TRENDS IN NON-COMMUNICABLE DISEASES IN NIGERIA

* By: Prof. G.C Onyemelukwe (MON); Professor of Medicine and Immunology, Ahmadu Bello University, Zaria. Former Chairman Expert Committee on Non-Communicable Diseases, Federal Ministry of Health, Nigeria. 

GLOBAL CONCERN AND RESPONSES

In the 1950s – 1960s, hypertension was said to be rare in Africans, but in recent decades’ hypertension has become prevalent and as high as 20% of adult Nigerians. (1,2) It has taken the nations of the world decades to come to recognize the impact of Non-Communicable Diseases (NCDs) on global health. The United Nations General Assembly in May 2010 passed a resolution (A/RES/64/265) on noncommunicable diseases, recognizing the enormous suffering, premature death and serious threat to global development as well as the negative socio-economic impact caused by NCDs(3) – diabetes, stroke, hypertension, cardiovascular diseases, cancers, asthma, chronic lung diseases, oral health disorders, injuries and violence, and sickle cell disease and has alerted that deaths from NCDs will increase by 25% in 2015 if unchecked.

NCDS AND MILLENNIUM DEVELOPMENT GOALS

The World Economic Forum has reported NCDs as leading macro economic risk at the global level(4). There is evidence that NCDs are undermining the attainment of Millennium Development Goals (MDGs) as the rising prevalence of high blood pressure, diabetes and other risk factors among women of child bearing age in developing countries have direct consequences on maternal health complications, pregnancy outcomes and child survival(5). Consequently, the 63rd World Health Assembly urged member states, international development partners and WHO, in a resolution on health related millennium development goals to recognize the growing burden of NCDs(6). The G1 millennium development goal of eradication of poverty and hunger is unachieved in Nigeria, where underweight children below 5 years are up to 42% as shown by National Demographic and Health Surveys. The G3 goal of empowering and educating women which will impact on behaviour and dietary changes that underpin NCDs is yet to be remarkably addressed in Nigeria.

A grand challenge, noted in Bill and Melinda Gates Foundation’s Grand Challenges in Global Health Initiative is “a specific critical barrier that if removed would help to solve an important health problem”. About 20 grand challenges with regards to NCDs are grouped under six goals – raise public awareness; enhance economic, legal and environmental policies; modify risk factors; engage business and community; mitigate health impacts of poverty and urbanization; re-orientate health system,(8). The expected change that necessarily includes behaviour change largely hinges on individual choices which aggregate to people and community choices.

With regards to research, the Global Alliance for Chronic Disease (GACD)(9) was launched in Seattle and initially operated by six national funding agencies from USA, Canada, Australia, United Kingdom, China, and India. South Africa later joined in 2010, but Nigeria is yet to join. GACD initial priorities in 2009 were hypertension/stroke; reduction of tobacco use, and reduction of indoor pollution from cooking. World Health Organization (WHO) estimates 2% annual reduction of NCDs over the next 10years if its plan of action on NCDs is vigorously pursued(10).

WHO has also developed a Global Strategy on Diet, Physical Activity, and Health, as well as passed a new resolution on “Marketing of foods and non-alcoholic beverages to children”. WHO is guiding a global strategy to reduce the harmful use of alcohol and has created the Non-Communicable Diseases Network(11), NCDNet. An estimated annual death of 36 million per year including 9 million dying before the age of 60 occurs in developing countries and especially in those with economies in transition, and amongst the poorest and vulnerable; while twice as many women die (per 100 adults) in Africa from NCDs(12,13).

DETERMINANTS

The magnitude of NCDs is rapidly increasing because of population aging (longer life span demographic transition – initially described by Warren Thompson), unplanned urbanization; trade globalization and marketing. Old age is associated with a poor dental state, increased insulin resistance, increasing blood pressure. The epidemiological transition from previously predominant infectious disease pattern to NCDs occurring in developing countries is another factor and a complex interplay of infectious diseases and NCDs exists with many of the NCDs now linked to or caused by infectious causes(14).

Risk Factors

A risk factor is defined as an attribute, characteristic or exposure of an individual which increases the likelihood of developing a disease or injury. Risk factors are either non-modifiable such as genetic endowment, race, age, and sex or are modifiable by behavioural or other interventions such as changing diet,  use of exercise and reduction of tobacco and alcohol use.

The level of exposure of people to risk factors of  unhealthy diets, physical inactivity, undue stress and pressure, tobacco use and harmful use of alcohol and drugs, has become higher in developing countries than in high-income countries where comprehensive interventions at promoting healthier behaviour, affordable and accessible health care services for early detection, effective treatment, and prevention of complications, are in place(15). The increased consumption of unhealthy foods which include added salt, refined foods high in fat and simple sugars and low in plant fibre compounded leading to increased prevalence of overweight in middle-to-low-income countries is referred to as nutrition transition which is a type of  malnutrition ensuing from dietary shifts to foods rich in added sugar, saturated fat and sodium for foods rich in vitamins, fibre, minerals and micronutrients such as fruits, vegetables and whole grains. Developing countries struggling with hunger are consequently dealing with problems associated with obesity both in children and adults. In many households, obesity and under nutrition co-exist. When overweight was determined by body mass index (BMI) in Nigerian Hausa-Fulani diabetics, it was found to be prevalent in 35% compared to 22% in controls. However, when it was determined as central obesity (abdominal obesity) it was prevalent in 95% of same diabetics and 0% in controls(16)

Furthermore, malnutrition and stress in pregnancy with low birth weight prevalent in developing countries including Nigeria (14% low birth weight as reported in National Demographic and Health Survey (NDHS), 2003) leads to intrauterine fetal programming(17), which is further exaggerated during later rapid childhood growth(8) and leads to noncommunicable diseases in adults. Surveillance of risk factors(15) is necessary for all nations and surveillance systems are still lacking in Nigeria.

Infection as determinants

Reference has been made to a comprehensive review describing the role of infections in NCDs(14) and in Nigeria, many infections cause or determine the emerging of patterns of noncommunicable diseases. Few examples include:

Group A beta haemolytic streptococci and Rheumatic heart diseases(18), Hepatitis B, C, D viruses and hepatocellular carcinoma confirmed in Nigerians by studies of Fakunle(19) and Ndububa(20) and Olubuyide and coworkers(21); Helicobacter pylori and peptic ulcer disease and gastric carcinoma(22); Coxsackie virus and myocarditis/cardiomyopathy(23); Human papilloma virus types  16, 18 and 11and cervical cancer (24, 25); HIV and malignancies including Kaposi sarcoma (26); Schistosomiasis and bladder cancer(27); Endomyocardial fibrosis associated with parasitic infections in the studies of Andy and colleagues (28); and Chlamydia linked to atherosclerosis, stroke, hypertension, asthma and other diseases(14).

