𝐥𝐞𝐬
WLab
21
SHIS age and sex distribution
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
22
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
23
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 documentation
o Comparability and reliability
24
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
25
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
26
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
27
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
28
Body mass index (BMI)
42.5
33.4
24.1
38.6
28.0
33.5
40.6
30.7
28.7
0
5
10
15
20
25
30
35
40
45
< 25.0 kg/m2 25-<30 30+
%
Males Females Total
29
Body mass index (BMI)
7.1
35.4
33.4
21.6
2.5
6.3
32.3
28.0
28.8
4.7
0
5
10
15
20
25
30
35
40
< 18.5 kg/m2 18.5-<25 25-<30 30-<40 40+
%
Males Females
30
Hypertension
7.7
6.5 7.1
17.7
12.5
15.115.3
9.9
12.6
46.5
34.3
40.5
0
5
10
15
20
25
30
35
40
45
50
Males Females Total
%
Self reported Total Measured Borderline
31
Hypertension by age
3.4
7.3
16.9
31.0
48.4
65.2
0
10
20
30
40
50
60
70
15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+
%
32
Hypertension diagnoses and control
61.2
52.9
57.8
5.8
4.9
5.4
13.9
20.5
16.6
19.1 21.7 20.2
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Males Females Total
Undiagnosed Not treated Controled Not controled
33
Hypertension status in numbers
3041271
1161787
998358
501409
383417 219988
2180043
795404
630309
415779
335444
170350
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
Borderline Total Measured Diagnosed Medication Uncontrolled
counts
Males Females
34
Hypercholesterolemia
6.2
3.2
4.8
9.5
7.3
8.5
7.0
6.1 6.6
19.5
20.6
20.0
0
5
10
15
20
25
Males Females Total
%
Self reported Total Measured Borderline
35
Hypercholesterolemia by age
3.5
5.7
10.9
16.3
20.2
28.7
0
5
10
15
20
25
30
35
15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+
%
36
Hypercholesterolemia diagnoses and control
62.6
68.9 65.1
4.1
4.6
4.3
31.9
23.0 28.3
1.4 3.5 2.3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Males Females Total
Undiagnosed Not treated Controled Not controled
37
Cholesterol status in numbers
1258505
658513
452563
414292
215226
9276
1183613
448783
347854
196582
116335
15405
0
200000
400000
600000
800000
1000000
1200000
1400000
Borderline Total Measured Diagnosed Medication Uncontrolled
counts
Males Females
38
Diabetes
9.2
6.5
7.9
14.8
11.7
13.4
9.7
8.5
9.1
17.0
15.5
16.3
0
2
4
6
8
10
12
14
16
18
Males Females Total
%
Self reported Total Measured Borderline
39
Diabetes by age
4.7
7.8
12.4
26.9
47.8
50.4
0
10
20
30
40
50
60
15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+
%
40
Diabetes diagnoses and control
41
Diabetes status in numbers
1172819
1024986
671754
627145
583319
230088
956421
720546
521321
395549 366678
167453
0
200000
400000
600000
800000
1000000
1200000
1400000
Borderline Total Measured Diagnosed Medication Uncontrolled
counts
Males Females
42
Current status of past pre-diabetics
56.0 54.9
23.3
19.820.7
25.3
0
10
20
30
40
50
60
Males Females
%
Normal PreDiabetic Diabetic
43
Current status for diagnosed pre-diabetic by
routine medical checkup
53.2
24.7
22.1
44.6
29.1
26.4
78.4
3.1
18.4
0
10
20
30
40
50
60
70
80
90
100
never this year in the past
%
Normal PreDiabetic Diabetic
44
Vitamin D
40.6
58.8
0.6
62.6
36.6
0.7
51.0
48.4
0.7
0
10
20
30
40
50
60
70
Deficient Sufficient Toxic levels
%
Males Females Total
45
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
46
Last routine medical checkup
74.8
15.2
6.2
3.8
76.3
14.3
6.2
3.2
75.5
14.8
6.2
3.5
0
10
20
30
40
50
60
70
80
90
100
Never 2013 2012 2 – 6 years ago
%
Males Females Total
47
Distance traveled for last routine medical checkup
64.9
18.6
15.6
1.0
55.0
20.4
22.4
2.2
61.0
19.3 18.3
1.4
0
10
20
30
40
50
60
70
