Focusing on Youth to Curb the Epidemic of Noncommunicable Diseases

Noncommunicable diseases, or NCDs, are the leading causes of death worldwide. Of the 41 million deaths they claim each year, 15 million occur prematurely to adults between the ages of 30 and 69, often when they are at the height of their economic productivity. And these premature deaths occur disproportionally in low- and middle-income countries.

NCDs pose a major threat to the health of populations, place an increasing burden on health systems, and threaten economic growth and development. NCD prevention is a critical priority for addressing the growing epidemic and is also essential for meeting the Sustainable Development Goals’ target to reduce by 2030 the premature mortality from NCDs by one-third. And focusing on youth is a key to reducing premature NCD mortality.

Over 80 percent of all premature deaths from NCDs are due to cardiovascular diseases, cancers, diabetes, and chronic respiratory diseases. These NCDs share four key risk factors: tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diet. These risk factors are all modifiable behaviors that typically start or are established in adolescence and young adulthood. A unique window of opportunity exists now to curb the growing NCD epidemic before young people develop unhealthy behaviors and while many low- and middle-income countries still have relatively young populations. By encouraging positive behaviors and discouraging negative ones among young people as they gain autonomy and more control over their lives, we can reduce premature deaths from NCDs and also set young people on healthier paths for their lives.

Modifiable Risk Behaviors Drive the Majority of Premature Deaths from NCDs



Tobacco Use

Tobacco use contributes to all four main NCDs and is the primary preventable cause of death globally. Each year, tobacco kills more than 7 million people. Of those, more than 6 million die from direct tobacco use. Exposure to secondhand smoke kills an additional 890,000 who are nonsmokers, including children and youth. Low- and middle-income countries bear the heaviest burden of tobacco-related illness and mortality because they are home to the vast majority (80 percent) of smokers in the world.

The World Health Organization (WHO) estimates that globally more than one of every 10 youth ages 13 to 15 uses tobacco. The maps show current tobacco use or use of any tobacco products in the past 30 days, among youth ages 13 to 15, using the latest data available from 191 countries between 2006 and 2016. Current tobacco use among boys is generally highest in WHO’s Western Pacific Region, followed by the Eastern Mediterranean, Africa, the Americas, and Europe. Among girls, the Western Pacific Region also has the highest rates, followed by Europe, the Americas, Africa, and the Eastern Mediterranean. Tobacco use is the lowest in South-East Asia for both boys and girls. Use varies widely, however, within each region: Tobacco use is typically higher among youth in low- and middle-income countries.

13-to-15-Year-Olds Using Any Tobacco in the Past 30 Days (%)

Note: A small number of countries reported data for ages 12 to 17. In such cases, the age category will appear when hovering over a country.

Sources: Jeffrey Drope et al., The Tobacco Atlas, Sixth Edition (Atlanta: American Cancer Society and Vital Strategies, 2018); WHO & Centers for Disease Control and Prevention (CDC), Global School-Based Student Health Survey; WHO & CDC, Global Youth Tobacco Survey.

The tobacco industry targets youth more actively in regions where regulations are weaker and income growth has made tobacco products more affordable, such as parts of Asia and Africa. Without changes in policies, Africa is projected to see the largest increase among world regions in smoking prevalence by 2030. Shifts in social norms are also making tobacco use more acceptable among youth, even among girls. In some countries, including Ethiopia, Nigeria, and Senegal, tobacco use among youth surpasses use among adults.

Cigarettes are the most popular tobacco products among youth globally, though other smoked and smokeless products are popular in some regions. Globally, around 25 million youth ages 13 to 15 smoke cigarettes and almost 13 million use smokeless tobacco products. Chewing tobacco and other smokeless tobacco products are popular in South-East Asia. Water pipes, while traditionally popular in the Eastern Mediterranean, are now gaining popularity among young people in other regions. The rising popularity of e-cigarettes and increasing availability of heated tobacco products (that produce aerosols containing nicotine and other chemicals) in some countries are another concern, as they attract youth and are typically addictive. To be effective, policies and programs addressing tobacco use among youth must target all products, not just cigarettes.



Alcohol Use

Alcohol use contributes to NCDs such as cardiovascular diseases, diabetes, cancers, and gastrointestinal diseases. Alcohol use among young people is also linked to many other health risks, including poor mental health, risky sexual behaviors, and violence. It also impacts physiological development of the brain. Early alcohol use is associated with an increased risk of alcohol dependency later in life. Because of the detrimental consequences, any alcohol use should be considered harmful among children and adolescents.

The graphs show the share of 13-to-15-year-old students who are current alcohol users or who have had any alcoholic beverages in the past 30 days. The graphs present the three countries with the highest rates in each WHO region with available data between 2012 and 2017 from the Global School-Based Student Health Survey (data on alcohol use among youth is limited, especially for countries and regions where alcohol use is socially taboo or prohibited). Unlike other regions, data for Europe refer to the top three countries with alcohol use at least once a week available in 2013/2014 from the Health Behaviour in School-Aged Children Survey.