The classic research of Greenwood and coworkers(29) in Nigeria showed that malaria parasite Plasmodium knows suppressed or aborted the spontaneously developing autoimmune disease in mice as well as adjuvant arthritis. The low prevalence of autoimmune mediated non-communicable diseases in Nigeria and sub-Saharan Africa  (like type I diabetes mellitus, autoimmune thyroid diseases,  rheumatoid arthritis which is not as common as in Caucasians) may be as a result of modulating the effect of malaria. Furthermore, malaria may have served as a selective factor for the sickle cell gene and glucose-6-phosphate dehydrogenase deficiency gene as these confer survival advantages(30).

Determinant – Hazardous Environment

Another driving factor is environmental pollution by heavy metals – arsenic, cadmium, mercury, iron, lead, zinc, radioactive elements (31,32) reported in Delta region, Lagos and other states in Nigeria. The use of leaded petrol in Nigeria, petrochemical activities and the mining activities in Kaduna, Plateau and other northern states where radioactive elements are also exposed are sources of pollution.

The finding of lead and other metals in the blood of Nigerians as well as fish(32) may contribute to the development of Alzheimer’s disease, cancers, neurotoxicity, cardiovascular and other diseases. High lead levels as found in Nigerians(33) (2-3 folds of levels in other countries: 10 – 58µg/dl) may cause depression of circulating 1,25:  dihydro-vitamin D, so that rickets and osteomalacia and other metabolic bone diseases evolve while anemia, neuropsychiatric manifestations, immunosuppression, hypertension, low sperm counts are other hidden deleterious effects. Iron content in domestic water was shown to be high in Rivers State (range 0.0014 to 80mg/l as against recommended levels of 0.3mg/litre)(34) due to sediments brought down by Niger and Benue rivers to riverine areas.

Table 1: Conventional Risk factors for NCD

Hypertension    Diabetes mellitus     Stroke    Cancer    Coronary artery disease    Mental illness    Heart disease    Asthma/COPD    Sickle cell disease    Blindness    Oral Health    Osteoporosis/Nutrition    violence

Physical Inactivity

 

 

 

X    X    X

 

 

Alcohol Excess

 

 

 

 

 

 

X    X

 

 

 

 

Drug abuse/use

 

X

 

 

 

Tobacco use/smoking

 

X

 

 

 

 

Salt excess

X

X

X

X    X    X    X    X

 

Unhealthy diets

 

X

 

 

 

 

Obesity

 

X    X    X

 

 

Abnormal lipids

 

X    X    X    X    X    X

Psychological stress

 

 

 

 

 

X

 

Low socio-economic status

 

 

 

 

 

 

 

 

 

 

Unsafe sex    X    X

 

X    X    X

X

 

Family history/heredity

 

 

 

 

 

 

 

 

 

 

Gender

X     X

 

 

X    X    X    X

 

 

= Increase risk of disease     X = Do not increase a risk of disease, COPD = Chronic Obstructive Pulmonary Disease.

 

 

 

 

 

Genetic Determinants

Genetic predisposition and environmental and lifestyles interact in determining the expression of NCDS (Fig I). The HLA genes of chromosomes 6 play important roles in the outcome of immunological interactions with infectious causative agents that lead to some non-communicable disease like type I diabetes mellitus. Famuyiwa and coworkers(35) showed that the pattern of HLA antigens in Nigerian diabetics differs from Caucasians. Properdin factor B allotypes in Nigerians also differs from Caucasians and Australians(36).

About 150 candidate genes have been identified for hypertension(37) including SNPs related to genes for atrial natriuretic peptide A and B types, which are associated with vessel relaxation, salt loss and inflammatory responses in salt sensitive hypertension.

Important genetic research findings in Nigerian women with breast cancer show susceptibility to four polymorphic variants of CYP1A1 and BRCA1(38,39) conferring increased risk and poor prognosis, related to insulin – like growth factors IGFBP2(40) and IGFBP5while cell surface marker  HER – 2(41) and reduced oestrogen and progesterone receptors are reduced in Nigerians.

Genetic research with regard to Alzheimer’s(42) disease showed that apolipoprotein   E  haplotype is different between Yoruba and African Americans.

Quaak and others(43) showed that genetic variants in dopaminergic systems, opioid receptors, the bupropion-metabolising enzymes CYPZB6 and nicotine-metabolising enzyme CYZA6 play important roles in habit formation and predicting smoking cessation responses to nicotine replacement therapy and bupropion treatment.

Longer  Leukocyte Telomere length (LTL), is associated with longer life span. This complex genetic trait, is longer in women than men, is shortened by environmental factors (smoking, obesity, psychological stress, low socioeconomic status), diseases like hypertension, insulin resistance, atherosclerosis, myocardial infarction, stroke and dementia(44) but lengthened by exercise(45).

Determinant – Cocacolonisation

Globalization of soft drinks culture (coca-colonisation) has been articulated by Zimmer(46) and linked with chronic diseases following excessive, persistent consumption of sugary drinks (dietary fructose) which lead to obesity and also adversely affect lipids, platelet adhesiveness, insulin levels(47). Fructose feeding induces diabetes in laboratory animals(49). The platelets of native West Africans have been found to easily disaggregate unlike in Europeans when aggregators like adrenalin, ristocetin, collagen are applied and rapid fibrinolysis also occurs in Nigerians(49).

Table 2: Sugar contents of soft drinks marketed in Nigeria

Soft drinks    Sugar (g/100ml)    Total

Glucose    Sucrose    Fructose

Cocacola    0.22    1.31    0.67    2.2

Fanta    0.42    1.20    0.70    2.32

Sprite    0.20    0.68    0.60    1.48

Pepsicola    0.17    0.81    0.58    1.56

Mirinda    0.22    0.95    0.54    1.71

Maltina    0.22    1.13    0.50    1.85

 

These protective advantages, which may account for the low frequency of coronary artery diseases in Nigerians and other West Africans, are being eroded with westernized lifestyle, and urbanization by excessive soft drinks culture and by the presence of diabetes(50). Nigerian soft drinks have been shown to be high in sucrose and fructose(50) which are much higher than the brands in South Africa(52). Burkitt in 1973 and 1982(53 ), described and postulated the emergence of diabetes, cardiovascular diseases and colorectal cancer and other malignancies with the westernization of African diets.