within 5 km 5 – 10 km 10 – 50 km 50 – 100 km
%
Males Females Total
48
Fruit and vegetable consumption, per day
30.9
33.2
28.7
7.2
32.4 33.0
26.6
8.0
31.6
33.1
27.7
7.6
0
5
10
15
20
25
30
35
< 1 serving 1 – 2 serving 2 – 5 servings 5+ servings
%
Males Females Total
49
Smoking status
70.5
6.9
21.5
1.2
97.9
0.6 1.1 0.4
84.0
3.8
11.4
0.8
0
10
20
30
40
50
60
70
80
90
100
Never smoked Ex-smoker Current daily Current non-daily
%
Males Females Total
50
Prevalence of daily shisha consumption
20.9
1.4
11.3
19.9
1.1
10.6
0
5
10
15
20
25
Males Females Total
%
Current Current Daily
51
Levels of physical activity
22.9 23.1
16.3
37.8
46.5
28.6
9.4
15.5
34.5
25.8
12.9
26.8
0
5
10
15
20
25
30
35
40
45
50
Inactive low Moderate High
%
Males Females Total
52
Time sitting, per day
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
0
5
10
15
20
25
30
35
40
45
No time sitting 0.5 – 2 hours 2 – 4 hours 4 – 6 hours >6 hours
%
Males Females Total
53
Time spent watching TV
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
0
5
10
15
20
25
30
35
40
45
Doesn't watch tv 0.5 – 2 hours 2 – 4 hours 4 – 6 hours >6 hours
%
Males Females Total
54
Difficulty walking a short distance
86.5
11.7
1.8
75.3
21.4
3.3
81.0
16.5
2.5
0
10
20
30
40
50
60
70
80
90
100
No difficulty Little or some High difficulty or Inability
%
Males Females Total
55
Ability to do vigorous activities
71.9
18.0
10.1
57.7
26.5
15.8
65.0
22.1
12.9
0
10
20
30
40
50
60
70
80
Able Very little or somewhat able Inability
%
Males Females Total
56
Self-rated health
80.3
14.5
5.1
73.8
19.5
6.7
77.1
17.0
5.9
0
10
20
30
40
50
60
70
80
90
100
Excellent or very good Good Fair or poor
%
Males Females Total
57
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
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.
59
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 rule
There 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.
61
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
62
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.
63
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.
64
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.
65
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.
66
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
67
Press conference in KSA to release SHIS results
68
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
69
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.
70
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)
71
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
72
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
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
Saudi health census
Saudi health expenditure
74
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 CDC
o 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
76
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.
77

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

  • 1. Chronic diseases and their risk factors in the Kingdom of Saudi Arabia October 15, 2014 Ali H. Mokdad, PhD Director of Middle Eastern Initiatives Professor of Global Health
  • 2. 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. 3
  • 4. 4
  • 5. 5
  • 6. 6
  • 7. 7
  • 8. Change in causes of premature death and disability 1990 2010 8
  • 9. Leading risk factors, 1990 versus 2010 9
  • 10. 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 10
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. Response rate to household interview • 12,000 households contacted • 10,735 respondents completed the household interview o Response rate of 89.5% 14
  • 15. 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 15
  • 16. 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 16