13-to-15-Year-Olds Drinking Any Alcohol in the Past 30 Days (%)*
        Americas         Africa         Western Pacific         South-East Asia         Eastern Mediterranean         Europe

Note: *For Europe, data refer to the percent of 15-year-olds drinking any alcohol in the past seven days.

Source: Jo Inchley et al., ed. Growing Up Unequal: Gender and Socioeconomic Differences in Young People’s Health and Well-Being, Health Behaviour in School-Aged Children (HBSC) Study: International Report From the 2013/2014 Survey (Copenhagen: WHO Regional Office for Europe, 2016); WHO & Centers for Disease Control and Prevention (CDC), Global School-Based Student Health Survey.

Alcohol use varies widely across and within regions. Countries with the highest rates of current alcohol use among adolescents are in the Americas, with rates for some countries at or above 50 percent among boys. Eastern Europe also has countries with high use, where around 25 percent of boys report drinking at least once a week. Alcohol use is much lower in South-East Asia, but some countries have alcohol use rates surpassing 20 percent. Girls generally are less likely to drink, but the gap is narrowing in many countries.

While alcohol use has declined among youth in some high-income countries, it is projected to increase in low- and middle-income countries as social trends shift and companies target countries with rising economies and sizable populations of young people with disposable income.



Unhealthy Diet

Unhealthy diet, combined with insufficient physical activity, contributes to overweight and obesity, and consequently, to NCDs such as type 2 diabetes, cardiovascular diseases, strokes, and certain cancers. Globalization and rapid social and economic change are shifting eating patterns dramatically around the world. People are consuming more processed, high-calorie foods with few nutrients that contain large amounts of sugars, salt, and fats (especially saturated fats and trans fats)—the primary contributors to overweight, obesity, and diet-related NCDs. Soda and other sugar-sweetened beverages are also popular among young people around the world today and are a major source of extra sugars in their diet.

Rates of obesity and overweight among children and adolescents ages 5 to 19 have grown alarmingly, according to WHO. In 1975, 1 percent of children and adolescents were obese and 3 percent were overweight. By 2016 those numbers had grown to 7 percent obese and 11 percent overweight. Childhood obesity is linked to the food industry’s marketing of unhealthy foods and drinks that target children. It is also associated with the extensive availability of low cost, unhealthy foods around the world.

13-to-15-Year-Olds Who Are Overweight or Obese (%)

Note: A small number of countries reported data for ages 12 to 17. In such cases, the age category will appear when hovering over a country.

Source: Jo Inchley et al., ed. Growing Up Unequal: Gender and Socioeconomic Differences in Young People’s Health and Well-Being, Health Behaviour in School-Aged Children (HBSC) Study: International Report From the 2013/2014 Survey (Copenhagen: WHO Regional Office for Europe, 2016); WHO & Centers for Disease Control and Prevention (CDC), Global School-Based Student Health Survey.

The maps show the share of 13-to-15-year-olds who are overweight or obese, using the latest data available from 132 countries around the world between 2007 and 2017. The share of boys who are overweight or obese boys is generally highest in the Americas and Western Pacific, followed by the Eastern Mediterranean and Europe. The region with the largest share of overweight or obese girls is the Americas, followed by the Eastern Mediterranean, Western Pacific, and Europe. South-East Asia has the lowest rates of overweight or obesity among both boys and girls. Comparable data, especially on Africa, is sorely needed to monitor this serious health threat.

While the overweight and obesity rates in high-income countries have stabilized, they are still on the rise among disadvantaged groups, contributing to widening health inequalities, and continue to increase in low- and middle-income countries. Many of these countries now face the double burden of undernutrition with increasing overweight and obesity.



Physical Inactivity

Insufficient physical activity contributes to the major NCDs, including cardiovascular diseases, cancers, and type 2 diabetes. WHO recommends that children and adolescents ages 5 to 17 engage in at least 60 minutes of moderate to vigorous-intensity physical activity every day, including muscle- and bone-strengthening activities three times a week. Worldwide, 81 percent of adolescents ages 11 to 17 did not meet the WHO’s recommendations in 2010. Girls are consistently less active than boys around the world and the gap has not narrowed. Gender-specific approaches are needed to combat this problem.

Aside from physical benefits such as maintaining a healthy body weight and developing healthy bones, muscles, and organs, exercise can ward off mental health disorders such as anxiety and depression that many youth experience. Physical activity among youth is also typically associated with lower levels of other NCD risk behaviors, such as tobacco and alcohol use.