Determinant – Breast feeding and artificial milk feeding

Retrospective surveys confirm that type 1 under five childhood diabetes is rare in Nigeria(54) compared to Caucasians (Rivers State, 1991 – 1996, of 5739 admissions, prevalence of 1.2/1000 compared to 0.95 per 1000 in Sudan, and 10 fold in Europe). Cow milk used for early human baby feeding in Denmark and Finland contains bovine serum albumin which cross-reacts with the P69 antigen of pancreatic beta cells causing autoimmune damage(57). Exclusive breastfeeding policy in Nigeria should be maintained as a preventive measure.

Cyanide content of Cassava Versus Bitter Leaf (Veronica Amygdaline)

Two Nigerian varieties of cassava – sweet, eaten raw in northern states with low cyanide content and the bitter variety in southern states which are toxic with high cyanide content. Processed cassava may have the little amount of cyanide which can be detoxified to thiocyanate by sulfur containing amino acids mainly found in grains(56). chronic low-level exposure to cyanide causes goitre and tropical ataxic neuropathy which was attributed to cyanide in cassava diets and such patients also have increased the prevalence of impaired glucose tolerance(56). Odeigah(57) demonstrated that feeding albino rats with unprocessed Nigerian cassava for 36 weeks resulted in acute blood glucose increase and glucose intolerance. Akah and Okafor(68) using bitter leaf (Vernonia Amygdaline) water extracts showed a noticeable reduction in blood sugar levels in both normal and alloxan diabetic rats. Traditional diets with bitter leaf utilized with the bitters may have conferred some protective advantage to traditional Africans.

Brief Comment on Nigerian Responses

The Federal Government has so far appointed the Expert Committee on NCDs (1981 – 2000) chaired by Prof. O O Akinkugbe and (2001 – 2007) chaired by Prof. G.C Onyemelukwe to formulate goals and policy for prevention, institutional manpower development  and to undertake national survey researchers to determine prevalence of NCDs and their risk factors. Guidelines for the management of diabetes mellitus, asthma, cancers, hypertension have been created. Nigeria in 2003/2004 signed the WHO Framework Convention on Tobacco Control, and a comprehensive anti-tobacco bill (2008) was passed by the National Assembly in 2011. Health promotion policy document with strong NCD components was produced in 2004/2005. Nigeria committed herself as an active member of Mega Country Health Promotion Network with other mega countries (a mega country has population of more than 100 million) – Bangladesh, Brazil, China, India, Indonesia, Japan, Mexico, Pakistan, Russian Federation, USA) – who make up two third of world’s population and 60% of persons at risk of NCDs. Institutional strengthening to deal with organ damage by NCDs has improved but are still inadequate as revealed by many uncared for and those who go outside overseas for expert care.  Cancer registries have been expanded and a proclamation to set up National Cancer Centre in Abuja was made in 2010.

Hepatitis B vaccine has been included in expanded immunization programme of children to combat chronic liver disease and hepatoma, but human papilloma virus vaccination is yet to be instituted. Cervical, prostate, and breast cancer screening centres are being set up across the country especially in tertiary and private institutions. National transplantation law has been included in the National Health bill (2011). National  Health Insurance Scheme provides for the financial cost of NCDs but incompletely.

Road traffic accidents are being addressed by Federal Road Safety Commission and Lagos State Assembly in 2006/7 passed the Helmet law for motorcyclists as an example to be emulated across other states. The NCD policy draft is yet to be completed while national surveys on NCDs (1997)(59), (2003) (60), surveys for Blindness, Mental Health(61), Youth Tobacco(62) use have been undertaken.

The example of Lagos State government (2007 – 2011) in instituting mass screening for NCDs as well as Kanu Nwankwo Foundation for heart valve and other cardiac surgeries are landmarks that need to be emulated and expanded by other state governments and private philanthropists.

HYPERTENSION

Hypertension has grown over the last fifty years as a public health challenge in Nigeria, with surveys revealing deficiencies in awareness, treatment, and control of hypertension and clear urban over rural prevalence in the studies of Oviasu; Akinkubge, Kadari, Ike, Soyanwo, and others.  Hypertension contributes greatly to cardiac and renal diseases and failures as well as strokes in Nigeria.

Table 3: Urban prevalence and burden of Hypertension in Nigeria.

Urban     Rural    Overall    Male     Female    Criteria

1990/2

National Survey Expert Committee NCD (1997) reports (>15 years age)    14.6%

9.8%    11.2%    11.1%    11.2%    Systolic > 160

Diastolic > 95

1998 – 2003

(Hospital Based – Enugu) Ike (2009)    –        18.4%    10.8%    7.6%    Systolic > 140

Diastolic > 90

2003 National Survey Expert Committee NCD, Lagos S.W zone    Systolic

28.9%

 

Diastolic

40.5%

13.7%

 

 

20.5%    Systolic

22.5%

 

Diastolic

29.7%            Systolic > 140

Diastolic > 90

2007 University of Ibadan, Jaja Ekore, Ajayi, Arije (2009) (Case finding)            30.6%    42.7%    57.3%    Systolic > 140

Diastolic > 90

DIABETES MELLITUS IN NIGERIA

Deaths and disabilities have continued to increase in Nigeria with tangible and intangible economic costs to families and the nation due to diabetic gangrene, diabetic renal disease, diabetic eye complications, ketoacidosis, and infections.

 

Table 4: Trend in Diabetes Prevalence in Nigeria

S/No    Year of study     Prevalence %     Another as     Site

1

2    1960’s/70

1971    0.56%

0.43%    Adadevoh

Osuntokun    Ibadan (Hospital based)

Ibadan   (Hospital based)

3    1988    1.7%    Ohwovoriole et al       Urban (Lagos)

4    1988     1.4%    Erasmus, Ebomoyi Fakaye     Rural (Kwara)

3    1996    1.6%    Bakari, Onyemelukwe et al     Semi-urban (Kaduna)

4    1997    2.73%    National Expert Committee     National

5    2003    3.0%        National Expert Committee     Lagos

 

Childhood diabetes – Type I diabetes in children is uncommon in Nigeria unlike in Caucasians. A six year period (1991 –  1998) in Rivers State showed a hospital prevalence of 1.2/1000(54)

CANCERS

The prevalent types of cancers have been collated in 13 cancer registries located in teaching hospitals in Ibadan, Jos, Lagos, Zaria Ile-Ife, Enugu, Ilorin, Maiduguri, Benin, Kano, Nnewi, Calabar and Sokoto over the years (27,63,64,65,66). The relative frequency (%) of common cancers in 4 cancer registries are shown in the table below:

Table 5: Cancer Frequencies (%) in Four Registries in Nigeria

Site     Ibadan

(2001-2005)    Kano

(1995-2004)     Calabar

(2004-2006)    Lagos

(2002-2007)    Average

%

Breast    25.2    11.4    29.6    39.1    26.3

Cervix    19.5    9.7    8.2    18.4    13.9

Prostate    8.5    8.3    34.7    3.3    13.7

Non-Hodgkin’s Lymphoma    1.4    3.8    1.4    5.3    3.0

Liver    2.6    1.6    2.2    6.5    3.9

Colorectal    3.5    6.4    2    3.6

Male (number) 4214    1001    255    446

Female (number) 2185    989    570    1369

Kaposi Sarcoma has begun to increase as a result of increasing 3.5 – 4.5% national prevalence of HIV in Nigeria. Over the years, breast and cervical cancers have been the common cancers in all these four registries as it has been reported by GLOBOCAN as a world trend. Currently, prostate cancer increasing in prevalence is the commonest killing disease in aging men in Nigeria (67).