  • 17. Household interview weight: WHI • Two steps o Probability of selection ─ 𝐩 𝐬𝐞𝐥𝐞𝐜𝐭𝐢𝐨𝐧 = 𝐍 𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝𝐬,𝐬𝐚𝐦𝐩𝐥𝐞𝐝,𝐫𝐞𝐠𝐢𝐨𝐧 𝐍 𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝𝐬,𝐭𝐨𝐭𝐚𝐥,𝐫𝐞𝐠𝐢𝐨𝐧 ∗ 𝐍𝐢𝐧𝐝𝐢𝐯𝐢𝐝𝐮𝐚𝐥𝐬,𝐭𝐨𝐭𝐚𝐥,𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝 ─ 𝐰 𝐩𝐞𝐫𝐬𝐨𝐧 = 𝟏 𝐩 𝐬𝐞𝐥𝐞𝐜𝐭𝐢𝐨𝐧 o Post-stratification ─ 𝒘 𝒑𝒆𝒓𝒔𝒐𝒏,𝒑𝒐𝒔𝒕−𝒔𝒕𝒓𝒂𝒕𝒊𝒇𝒊𝒆𝒅 = 𝐰 𝐩𝐞𝐫𝐬𝐨𝐧 ∗ % 𝐩𝐨𝐩 𝐒𝐚𝐮𝐝𝐢,𝐚𝐠𝐞,𝐬𝐞𝐱 % 𝐩𝐨𝐩 𝐬𝐚𝐦𝐩𝐥𝐞,𝐚𝐠𝐞,𝐬𝐞𝐱 WHI 17
  • 18. SHIS age and sex distribution 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 18
  • 19. Response rate to clinic visit • 10,735 respondents completed the household interview • 5,590 visited a local clinic for blood analysis o Response rate of 52.1% 19
  • 20. Predictors of clinical visits following the survey Participated in the lab exam Independent variables Categories No % Yes % AO R 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 20
  • 21. Laboratory weight: WLab • Two steps o Non-post-stratified laboratory weight ─ 𝐰𝐥𝐚𝐛 = 𝐍𝐢𝐧𝐝𝐢𝐯𝐢𝐝𝐮𝐚𝐥,𝐬𝐚𝐦𝐩𝐥𝐞𝐝,𝐫𝐞𝐠𝐢𝐨𝐧 𝐍𝐢𝐧𝐝𝐢𝐯𝐢𝐝𝐮𝐚𝐥𝐬,𝑳𝒂𝒃,𝐫𝐞𝐠𝐢𝐨𝐧 𝐰 𝐩𝐞𝐫𝐬𝐨𝐧 o Adjusted post-stratified laboratory weight ─ 𝐰𝐥𝐚𝐛,𝐩𝐨𝐬𝐭−𝐬𝐭𝐫𝐚𝐭𝐢𝐟𝐢𝐞𝐝 = 𝐰𝐥𝐚𝐛 𝐩𝐥𝐨𝐠𝐢𝐬𝐭𝐢𝐜 𝐅 % 𝐩𝐨𝐩 𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝𝐒𝐚𝐦𝐩𝐥𝐞𝐯𝐚𝐫𝐢𝐚𝐛𝐥𝐞𝐬 % 𝐩𝐨𝐩 𝒄𝒍𝒊𝒏𝒊𝒄 𝒗𝒊𝒔𝒊𝒕,𝐯𝐚𝐫𝐢𝐚𝐛𝐥𝐞𝐬 WLab 21
  • 22. SHIS age and sex distribution 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 22
  • 23. 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 23
  • 24. 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 documentation o Comparability and reliability 24
  • 25. 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 25
  • 26. 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 26
  • 27. 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 27
  • 28. 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 28
  • 29. Body mass index (BMI) 42.5 33.4 24.1 38.6 28.0 33.5 40.6 30.7 28.7 0 5 10 15 20 25 30 35 40 45 < 25.0 kg/m2 25-<30 30+ % Males Females Total 29
  • 30. Body mass index (BMI) 7.1 35.4 33.4 21.6 2.5 6.3 32.3 28.0 28.8 4.7 0 5 10 15 20 25 30 35 40 < 18.5 kg/m2 18.5-<25 25-<30 30-<40 40+ % Males Females 30
  • 32. Hypertension by age 3.4 7.3 16.9 31.0 48.4 65.2 0 10 20 30 40 50 60 70 15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+ % 32
  • 33. Hypertension diagnoses and control 61.2 52.9 57.8 5.8 4.9 5.4 13.9 20.5 16.6 19.1 21.7 20.2 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Males Females Total Undiagnosed Not treated Controled Not controled 33
  • 34. Hypertension status in numbers 3041271 1161787 998358 501409 383417 219988 2180043 795404 630309 415779 335444 170350 0 500000 1000000 1500000 2000000 2500000 3000000 3500000 Borderline Total Measured Diagnosed Medication Uncontrolled counts Males Females 34
  • 37. Hypercholesterolemia diagnoses and control 62.6 68.9 65.1 4.1 4.6 4.3 31.9 23.0 28.3 1.4 3.5 2.3 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Males Females Total Undiagnosed Not treated Controled Not controled 37
  • 38. Cholesterol status in numbers 1258505 658513 452563 414292 215226 9276 1183613 448783 347854 196582 116335 15405 0 200000 400000 600000 800000 1000000 1200000 1400000 Borderline Total Measured Diagnosed Medication Uncontrolled counts Males Females 38
  • 40. Diabetes by age 4.7 7.8 12.4 26.9 47.8 50.4 0 10 20 30 40 50 60 15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+ % 40
  • 42. Diabetes status in numbers 1172819 1024986 671754 627145 583319 230088 956421 720546 521321 395549 366678 167453 0 200000 400000 600000 800000 1000000 1200000 1400000 Borderline Total Measured Diagnosed Medication Uncontrolled counts Males Females 42
  • 43. Current status of past pre-diabetics 56.0 54.9 23.3 19.820.7 25.3 0 10 20 30 40 50 60 Males Females % Normal PreDiabetic Diabetic 43
