PROJECTING THE PREVALENCE OF MAJOR NON-COMMUNICABLE DISEASES / RISK FACTORS FOR THE JORDANIAN YOUTH POPULATION FOR THE YEARS 2007 - 2050

Amman - Jordan 2013

This paper was prepared by the Eastern Mediterranean Public Health Network (EMPHNET) in fulfillment of its agreement with the Higher Population Council in Jordan. The results of this report were presented at TEPHINET Seventh Global Scientific Conference held in Amman, Jordan, 10-15 November, 2012. 2  

PREFACE The relentless spread of non-communicable diseases (NCDs) offers an opportunity for countries like Jordan to join forces with the rest of the World in addressing a major global challenge that threatens health and social economic development alike. This issue poses a major concern for the Government of Jordan, which holds an obligation for diminishing premature deaths and disability in the country, especially among its youth population as the prevalence of chronic diseases such as (diabetes, hypertension and high cholesterol) and risk factors associated with these diseases (obesity, overweight and smoking) might witness an alarming increase by the year 2050, thus, resources and action plans should be in place to manage its prevalence. Jordan’s current hardship in allocating resources to deal with the burden of NCDs is challenged by the growing demand on health care cost, especially costs involving care due to changes in the population structure. The country is undergoing a demographic transition that is bound to bring on considerable increase in the youth population over the next two decades as a result of certain projected scenario’s due to changes in fertility. If there is an increase in the prevalence of NCDs, a considerable number of Jordanians between the ages of 18 and 34 will be diagnosed with hypertension, diabetes, high cholesterol and more will be obese. Young people (18 - 34 years old) are currently estimated to be 36% of the Kingdom’s population (representing approximately 2.3 million people) and are the core group for future growth with noticeable important contributions to economic and social development progress. Hence, the increased prevalence of chronic diseases and their risk factors among the youth population will affect their productivity considerably. Therefore, conducting epidemiologic studies that provide estimated disease projections for NCDs in Jordan, particularly among youths, will present health planners, decision makers, and researchers with evidence for strengthening the public health system by addressing future disease threats that influence the quality of life in the kingdom.

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As a major player in population health and development, the Higher Population Council (HPC) collaborates with various stakeholders and partners in Jordan to maintain a balance between population growth and resource utilization. In this context, the HPC collaborated with the Eastern Mediterranean Public Health Network (EMPHNET) in estimating projections for the prevalence of major NCDs and their related risk factors for the Jordanian youth population (18-34) for the years 2007-2050. The technical support provided by EMPHNET was enhanced by involving the Technical Team of the National Population Projection Committee thus maximizing collaboration for the sake of avoiding duplication and ensuring impartiality. The estimated projections for the prevalence of major NCDs among the youth population in Jordan present a set of findings and recommendations in a proactive way that we believe will provide policy makers, service providers, research-funding agencies and donors with adequate evidence to support the development of future health strategies. Such strategies will definitely lead to appropriate interventions that will guarantee success in dealing with the estimated increase in the prevalence of NCDs and their preventable risk factors. I would like to express my gratitude and appreciation to the various organizations, individuals and staff members who participated in course of this study. I offer particular acknowledgement to EMPHNET for providing technical assistance in preparing the estimates and the report. We pray to the Almighty to keep on giving us the chance to contribute to the progress of our beloved country under the wise leadership of His Majesty King Abdullah II Ibn Al-Hussein. May GOD Bless and Keep Him always. Prof. Dr. Raeda Al Qutob Secretary General

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TABLE OF CONTENTS PREFACE

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I. INTRODUCTION

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II. PURPOSE

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III. OBJECTIVES

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IV. PROJECTION METHODOLOGY

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IV-1 Data Set

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IV-2 Measurement of Disease/Risk Factor

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IV-3 Population Projection

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IV-4 Projection Models

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V. MODEL ESTIMATES

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VI. STRENGTHS AND LIMITATIONS

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VII. POLICY AND RESEARCH IMPLICATIONS

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REFERENCES

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ANNEX 1

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ANNEX 2

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I. INTRODUCTION Jordan is undergoing a demographic transition that is bound to bring on considerable increase in the youth population over the next two decade. The last population census (2004) done in Jordan indicated that the age structure of the Jordanian population has changed considerably since 1979 as a result of changes in fertility, mortality, and migration dynamics. The proportion of the population under 15 years of age declined from 51% in 1979 to 37% in 2004, while life expectancy continues to increase reaching 74 years for females and 71 for males [1]. In addition, despite its steady decline in recent years to reach 3.8 in 2009 the total fertility rate (TFR) remains relatively high in Jordan, [2]. The declining mortality rate and the high total fertility rate have contributed to the average annual population growth rate of 2.2% in 2011 [1]. Jordan’s 2011 estimated population number 6,249,000 comprised of 36.9% under 15 years, 59.6% between 15 to 64 years and 3.5% over 65 years [2]. While Jordan’s population has doubled over the last 20 years, demographic projections indicate that this population will most likely double again by year 2035. Changes in the number of Jordan’s population will be most prominent in the working age population which will definitely double over the coming few decades. Therefore, it’s of utmost importance that policy makers and health planners address the growing needs of Jordan’s population particularly those of the younger age groups in order to guide and direct resources and assure high quality of life [2,3]. At the same time, Jordan is experiencing an epidemiological transition where infectious diseases are declining and chronic diseases, such as cancers, are becoming more predominant [4]. The causal relationships between food, nutrition and physical activity and non-communicable diseases are well established. Sedentary lifestyle, high fat diet, and smoking are becoming common in Jordan [5, 6]. Currently, approximately half of deaths in Jordan are attributed to NCDs, namely, cardiovascular