Childhood Cancers: Data from various parts of Nigeria show five commonest childhood cancers are non-Hodgkin’s lymphoma (mainly Burkitt’s lymphoma), retinoblastoma, nephroblastoma, sarcomas, and leukemia. Earlier Ibadan studies showed a remarkable percentage of brain tumours and leukemia, with Burkitt’s lymphoma commoner in southern states of Nigeria than northern savannah areas. While retinoblastoma and nephroblastoma are commoners under 5 years of age, lymphomas and sarcomas occur in older children (male to female ratio 1.4:1to 1.6:1, except for retinoblastoma with equal sex prevalence (27,68,69).

CORONARY HEART DISEASE/ISCHAEMIC HEART DISEASE

The World Health Organization projects that the number of deaths from ischaemic heart disease in the African region will double by 2030. The incidence of myocardial infarction in Nigerians (70,71) is low despite the presence of predisposing disease like diabetes(72) and hypertension being only about 6% of all cardiovascular diseases in black Africans. Although the trend is towards increased especially in Ibadan, Lagos(73) and urban centres(74), such increases have been attributed to urbanization, westernized diet, diabetes, reduced level of physical activity, obesity, hyperlipidemia, hypertension.

In the north of Nigeria, the first case was reported in 1997(75) and in a ten-year review (1985 – 1995) Danbauchi(74) reported 10 cases of ischaemic heart disease, with seven presenting as myocardial infarction (4 were non-Nigerians). Compared to Europeans,  Nigerians have relative thrombocytopenia, spontaneous fibrinolysis, rapid platelet disaggregation after ADP – induced platelet aggregation, reduced or absent ristocetin induced platelet aggregation in Nigerian platelet – rich plasma, probably due to a plasma component interacting with Von Willebrand factor (VWF); high factor VIII coagulant activity, factor VIII related antigen(49).

CARDIOVASCULAR DISEASE – SPECIAL FEATURES IN NIGERIA

Over the last fifty years, most cardiac diseases in Nigeria have been as a result of hypertension and rheumatic heart disease and cardiomyopathy.

Peripartum Cardiac Failure (PPCF)

Among the Hausa and Fulani in northern states of Sokoto, Kaduna, Bauchi, Katsina women after delivery by tradition ingest heavy loads of sodium (Kanwa(135) – 30g per day 3mol/g, rock salt) to “promote breast milk” and  also heat their bodies by lying on hot clay with fire beneath, splashing themselves with hot water twice daily – for 42 days(76). A follow-up study of 227 women from 1969 to 1993 – 1995 documented sodium hypervolemia, oedema, high cardiac output and hypertension in the acute phase(77,78). The cultural practices are being changed but persist in many areas. In Sokoto, incidence rate of PPCF was 1 per 100 deliveries, accounting for 60% of admissions for heart failure in 2003 – 2005 of both primiparous and multiparous women.(76)

Rheumatic Fever(RF) and Rheumatic Heart Diseases(RHD)

Over the last fifty years, RF and RHD have remained a burden in all parts of Nigeria, located in the area of the highest prevalence of rheumatic heart disease of 6 – 7 cases per 1000 children, aged 5 – 14 years (79). WHO has alerted nations about the prevailing and unchecked permanent valvular damage that follow repeated streptococcal sore throat infections with group A streptococci carrying virulence factors. Epitopes in the cell wall, cell membrane, and the A, B, C repeat regions of streptococcal M protein, on the basis of molecular mimicry, cross-react immunologically with heart myosin, tropomyosin, keratin, laminin, vimentin, N-acetylglucosamine.(80) Classical clinical features of acute rheumatic fever (ARF) may be masked while valvular heart damage continues.

Nigerian Heart Foundation could spearhead and coordinate the opening of ARF registry all over the country; monitor and document children with a sore throat to prevent repeat attacks with antibiotic treatments and follow up ARF or rheumatic heart disease development thus taking every a sore throat in Nigeria serious. The need to set up a system of primary, secondary and tertiary prevention is urgent(81). Ogunbi reported in 1978, the epidemiology of rheumatic fever and rheumatic heart disease in Lagos(83). Jaiyesimi and Antia(143) reported from Ibadan that pharyngitis was associated with measles infection in the patients with mean age of 8.8years. Between 1999 and 2002(84) a Zaria study showed that the patients with rheumatic heart disease were in the age range of 5 -52 years with mitral incompetence and aortic incompetence prevailing.

Pre-eclampsia, Eclampsia, and Hypertension

The estimated prevalence of preeclampsia is 6 -10% of pregnancies in Nigeria worse in Northern states and areas without antenatal care across. About 30% mortality of pregnant women has been reported in Kano studies due to eclampsia. Preeclampsia is the leading cause of maternal mortality in pregnant women in developing countries(85). Ekwempu(86) had suggested that infections were trigger factors. The exact mechanisms are yet undefined but tumour necrosis factor (TNF) was markedly raised in preeclampsia/eclampsia when compared to normal pregnant women and non-pregnant women and the reverse was found with interleukin – 10 (IL -10) (in a Zaria study unpublished, 2008). TNF may be responsible for maternal and fetal deaths in these diseases/subsequently, the development of hypertension in post partum survivors occurs and has been described as sixteen (32.7%) of 49 females with hypertension suffered from preeclampsia in previous pregnancies(87).

STROKE

The importance of hypertension in stroke causation has been growing with the years. Over 66% of stroke patients were found to be hypertensive in Lagos by Danesi(88) and 79% by Bwala in Maiduguri(89). Community-based prevalence of 58 to 400 per 100,000 population was reported in 1987 by Osuntokun and coworkers(58).