  • 44. Current status for diagnosed pre-diabetic by routine medical checkup 53.2 24.7 22.1 44.6 29.1 26.4 78.4 3.1 18.4 0 10 20 30 40 50 60 70 80 90 100 never this year in the past % Normal PreDiabetic Diabetic 44
  • 46. 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 46
  • 47. Last routine medical checkup 74.8 15.2 6.2 3.8 76.3 14.3 6.2 3.2 75.5 14.8 6.2 3.5 0 10 20 30 40 50 60 70 80 90 100 Never 2013 2012 2 – 6 years ago % Males Females Total 47
  • 48. Distance traveled for last routine medical checkup 64.9 18.6 15.6 1.0 55.0 20.4 22.4 2.2 61.0 19.3 18.3 1.4 0 10 20 30 40 50 60 70 within 5 km 5 – 10 km 10 – 50 km 50 – 100 km % Males Females Total 48
  • 49. Fruit and vegetable consumption, per day 30.9 33.2 28.7 7.2 32.4 33.0 26.6 8.0 31.6 33.1 27.7 7.6 0 5 10 15 20 25 30 35 < 1 serving 1 – 2 serving 2 – 5 servings 5+ servings % Males Females Total 49
  • 50. Smoking status 70.5 6.9 21.5 1.2 97.9 0.6 1.1 0.4 84.0 3.8 11.4 0.8 0 10 20 30 40 50 60 70 80 90 100 Never smoked Ex-smoker Current daily Current non-daily % Males Females Total 50
  • 51. Prevalence of daily shisha consumption 20.9 1.4 11.3 19.9 1.1 10.6 0 5 10 15 20 25 Males Females Total % Current Current Daily 51
  • 52. Levels of physical activity 22.9 23.1 16.3 37.8 46.5 28.6 9.4 15.5 34.5 25.8 12.9 26.8 0 5 10 15 20 25 30 35 40 45 50 Inactive low Moderate High % Males Females Total 52
  • 53. Time sitting, per day 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 0 5 10 15 20 25 30 35 40 45 No time sitting 0.5 – 2 hours 2 – 4 hours 4 – 6 hours >6 hours % Males Females Total 53
  • 54. Time spent watching TV 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 0 5 10 15 20 25 30 35 40 45 Doesn't watch tv 0.5 – 2 hours 2 – 4 hours 4 – 6 hours >6 hours % Males Females Total 54
  • 55. Difficulty walking a short distance 86.5 11.7 1.8 75.3 21.4 3.3 81.0 16.5 2.5 0 10 20 30 40 50 60 70 80 90 100 No difficulty Little or some High difficulty or Inability % Males Females Total 55
  • 56. Ability to do vigorous activities 71.9 18.0 10.1 57.7 26.5 15.8 65.0 22.1 12.9 0 10 20 30 40 50 60 70 80 Able Very little or somewhat able Inability % Males Females Total 56
  • 58. 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 58
  • 59. 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. 59
  • 60. Outline Saudi Health Interview Survey Key findings Risk factors and health behaviors Conclusions Recommendations Next steps 60
  • 61. 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 rule There 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. 61
  • 62. 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 62
  • 63. 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. 63
  • 64. 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. 64
  • 65. 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. 65
  • 66. 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. 66
  • 67. 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 67
  • 68. Press conference in KSA to release SHIS results 68
  • 69. 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 69
  • 70. 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. 70
  • 71. 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) 71
  • 72. 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 72
  • 73. 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 73
  • 74. 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 Saudi health census Saudi health expenditure 74
  • 75. 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.
  • 76. Next steps 1. Establish a burden of disease unit under Public Health Directorate linked to Saudi CDC o 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 76
  • 77. 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. 77