THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE
PART II - HEALTH CONDITIONS
5. HEALTH IMPACTS OF NON COMMUNICABLE DISEASES AND RELATED TIME-TRENDS
5.1.1. Main non-communicable diseases and their risk factors
5.1.1. Main non-communicable diseases and their risk factors
Main non-communicable diseases with a high impact in terms
of mortality and morbidity include cardiovascular diseases; cancer; asthma and
other respiratory diseases; diabetes; obesity and other conditions related to
an imbalanced diet; hepatic cirrhosis and other chronic liver diseases;
nephrological diseases; musculoskeletal diseases; mental disease and disorders;
neurodegenerative and non psychiatric diseases. Injuries, poisoning and
violence also contribute significantly to mortality in the EU. Main non lethal
chronic diseases include dermatological diseases, allergic diseases and
In developed countries and lower/middle income developing
countries, cardiovascular complications and neoplasia represent the main cause
of death. In low-income developing countries, infections still remain the
dominant cause for short life-expectancy, but chronic non-communicable diseases
are clearly on the rise also in these countries. Non-communicable diseases,
disorders and disabilities represent the greatest burden of mortality and
morbidity within the European Union as a whole as well as in each Member States
(Figure 5.1.1). At individual level, the control of behavioural risk factors,
such as smoking, alcohol use, obesity, excessive fat intake, lack of exercise
and exposure to stress, remains essential in order to reduce the incidence and
alter the course of chronic non-communicable diseases (Table 5.1.1). On the
other hand, several environmental and occupational risk factors have been
identified; thus it is now possible to establish preventive policies. Screening
and case identification strategies allow, in some cases, for early detection
and diagnosis across populations and within individuals. Treatment has become
increasingly effective for some conditions such as coronary hearth diseases.
Finally, rehabilitation remains an important element of disease management for
Figure 5.1.1a. Proportion of cardiovascular
disease, cancer and violence (injury and poisoning) within total causes of
death; 3 years average (2001-2003), EU27 – A) Women
Figure 5.1.1b. Proportion of
cardiovascular disease, cancer and violence (injury and poisoning) within total
causes of death; 3 years average (2001-2003), EU27 – B) Men.
Table 5.1.1. Risk factors for
CVD clinically manifests itself in middle life and older
age, after many years of exposure to unhealthy lifestyle (smoking habit,
unhealthy diet, physical inactivity) and risk factors (elevated total and low
density lipoprotein cholesterol, high blood pressure, diabetes, dyslipidemia
and obesity). CVD is a multifactorial disease, which means that several
predisposing factors simultaneously affect its development, although each of
them plays a different role: to give an example, hypertension, smoking habit
and excessive alcohol consumption have a major role in predicting stroke;
elevated total and LDL cholesterol, low HDL cholesterol, hypertension,
diabetes and smoking are crucial to explain differences in IHD. Among all CVD
risk factors, age remains the most important risk factor for CVD. A too rich
diet (excess of saturated fats and/or trans-unsaturated fats, salt, alcohol,
free sugar and low consumption of antioxidants and fibres, associated with
low intake of fruit and vegetables and integral cereals) along physical
inactivity. Other risk factors are: air pollution (carbon monoxide, ozone,
inhalable particles);environmental tobacco smoke (ETS);
lead; noise; stress.
The risk factors identified as the most important at
population level selected from WHO HFA database (http://www.euro.who.int/hfadb,2007) were : hypertension,
hypercholesterol, obesity, diabetes and smoking habit. Differences exist in
the methodology adopted for data collection (self reported or measured), the
diagnostic criteria adopted in risk definition (hypertension and
hypercholesterol) and the age ranges considered from different countries.
The majority of cancers can be attributed to the
particular environment in which an individual is living and though
Stomach cancer: It has been estimated that most cases of this
cancer are preventable by appropriate diets and associated factors.
Non-starchy vegetables, allium vegetables, and fruits protect against stomach
cancer; salt and also salt-preserved foods are causes of this cancer. There
is strong evidence that infection with a certain bacteria, Helicobacter
pylori, is associated with an increased risk of stomach cancer (WCRF, 2007).
Colorectal cancer: the evidence that physical
activity protects against colorectal cancer is convincing, although
the evidence is stronger for colon than for rectum. The evidence that red
meat, processed meat, substantial consumption of alcoholic drinks (in men),
body fatness and abdominal fatness, and the factors that lead to greater
adult attained height, or its consequences, are causes of colorectal cancer
is convincing. Substantial consumption of alcoholic drinks is probably a
cause of this cancer in women. Foods containing dietary fibre, and garlic,
milk, and calcium probably protect against this cancer (WCRF, 2007). Cancer
control priority should be given to the promotion of those health
determinants related to colorectal cancer aetiology, such as healthy diet and
Lung cancer: smoking is a primary cause of lung cancer, although
pollution and exposure to certain gases/chemicals may also be influential.