Recent community-based studies in 2007 and 2008(90) in Lagos revealed the prevalence of 114 per 100,000 per year and crude incidence rate of 25.1 per 100,000 per year. Over 80% of Nigerian stroke cases in this study were below 45 years of age. Crude incidence rate varied between 6.1/100,000 per year in the age group of 25 – 34 years; 20.1/100,000 per year in the age group 35-44 years and 39.9 per 100,000 per year in the age group 65 – 74 years showing the increasing vulnerability with advancing age.

The types of stroke in Nigeria consist of ischemic stroke 70 – 80% (atherothrombotic infarction 14 – 40%; cardioembolic 15 – 30%) and lacuna infarction. Haemorrhagic strokes constitute 20 – 30% of stroke made of intracerebral hemorrhage (10 – 20%) and subarachnoid hemorrhage 5 – 15%(90). Sickle cell diseases causes strokes and acute cerebral syndrome in Nigerian children with deficiencies of antithrombin III and other anti-thrombotic factors(91) which blood transfusion reverse.

ASTHMA

National survey and the epidemiology of asthma have not been fully undertaken in Nigeria. However, allergic asthma due to house dust mite (Dermatophagoides pteronnysinus and Dermatophagoides farinae predominate in forest and savannah regions of Nigeria(92). Other allergens – egg yolk, egg white, okra, frying oil, pepper, etc airborne fungi during harmattan and pollens have been reported in various parts of Nigeria by Sofowora(93), Soyinka(94) (South West) Haddock and Onwuka(95). Exercise induced asthma occurs as well as parasite associated asthma especially in children who harbour parasites with lung migratory larval stages like Hookworm, Strongyloides, filaria, and others. In the annually repeated climatic harmattan haze over the North of Nigeria that shifts to the southern states, genera of fungi found include Fusarium, Alternaria, Penicillium, and others(96) with various respiratory diseases manifestations. Global Initiative for Asthma (GINA) guidelines of 1995, (revised 2006) (97) provide the instrument to address the lack of exact statistics of asthma prevalence and burden in Nigeria as well as the use of the  International Study of Asthma and Allergies in Childhood (ISAA), Asthma Insights and Reality (AIR) surveys instruments(98).

OSTEOPOROSIS

Osteoporosis especially of the vertebra (lumbosacral) with associated osteophytes and nerve roots compression is being reported in diabetic patients, in obesity and in women who have had multiple pregnancies. This silent development requires a national survey to document its true burden.

FACTUAL INSIGHTS INTO SURVEYS

A national survey by Expert Committee on NCDS with Chairman as Prof O. O. Akinkugbe reported (1997)(59).

Hypertension (> 160/90) was found in 11.2% (or 4.3 million adult Nigerians, (66% with mild hypertension; 20% with moderate hypertension, 14% with severe hypertension, 12.5% borderline hypertension. Urban centres had more than rural). Sickle cell trait (AS) was found in 23.04%, while 0.5% of adults had sickle cell disease (SS). Total cholesterol was low generally (mean 122.4 ± 42.0 mg per dl) with urban men and women having higher levels than rural dwellers. Diabetes mellitus was found in 2.2% nationally and 2.1% in males and 2.3% in females. Highest diabetes prevalence was in Lagos 4.7%, lowest in Plateau (0.6%). Urban communities had higher diabetes prevalence (3.3%) than rural communities (2.6%).    Family history, advancing age, increasing body mass index, positive alcohol history, and sedentary lifestyle were contributory risk factors. 80% of diabetic persons were not aware of their condition.

A national survey by Expert Committee 2003, South West Zone – Lagos (South West Zone) with Prof. G. C. Onyemelukwe as Chairman(60).1082 subjects in urban and rural areas in Lagos state were surveyed.

Overweight was 36.3% (female 44.7%, male 26.7%). Hypertension BP>140/90 overall systolic (>140) 22.5%; diastolic 29.7%, Urban systolic (28.9%), rural systolic (13.7%), urban diastolic 40.5%, rural diastolic 20.5%. Genotypes obtained were AA (70.4%); AS (24.1%); AC (4.7%); SC (0.4%); SS (0.4%). Blood lipids – triglycerides > 120mg/dl in 12.6% of subjects. Blood sugar > 126mg/dl in 2.3% > 110mg/dl in 2.8% and 110-126mg/dl in (0.5%). Traffic safety – never used seat belts ( front seats) 65%; never used seat belts (back seat) 86.6%). Females health–never performed pap smear (97.2%),   never performed self-breast examination regularly (71.3%). Male health – never performed screening  for prostate cancer (98.1%)

With regards to risk factors, the following information was obtained;

Smoking currently (9.6%); started smoking at 20 years of age 47.4%; consumed alcohol ever (32.7%); Physical activity with recreation five times per week 41.1%; Fruits, not eating at all (13.7%): not eating fresh vegetables at all (32.7%) and using extra salt with food (10%)

NATIONAL SURVEY OF BLINDNESS IN NIGERIA (2005 – 2007)(99)

This survey was conducted on 13, 599 persons 40 years and above nationally, national extrapolations have revealed 1,130,000 persons, aged more than 40years are currently blind, (North West zone had 28.6%): 2,700,000 adults have the moderate visual impairment. 400,000 are severely visually impaired. This survey gave a total of 4.25 million adults visually impaired or blind. No urban/rural differences were found. Cataract accounted for 45.3% of visual impairment, and 43% of blindness. Glaucoma occurred in 16.7%; corneal scarring in 7.9%; hypertension stage 2 occurred in 10.9%. hypertension stage 3 occurred in 3.9% while diabetes mellitus occurred in 7.1%.

NATIONAL SURVEY ON MENTAL HEALTH WELL BEING  (NSMHW) (2002 – 2003)(61)

NSMHW was conducted on 6752 respondents in six zones of Nigeria in subjects, aged 18years and above. The prevalence of any International Classification of Diseases (ICD-10) in prior 12 is 7.3% (6.6% in males and 8.0% in females). Anxiety disorders were most prevalent (males 4.1%, females 7.0%). Specific phobias were commonest anxiety disorders (3.2% males, 5.1% females). Substance abuse disorder, mainly alcohol occurred in 1.4% males. Lifetime prevalence of mental disorder was 14.2% i.e. 1 in every 5 adult Nigerians had experienced an impairing level of the mental health condition. Lifetime prevalence of nonaffective psychosis was 2.1% with visual hallucinations experienced by 1.2%. Sleeping difficulties lasting at least two weeks in the month occurred in 12% of respondents (13.5% females, 10.1% males). The suicidal thought occurred in 3% of the sample, females had more suicidal ideation. Only about 12% of persons with ICD -10 mental disorders had received treatment in previous 12 months to the survey. Prevalence of life time substance use occurred in significant percentages in low, average and high-income respondents and Protestants, Catholics and Muslims, and other religious groups. Nigeria suicidal rate is lower than other countries 0.70 per 100,000 per year, compared to Uganda 7.0, Zambia 12.8, England 10, Hungary 40, Greece 2.8, Geneva 22.75.(100). It is necessary to note that depresses may manifest with bizarre symptoms of crawling sensations, muscle twitches, internal heat in the so called internal heat syndrome(101) which may pose difficulties for clinicians to diagnoses.

