Table 5.1.1. Risk factors for non-communicable diseases

Cardiovascular diseases

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.

Cancer 

The majority of cancers can be attributed to the particular environment in which an individual is living and though lifestyles. 

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 physical activity.

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.

Diabetes

 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;

·          type 2 diabetes runs in the family;

·          Asian, Afro-Caribbean or Middle-East background;

·          has given birth to a large baby (over 9 lbs/4 kg); or

·          has experienced gestational diabetes, (diabetes during pregnancy only,) and

·          old age.

 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. 

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Neuropsychiatric diseases and disorders

·          Mood/anxiety 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.

·          Eating disorders

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 loneliness.

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.

·          Autism

Controversy about the plausible interaction between genetic and environmental risk factors for Autism is still unresolved.

·          Dementia

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 cardio-vascular diseases.

·          Multiple Sclerosis

Multiple Sclerosis is a complex multifactorial disorder, in which environmental factors are hypothesised to interact with generally susceptible individuals.

·          Parkinson’s Disease

The cause of the neurodegenerative process of Parkinson’s Diseases is still unknown.

·          Other nervous system disorders

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 incident patients.

Food Allergy

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 proteins.

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.

Liver Cirrhosis

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.

Dermatological diseases

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 compounds.

Periodontal diseases

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 disfunctions

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.

Developmental disorders

Various effects on development can be caused by exposure to lead, cadmium, mercury, smoking and environmental tobacco smoke, some pesticides and endocrine disruptors.