Geographic patterns of lung cancer incidence and mortality are influenced by
past exposure to tobacco smoking, and the geographic pattern in women
reflects the rather different historical patterns of smoking as compare to
men (Parkin et al, 2005). Although male lung cancer incidence is decreasing
in all European macro-areas, lung cancer remains the first cancer diagnosed
in men in Eastern and Southern Europe and the second in Western and Northern
Europe. Therefore, awareness of tobacco as a risk factor promoting lung
cancer is increasing, but the war against tobacco has not been won yet. To
this end additional efforts are needed. For instance specific actions
addressed to women and young are necessary.
Breast cancer: Breast cancer is hormone related, and the factors
that modify the risk of this cancer when diagnosed premenopausally and when
diagnosed (much more commonly) postmenopausally are not the same. Risk
factors for breast cancer in women include the events of reproductive life
and lifestyle factors (diet, alcohol, ecc) that modify endogenous levels of
sex hormones (Key et al, 2002). Physical activity
probably protects against breast cancer in postmenopause, and there is
limited evidence suggesting that it protects against this cancer diagnosed in
premenopause. The evidence that alcoholic drinks are a cause of breast cancer
at all ages is convincing. The evidence that the factors that lead to greater
adult attained height, or its consequences, are a cause of postmenopausal
breast cancer is convincing, and these are probably also a cause of breast
cancer diagnosed in premenopause (WCRF, 2007).
Cervical cancer: the main risk factor is the infection by some forms
of genital human papilloma virus or HPV (Stewart and Kleihues, 2003). Genital
HPV is usually spread by sexual contact. Abnormal cells, derived from HPV
infection, take many years to progress into cervical cancer, and once
detected early by screening via PAP-smear test, these cells can be easily
removed so they do not develop into cervical cancer.
Prostate cancer: age is the strongest risk factor for prostate
cancer: development of this malignancy is a multi-step process associated
with a long natural history. Other certain risk factors are an high fat diet
and family history, while possible risk factors are androgens and race
(Stewart and Kleihues, 2003).
Other types of cancer: Body fatness has been associated with oesophageal,
pancreas, colon, endometrial and kidney cancer and, through the formation of
gall stones, also to gallbladder cancer.
Other risk factors are: air pollution (inhalable
particles, environmental tobacco smoke, polycyclic
aromatic hydrocarbons, radon gas, asbestos); some pesticides; natural toxins
present in food; some metals (arsenic, cadmium, chromium); dioxins;
radiation, including UV radiation in sunlight.
The major risk factor for Type 2 diabetes is excess body
weight, particularly when this excess weight is due to abdominal
fat In case of a genetic susceptibility it is this fat accumulation that
drives towards progression to the disease. Further risk factors for
developing type 2 diabetes:
obese or with high blood pressure or high cholesterol;
2 diabetes runs in the family;
Afro-Caribbean or Middle-East background;
given birth to a large baby (over 9 lbs/4 kg); or
experienced gestational diabetes, (diabetes during pregnancy only,) and
Type 1 diabetes genetic susceptibility in combination
with one or many environmental factors will lead to the immune-mediated
progressive failure of the beta cells. So far, no prevention is possible for
this type of diabetes. A number of other causes of diabetes exist. Maturity
onset diabetes of the young, or MODY ‘s are monogenetic forms of diabetes,
with different patterns in time and different treatment. Certain medical
conditions such as acromegaly or Cushing’s disease can lead to increased
insulin resistance and diabetes. Chronic pancreatitis can damage the insulin
producing cells, meaning that patients with the disease eventually may also
present diabetes. Cystic fibrosis can be complicated by diabetes. These
forms are not dealt with in this report.
Neuropsychiatric diseases and disorders
disorders and suicide
The following are main causes of suicide: mental
illness (including depression and other diagnosed mental disorders);
social isolation; physical illness; substance abuse; family violence; and
access to means of suicide.
Social pressure to be thin, fitter and look more
aesthetically are critically important risk factors influencing personal
health and may contribute to fall ill. Eating disorders are not only influenced
by social factors, but rather anorexia and bulimia are caused by a complex of
conditions including psychological factors, interpersonal factors, social
factors as well as biological factors. In other words, eating disorders are
caused by an environment where it is easy to become anorectic or bulimic:
Psychological factors: low self-esteem, feelings of
inadequacy or lack of control in life, depression, anxiety, anger, or
Interpersonal factors: trouble with family and
personal relationships, difficulty in expressing emotions and feelings, being
teased or ridiculed, physical or sexual abuse.
Social Factors: cultural pressure that glorify
“thinness” and the “perfect body”.
Biochemical factors: chemicals in the brain that
control hunger, appetite, and digestion; genetic factor.
Controversy about the plausible interaction between
genetic and environmental risk factors for Autism is still unresolved.
A number of risk factors and possible protective
factors have emerged. Some, such as food, physical
activity and mental stimulation, can be changed as it is a question
of lifestyle. Others, such as age, gender and genetics cannot. Moreover, it
is likely that a combination of factors may be beneficial such as a healthy
diet, regular moderate exercise, social contact and mental stimulation.