  V  ROAD TRAFFIC ACCIDENTS – WHO GUIDED POPULATION BASED SURVEY

Road traffic accidents have continued to increase since the 60s in Nigeria. Nigerian Health Nutrition and Population country status report 2005 stated that as at 2001, Nigeria ranked second on the weighted scale of countries with very high road traffic accidents in Africa according to WHO. As recorded by the Federal Road Safety Commission (FRSC) (102), 98,404 traffic crashes occurred from 2000-2006 with 47, 092 deaths. In 2003, 4514 road traffic accidents occurred in Lagos State alone. A survey of South West Zone (Lagos, Ogun, Oyo, Osun States) showed that human, vehicular, and poor environmental factors contributed to 79.4% of road traffic cases in the area. Over the last 30 years, there had been a five fold increase in traffic related deaths in Nigeria with fatality per accident rate 20 times higher than in developed countries(103). Prevalence of road traffic accidents is lower among drivers who do not take alcohol, kolanuts, central nervous stimulants and those who undertake regular maintenance of vehicles and regular eye examination.

Table 6: Percentage of sample respondents with RTI in last 12 months by Social and Demographic Characteristics

ANY INJURY

Had injury    Had RT injury        TOTAL

N I Number    %    N2 Number    %    Number

Over all         349    11.3    127    4.1    3100

Sex    Male    218    13.8    89    5.6    1579

Female    131    8.6    38    2.5    1521

 

Age group    Below 5    23    5.3    0    0    431

5 – 17    95    8.8    34    3.1    1085

18 – 19    91    14.2    39    6.1    643

From Labinjo et al, 2009(104).

A technical report on the survey to assess the burden of Road Traffic injuries was funded by WHO and conducted by Labinjo and others(104) using WHO guidelines for conducting a community survey on injuries and violence. 3100 respondents were sampled in 80 households each in seven states with high social, commercial and political activities (Kaduna, Borno, Plateau, Abuja, Lagos, Anambra, Rivers). Percentage of sampled residents that suffered road traffic injuries was 41% with a male to female ratio of 2.2 to 1, with 18 – 29  age group most implicated.

Rivers State had highest (29.9%), Abuja had 20.5%, Lagos 12.6%, and Kaduna 6.3%. 18 – 29 age group followed by 5 – 17 age groups and 30 – 44 had most injuries. By type of crash, a motor vehicle crash was 29.9%, a motorcycle crash was 54.3%, tricycle crash was 1.6%, pedestrian 11.8%, bicycle 2.4%. The slight injury occurred in 55.9%, serious injury 38.8%, permanent disability in 3.9%, death at crash 0.8%, death at hospital 1.6%.

VI  SURVEY OF VIOLENCE: POLICE-COMMUNITY VIOLENCE

Related to physical causes of morbidity and mortality due to road traffic accidents are the deaths and injuries that occur in Nigeria because of ethnic and police and law enforcement clashes with communities.  A national survey to determine the root cause of police community violence was undertaken by Center for Law(105) Enforcement (CLEEN) and National Human Rights Commission. Violence conceived as a homicide, summary executions, injuries, and brutality were documented. Other sources of violence include, ethnic, religious and political violence which have been prevalent for decades through political riots of Western Nigeria (1961 – 66) and Tiv riots (1961 – 64), Northern Region (1966 – 1967), Civil war (1967 – 71),  Maitasene and multiple religious riots (1980 – 2010), Boko-Haram riots and Riverine violence by MEND.

VII  GENDER BASED VIOLENCE

Gender based violence (GBV) which is almost synonymous with Violence against women(106) (VAW) according to United Nations Development of International and Social Affairs is endemic in Nigeria (with patriarchal society) manifesting as physical abuse (beating and genital mutilation), sexual violence (rape), verbal and emotional abuse. In a 1999 study of 9686 randomly selected single female (aged 10 – 24) hawkers in motor parks, 60% experienced sexual harassment, 7.4% were raped. In Ibadan study(107), of the 350 female apprentices,  22.9% were sexually harassed,  27.7% experienced attempted rape and 5.7% were raped. Sexual harassment in  primary, secondary and tertiary institution has risen over the years in Nigeria. Commercial sex is forced on women trafficked out of Nigeria. Between March 1999 and April 2002, 1126(108) women trafficked out of Nigeria were deported from various countries. Agencies like the National Agency for Prohibition of Trafficking in Persons (WAPTIP), Women Rights Advancement and Protection Alternative (WRAPA) and Women Trafficking and Child Labour Eradication Foundation (WOTCLEF) have been formed in Nigeria to combat these issues. Female Genital Cutting/Mutilation (FGC/FGM), from the National Demographic Health Survey of 2003(109), showed that the practice was 19% prevalent with the Yorubas accounting for 61% of cases, Igbos 45%, Fulanis 0.6% and Hausas 0.4%.

VII  DEMENTIA AND ALZHEIMER’S DISEASE SURVEY       

The Indianapolis – Ibadan dementia project(110), comprised a community study with base line survey (1992-1993) followed with prospective two years study (1994 – 1995) and prolonged to five years study (1997-1998) of 2459 community dwelling Ibadan residents and 1214 community dwelling African Americans in Indianapolis, USA. The prevalence rates of dementia in Nigerians and African-Americans were 2.29% and 8.24% respectively(111). The prevalence rates of Alzheimer’s disease in Nigerians and African-Americans were 2.29% and 8.24 % respectively. Old age (>65 years of  age), female gender and family history were significant risk factors while living with others appeared to be protective. The possession of apolipoprotein E epsilon 4 allele was contributory and predisposing   for African-Americans.  Because of the rising prevalence of hypertension and diabetes, the need to extend the study of Alzheimer’s disease to other parts of Nigeria is urgent.