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diseases, diabetes, and cancer, [7]. Worldwide, the burden of non-communicable diseases (NCDs) is escalating posing a major current and future public heath challenge [8, 9]. Mortality, morbidity and disability attributed to NCDs account for about 60% of global deaths and nearly half of the global burden of disease [10, 11, 12]. Approximately 80% of deaths attributed to NCDs occur in low- and middle-income countries [8]. Results of the latest (2007) National Jordan’s Stepwise Surveillance survey conveyed that nearly one-third of participants ( >= 18 years) smoked cigarettes and 19% were diagnosed with diabetes according to laboratory testing. Approximately one-third of participants of the medical evaluation were either overweight (30%) or obese (36%) [13]. This report presents projection of selected NCDs and risk factors and their implications for the youth population of Jordan based on nationally adopted population projections done by the Higher Population Council [14].

II. PURPOSE The importance of preventing and controlling NCDs in Jordan is vital when considering the imminent changes in the population structure. Calculations of NCD estimates can yield major gains in population health by quantifying future disease prevalence in an attempt to reduce the burden of NCDs and their risk factors. The overall purpose of this study was to address the need for morbidity projections in Jordan by providing projections of future trends related to most common NCDs, mainly: diabetes mellitus (type 2), hypertension, high cholesterol and obesity. Projections for NCD data figures will assist the efforts made to strengthen the public health system in Jordan by ensuring availability of strategic epidemiologic information to major stakeholders, particularly research entities and the Ministry of Health.

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III. OBJECTIVES This study was planned with the intention of promoting the use of information and data among health service planners and policymakers in Jordan. The study aimed at generating and providing projections for the prevalence of major non-communicable diseases (NCDs) and risk factors among Jordanian youth aged 18-34 years using data from the 2007 Stepwise surveillance survey and applying it to the nationally adopted population projections data developed by the Higher Population Council in 2009. Estimates and projections of diseases in Jordan can contribute to better understanding of population needs and trends in the next few decades. This study was guided by the following objectives: • Empower health service planners with information that have implications for planning and policy making. • Estimate the prevalence rates for diabetes, hypertension, high cholesterol and obesity among the youth population, and their specific trends in the next 40 years in Jordan (up until year 2050) • Highlight important recommendations for policymakers and public health program planners to reduce the burden of NCDs based on future trends of the most common chronic diseases and risk factors in Jordan: diabetes, hypertension and major risk factors: high cholesterol and obesity • Provide projection models for the youth population (18 – 34 years) with different population projections scenarios: constant fertility levels , optimistic and pessimistic This report was prepared and disseminated at TEPHINET Seventh Global Scientific Conference held in Amman, Jordan. The results were presented in a session on NCDs in Jordan.

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IV. PROJECTION METHODOLOGY The projection model used in this study included the following tasks: 1) generating baseline prevalence estimates of Hypertension, Diabetes Mellitus, High Cholesterol, Overweight and Obesity for the Jordanian youth population; 2) outlining assumptions about the future of NCDs (projection models) and 3) projecting the numbers of youth with selected NCDs and risk factors under different population projections scenarios. The following sections describe the data sets, morbidity/risk factor measures and the procedures used to generate baseline data, the morbidity prevalence scenarios and the projection methodology.

IV-1 Data Set During 2007, the Jordan Ministry of Health conducted its third Stepwise Household Surveillance Survey. The survey selected a nationally representative sample of adults aged 18 years or older. A multistage sampling design was used to select households, from which one person was randomly selected to participate in the survey. The sample was stratified by urbanity (urban and rural) and by region (North, Middle, and South). In total 3,688 households were selected and 3654 adults were interviewed, yielding a response rate of 99.1%. A subsample of 889 subjects was invited to participate in a physical examination and laboratory assessment, of whom765 responded, yielding a response rate of 86.1%. Data for the current report were limited to the age group 1834 years of this subsample (n= 674).

IV-2 Measurement of Disease/Risk Factor The participants of the studies age group were evaluated at a local health center where blood pressure, height, weight, and waist circumference were obtained. A blood sample was obtained from each after an overnight fast and sent to a central laboratory where many measurements

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were performed including total cholesterol and fasting blood glucose. Standardized training was provided to all attending physicians of the participating local health centers on all study procedures. Height and weight were measured by the participating physicians using a standard technique. The survey took place between June 1st and August 23rd 2007. For persons participating in the medical examination, body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared. Participants were classified as normal weight if their BMI was