Certain factors, such as alcohol intake and cigarette smoking, have been
found to both increase the risk of but also protect against dementia (Haan
and Wallace, 2004). Whilst a low level of education and/or a manual
occupation have been associated with an increased risk of developing
dementia, it is difficult to disentangle other social factors which are
associated with them. It is becoming increasingly clear that certain possible
protective factors, such as healthy eating, exercise, avoiding being
overweight and limiting alcohol intake, may also contribute towards the
prevention of other conditions and diseases such as cancer and
Multiple Sclerosis is a complex multifactorial
disorder, in which environmental factors are hypothesised to interact with
generally susceptible individuals.
The cause of the neurodegenerative process of
Parkinson’s Diseases is still unknown.
Exposure in utero or during development to some
chemicals, such as methyl mercury, cadmium compounds, lead can impact on the
development of cognitive function. Exposure to polychlorinated biphenyls
(PCBs), some solvents or organophosphorus pesticides can cause neuropathies.
Musculoskeletal conditions and problems
See section 5.6.
Respiratory diseases including asthma
The main determinants considered in primary prevention
policies at the moment are: exposure to allergens (pollen, fungal spores,
dust mites, pet hair, skin and excreta) and sensitization; cigarette smoking
and tobacco environmental exposure; indoor and outdoor air pollution (sulphur
dioxide, nitrogen dioxide, inhalable particles, ground level ozone), damp and
changes in dietary habitudes.
Chronic Obstructive Pulmonary Disease
Active and passive cigarette smoking, occupational
factors and indoor-outdoor pollution from biomass fuel are well recognized
risk factors. Cigarette smoking is a major risk factor for COPD.A study by
Lundback (2003) showed that age and smoking were the two major risk factors,
in a multivariate analysis including age, gender, smoking habits, family
history of obstructive airway disease and socioeconomic group as COPD
determinants. In the analysed population, aged 46 to 77, odds ratio
associated with smoking more than 5 cigarettes per day was about 8, compared
to non-smokers. Prevalence of COPD reached 50% in elderly smokers.
Chronic Kidney Disease and End Stage Renal Disease
Hypertension and diabetes, obesity and perhaps
non-traditional risk factors like anemia, hyperphosphatemia, high plasma C
Reactive Protein and Fibrinogen, high sympathetic activity and accumulation
endogenous inhibitors of nitric oxide synthase appear to be the main drivers
of CKD at population level. Patients with neoplasias and with chronic
infections diseases like HIV and viral hepatitis (HBC) and patients exposed
to nephrotoxic drugs are at higher risk for CKD. Currently, diabetes mellitus
is the most common cause of RRT for ESRD, affecting more than 22% of the
In adults, main foods responsible for about half of all
allergic reactions are fruits of the latex group, fruits of the Rosaceae
family, vegetables of the Apiaceae family, nuts and peanuts, whereas in
children three fourths of reactions are limited to eggs, peanuts, cow’s milk,
fish and nuts
Celiac disease (also known as gluten-induced
entheropathy) is an autoimmune disorder triggered by gluten associated with
the exposure to foods containing wheat, barley and Raye alcohol-soluble
The timing of weaning is likely to have an impact in the
development of food allerfy, even if definitive evidences are not available.
Early weaning is reported to be associated with an increase of food allergy
because of the incomplete development of the enterocytes, thus allowing the
passage to the intestinal lamina propria or large molecula. On the other
hand, late weaning is likely to determine an higher incidence of food
allergy, because of the loss of immune oral tolerance that occurs in the
toddlers usually after 10 months of age.
The patterns in mortality from cirrhosis are largely
attributable to changes in the two major recognized causes of this disease,
i.e., hepatitis B and C virus (HBV and HCV) infection and alcohol drinking.
Main contact dermatitis refers to either: irritant
contact dermatitis (e.g. frequent exposure to mild irritant soaps seen in
trainee nurses or hairdressers) or allergic contact dermatitis, where
subjects develop a delayed type of allergic response to certain potentially
sensitizing substances such as metals, perfumes, preservatives, or rubber
The available evidence shows that important risk factors
for periodontal disease relate to poor oral hygiene, tobacco use, excessive
alcohol consumption, stress, and diabetes mellitus. The focus
of recent studies in periodontics is on systemic connection between untreated
periodontal disease and other health problems, including heart disease,
stroke, obstructive pulmonary disease and diabetes. It has been shown a long
time ago that some of these conditions (especially diabetes) worsen
periodontal status of patients already affected by periodontitis and make
them 2-5 times more susceptible to develop severe periodontal disease.
Overweight and obesity
Excessive food intake as compared to needs deriving from
physical activity and basal metabolism. Inadequate intake
of specific nutrients.
Reproductive disfuncions can be caused by some
pharmaceuticals. Some chemicals (e.g.: polychlorinated biphenyls (PCBs), DDT,
cadmium, phthalates), known as endocrine disruptors, affect reproductive
function in wildlife and are suspected to have similar effects in humans.
Various effects on development can be caused by exposure
to lead, cadmium, mercury, smoking and environmental tobacco
smoke, some pesticides and endocrine disruptors.