VIII.  ALCOHOL AND SUBSTANCE ABUSE  – WHO Rapid Assessment and Response (RAR)

 

This project used the snowball sampling technique to recruit 1142 (145 or 13% were ex-injectors and 912 or 87% non-injecting drug users) street drug users(112) from eight state capitals – Lagos, Kano, Port Harcourt, Ibadan, Benin, Calabar, Maiduguri, Kaduna,) in 2000, 2003, 2005. The study convincingly proved the existence of injection drug users in Nigeria using heroin, cocaine, speedball and pentazocine. Drug trafficking has grown in Nigeria over the last twenty years as data of seizure trends of cannabis, cocaine, heroin and other drugs by National Drug and Law Enforcement Agency (NDLEA) (113) showed the increasing trend and links to the central role of Nigerian syndicates. The drug nexus in African utilizes seaports, airports, overland routes and interior transport corridors.

Table 7: NDLEA data on trends of illicit drug seizures

Year    Cannabis (kg)    Cocaine (kg)     Heroin (kg)    Others (kg)

1999    170.60    110.60    861.25

2000    272,260.02    53.42    56.60    234.28

2003    535,593.75    134.74    87.58    937.41

2005    125,989.00    395.91    70.42    88.72

CRIMINAL BEHAVIOURAL DETERRENCE – ROAD ACCIDENTS AND OTHER VIOLENCE

Road safety improvements which are required in Nigeria and which have been demonstrated in Australia (since 1980s) USA and Canada etc is based on deterrence doctrine(90) after classical Deterrence Theory of 18th century utilitarian philosophers (Bentham and Beccaria) that the deterrence process of human behavior in a variety of criminal acts (robbery, violent crimes, shoplifting, drug abuse, road traffic offences which include drink driving, over speeding, use of drugs, stimulants/substances, reckless driving etc) are decreased with, perceived severity of legal sanctions/punishments, certainty of apprehension, and swift administration of punishments(114). Specific deterrence when effective, refers to one’s reluctance to commit further offending behavior for fear of incurring additional punishment. This concept along with social/communal control(115) are useful tools to examine and  to implement in order curb violence, traffic offences and violence, community- police violence and other crimes in Nigeria. The deployment of  speed detection cameras, alcohol breath tests, blood drug tests, vehicle sanctions and the police and law enforcement agencies understanding the dimensions of violence are important components of deterrence requiring additional and adequate funding(116).

  1. TOBACCO – GLOBAL YOUTH TOBACCO SURVEY (GYTS)

Lopez et al(117) had described the WHO adopted conceptual four stages of tobacco epidemic in which prevalence of smoking in men, women and young persons as well as prevalence of tobacco associated diseases and deaths are quantified. Nigerian is located between stage I (prevalence of less than 20%, females (<10%) to stage II (increasing prevalence, increases in women smoking, shifting to smoking initiation in younger ages.

In 1990 – 1992 national NCDs survey about 4.14 million Nigerians above 15 years(59)smoked. In 2003, Lagos survey(60) 14.1% ever smoked. In WHO report on Global Tobacco   epidemic in 2008(118), Nigeria smoking prevalences were 17.1% in male, and 0.9% in adult females respectively. World Bank report also showed that cigarette consumption in Africa increased by 38.4% between 1995 and 2000. WHO MPOWER report has also indicated passive smoking prevalences of 34.8% in Nigeria, 21.9% in Ghana and 79.6% in Lebanon.

Smoking habits usually begins at youth age. The GYTS reveals the use of tobacco use in boys and girls aged 13 – 15 years. Cross Rivers State study (2000 and 2008) showed over all current tobacco smoking (7.0% and 4.1% respectively). The situation among boys and girls shows 7.7% and 3.3% in 2000 respectively and 6.8% and 1.2% in 2008 respectively as preventive measures had started in Cross River States through promulgated edict banning cigarette advertisement. Recent national  GYTS(62) of 4389 youths in schools from Abuja, Kano, Ibadan, Lagos and Cross River states, conducted in 2008/2009 showed that over 8.9% of youths smoked nationally with highest rate in Kano (6.2%; overall boys 11.4% girls 5.5%) with Lagos rates of 2.6% overall (boys 2.8%; girls 1.8%). Tobacco smoke has been associated with the metabolic syndrome in adolescents(119).

  1. ORAL HEALTH IN NIGERIA- Surveys

Periodontal disease, dental carries, malocclusion, dental fluorosis (in northern states) are common(120,121). Access to oral health is poor in rural area prompting the need for the introduction of alternative oral health delivery methods like the New Zealand dental nurse scheme or the WHO assisted community oral Health model of Thailand. The Inter-country Oral Health Centres (ICOH) in Jos and Idikan – Ibadan are tasked with expanding community oral health care in conjunction with Dental Association of Nigeria .

Table 7:Prevalence of Periodontal Diseases in Nigeria

Age (years)    Area in Nigeria    Prevalence (%)

1    Enweonwu 1966    15 – 19

15 – 19    North

West    15

40

  1. McGregor and Sheiham 1974 10 – 19

20 – 29    West

West    33%

58%

  1. Adegbembo et al 1999 15

25 – 39    Nation wide

Nation wide    39%

57%

 

Using Oral Health Index (OHI) and Community Periodontal Index (CPI), smokers in Nigeria(122) have poor oral hygiene. Also using gingival index to assess severity of gingival soft tissues inflammation (on a scale of 1 – 3 ) Odai and coworkers between 2008 – 2009(122) showed that only 0.9% of 340 primary and post primary children in Benin had no gingivitis, while severe gingivitis occurred in 56.47%. The surveys of periodontal diseases in Nigeria have shown(121) high prevalences over the years as in the table below.

Dental fluorosis, another important public problem occurs in Northern Nigeria as a result of high fluoride in drinking water exceeding threshold limit of 0.004 – 0.007mg/kg body weight during period of tooth mineralization.

Dental caries has shown increasing prevalence of   4-30 % in surveys from 1968 to 2003. The mean number of decayed, missing and filled teeth (DMFT) recorded in most epidemiological studies in Nigeria has been below 4 in children and young adults as exposure to cariogenic westernized diet along with oral mutant streptococci colonization is prevalent(101).

Table 8:Prevalence of caries in urban and rural Nigerians

Age (yrs)    Urban %    Rural %    Mean DMFT

Urban     Rural

Sheiham (1966)    < 34    33    3    –    <1

Henshaw and Adenubi (1975)    10 – 40+    58    32    2 – 8    0 – 2

Akpata and Johnson (1979)    1 – 21    42        1.2

Adegbembo et al (1995)    12

15    37

49    24

36    0.8

1.5    **

1.1

Akpata et al (2003)

Southern Nigeria

Northern Nigeria

15

15

 

 

3

13

1.0

2.6

  1. NUTRITION SURVEY IN NIGERIA

The documentation of the geographical distribution and manifestations of undernutrition and overnutrition of macronutrients and micronutrients in Nigeria have been provided in  national nutrition surveys conducted with supports and collaborations of USAID, UNICEF, USDA, PEPFAR, UNFPA and  World Bank from 2001 to 2008(122). Low birth weight, which may lead to non-communicable diseases later in life because of fetal programming(17) has remained. The Child Stunting and wasting which also have similar impact in leading to non-communicable diseases later, as well as  overweight and obesity in children and women are prominent features in these reports. Zinc, Iodine, vitamin A, Iron deficiencies have remained common over the years. The National Health Demographic Survey and International Institute of Tropical Agriculture. Ibadan study(124)  have documented these since 1990 to 2008.

In 2008 National Demographic and Health Survey for example, 41% of children under five are stunted, indicating  chronic malnutrition, commoner in rural areas (45%) than urban areas (31%) with zonal ranges from 22% in South East zone to 53% in North West zone. Some findings from National Demographic and Health Surveys are shown in the tables below.

Table 9:Nutrition Status of Under Five Children In Nigeria

Low birth weight    Stunting    Wasting    Overweight

2003 NDHS    14%    42%    11%

2008 NDHS        41%    14%    9%

The prevalence of childhood (6 – 9years) obesity is 3.2% to 5.2%

Table 10: Women Nutritional Status (15 – 49 Years)

*BMI    NORMAL

(18.5-24.9)    THIN

(<18.5)    OVERWEIGHT

(25 – 29.9)    OBESE

>30

2008 NDHS    66%    12%    16%    6%

2001–2003    68.5%    11.6%    14.2%    5.7%

*BMI – Body Mass Index

The Roles of Measles and Aflatoxins

It is important to recognize the importance of measles in precipitating malnutrition  as described by Dossetter(126) and West(127) by causing protein losing enteropathy and malabsorption as well as vitamin A deficiency especially in northern states and other areas where inadequate vaccination coverage for measles occurred. The role of aflatoxins and other mycotoxins contaminating Nigerian foods in precipitating malnutrition with cancrum oris  in under fives as described by Enweonwu(128) should be noted as many Nigerians have significant blood level of aflatoxins(129).

The nutritional status of Nigerian children is poor, showing little improvement since 1990 when the stunting (chronic malnutrition) was 42%. The proportion of children aged 6 – 35 months who were chronically malnourished increased from 44% in 1990, to 50% in 1999 (NDHS).

CONCLUSION

All the non-communicable diseases clearly have shown on the trend of increase in the last fifty years in Nigeria. The future direction should be on urgent and comprehensive intersectoral collaboration involving Federal, state, local governments, communities, professional associations, women societies and labour organizations with sustained programmes that emphasize amongst other issues, surveillance –for risk factors using WHO step wise approach; health education  that results in attitudinal and behavioural changes, and engagement in healthy lifestyles; promotion of tobacco smoking cessation; promotion of healthy diets; and the use of Nigerian foodstuffs to create food pyramids and the teaching of the populace cooking methods that maximize nutritional value.

The promotion of physical activity – both at home, school, workplaces and at leisure and the promotion of healthy attitudes and health seeking  behavior are important.

The roles of communication by media, churches and mosques need to be emphasized both for exercising, health promotion talks and screening. The health care system must be expanded and strengthened at the levels of primary, secondary and tertiary health care. National Health Insurance Scheme should be restructured to fund chronic non-communicable disease.

The Monitoring and eliminating environment pollution and enforcing the legal backing for tobacco control, reduction of use of alcohol including local brews, elimination of drug abuse and the setting up of addiction treatment centres.

The checking of violence and the maintenance of road safety should be based on deterrence, social re-education, and good governance as well as the committing adequate funds for training of staff. There is need to disseminate and use of available guidelines and policies, some of which are listed below.

List of Guidelines available that need to be disseminated

Hypertension guidelines – developed with Hypertension Society of Nigeria under leadership of Prof A. Isah

Diabetes guidelines – developed  with Diabetes Association of Nigeria (2010).

Asthma guidelines – developed under leadership of Dr. Chukwu and ASMARCAP (Asthma –family handbook)

Sickle Cell- guidelines – Sickle cell foundation under leadership of Prof. A. Akinyanju

Non-communicable disease Handbook  for Primary Health care – 1996 series III under the chairmanship of Prof. Akinyanju.

Non-Communicable diseases Handbook for health professionals series II under the chairmanship of Prof. O Akinkugbe.

Guidelines for Smoking Cessation in Africa and Middle East – Smoking  cessation in the Africa and Middle East. A multidisciplinary consensus on intervention strategies for health care providers. Ahmed Ali, Tarek Safwat, Onyemelukwe GC, Otaibi M.A, Amin A.A, Nawas Y.N, Aouina H., Afif H., Bolliger C.

Food – based dietary- Dietary guidelines by Nutrition division of Federal Ministry of Health with WHO

Guidelines on health promotion – Health promotion policies, Federal Ministry of Health.

Guidelines for school exercises. Ministry of Education

Guidelines for good agricultural  practices  and elimination of environmental pollution . Ministries  of Environment/Agriculture.

Guidelines for elimination of pollutants – Ministry of Environment

The Expert Committee on Non-communicable diseases has developed and publisized the civic duties of Nigerians with regards to NCDs as below;

 

Table 11: Ten Command Civic Duties of all Nigerians

S/N    DUTIES    BENEFITS

Exercise daily (including walks)    Prevention of hypertension, diabetes, obesity, mental ill health, cancers etc.

Know blood pressure from age 30 and above (annually/six monthly    Detect hypertension early (blood pressure increases with age)

Know blood sugar from age 40 years    Detect diabetes mellitus (blood sugar increases with age)

Know sickle cell genotype of all family    For counseling of family

Monthly breast self examination by females from age 17    To detect lumps and early breast cancer

Know presence of hepatitis B surface antigen in blood of family members    Prevent liver cancer and other diseases

Know prostate specific antigen (PSA) blood level (men 50 years)    To detect prostate cancer

Women screen cervical smear (PAP Smear) every 2 – 3 years    To prevent, detect early cervical cancer.

Know blood cholesterol by obese or overweight people from age 40 years    Prevent coronary heart disease

Know body mass index (BMI) weight in kg)

Height X height (mtrs)    To watch nutritional excess or deficiency

Issued by NCD Expert Committee on Non-Communicable Diseases

Note:     BMI > 30kg/mtr2 is Obesity

BMI > 25kg/mtr2 is overweight

BMI < 18.5kg/mtr2 shows under-nutrition

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