As low- and middle-income countries rapidly urbanize, work and transportation depend less on physical activity. Heavy traffic, poor air quality, and crime also deter people from engaging in outdoor physical activity. Other factors that reduce people’s exercise levels include the lack of safe, well-lit sidewalks or parks and other recreational spaces. Young people are not only getting less exercise, they are also spending more time on sedentary activities (watching television, playing video games, etc).

One explanation for the increase in sedentary behaviors among youth is an increase in screen-based activities. The line graphs show trends in the share of 15-year-olds who reported using a computer for two or more hours on weekdays between 2002 and 2014 in select countries in Europe. The graphs show countries with the highest and lowest rate of use from each of the four subregions in 2002. All countries, even those with initially low rates of computer use in 2002, show sharp increases over time. Boys overall have higher rates than girls, but girls have much larger increases in the rates over time. The data (not presented here) also showed that while television watching has declined among youth across Europe during the same period, the decline was more than offset by the increase in computer use. Adolescents in low- and middle-income countries are following a similar trend, as computers and other electronic devices become more widely available.

15-Year-Olds in Europe Using Computer for Two or More Hours per Weekday (%)

Note: The four European subregions in the boys’ map correspond to Northern (Finland, Norway), Western (France, Germany), Eastern (Hungary, Poland), and Southern (Croatia, Portugal) Europe; those in the girls’ map correspond to Northern (Finland, Sweden), Western (Netherlands, Switzerland), Eastern (Czechia, Russia), and Southern (Greece, Portugal) Europe.

Source: Jo Inchley et al., ed. Adolescent Obesity and Related Behaviours: Trends and Inequalities in the WHO European Region, 2002-2014. Observations From the Health Behavior in School-Aged Children (HBSC) WHO Collaborative Cross-National Study(Copenhagen: WHO Regional Office for Europe, 2017).

Mental Health Disorders Among Youth Also Need Immediate Attention

Beyond the four main NCDs, mental health disorders among youth must be addressed. Mental health disorders, such as depression and anxiety, make up a large share of the global NCD burden among young people, and up to one-half of all mental health disorders in adults start by age 14. Mental health disorders contribute directly to premature deaths but are also associated with the development of other NCDs, such as cardiovascular diseases and cancer. They are also linked to the four key NCD risk behaviors. Youth with mental health disorders, however, often go undiagnosed and untreated. Integrating mental health screening and early interventions in primary care or community-based settings can help reduce mental health disorders among youth and lower the overall NCD burden.



What Can We Do to Address NCD Risk Factors Among Youth?

Given the role of both personal choice and the environment in shaping behavior, interventions must target young people and those who influence them with a range of policies and programs to encourage healthy behaviors. We need strong public and political commitment and better coordination and collaboration across multiple sectors, such as health, education, finance, and urban planning, to successfully reduce risk behaviors. Partnerships across the public and private sector and civil society, along with youth participation, will be key to slowing the growing epidemic of NCDs.

Policy

Programs

Data

Adopt and Enforce Policies and Regulations to Reduce Risk Behaviors

Policy changes and new regulations can discourage risk behaviors and facilitate healthy ones. WHO recommends a number of policy options and “Best Buy” interventions for preventing and controlling NCDs. 

Tobacco Use

  • Increase taxes and prices.
  • Prohibit tobacco sale to minors.
  • Use plain packaging and large, graphic warnings on all packages.
  • Ban tobacco advertisement, promotion, and sponsorships.
  • Eliminate secondhand smoke exposure in all public places.

Alcohol Use

  • Increase taxes.
  • Establish a minimum legal drinking/purchase age.
  • Ban or restrict exposure to alcohol advertisements.
  • Restrict hours of alcohol sale.

Unhealthy Diet

  • Reduce salt content in processed foods.
  • Tax sugar-sweetened beverages.
  • Reduce meal portion and package size.
  • Require nutrition labelling to reduce calorie intake and intake of sugars, salts, and fats.

Physical Inactivity

Offer safe and convenient public spaces to encourage physical activity and active transport, such as walking and bicycling.

Implement Intervention Programs in Diverse Settings

Increasing young people’s knowledge about NCD risks can encourage them to adopt healthy behaviors. Screening for risk factors and counseling young people can also help them change behaviors and sustain healthy ones. School is a logical place to intervene because young people spend so much of their time there and school-based interventions tend to be cost-effective, with some programs reporting success. WHO recommends “whole-of-school” programs that involve:

  • High-quality physical education.
  • Adequate facilities.
  • Programs to support more physical activity.

Given the many influences in young people’s lives, interventions should also try to reach young people within their broader social and cultural environments. Mass media and social media are also good ways to reach youth with health promotion messages. Mass media campaigns that aim to educate the public are among the “Best Buy” interventions WHO recommends for being cost-effective and feasible. Some of them:

  • Warn the public about the dangers of tobacco use and secondhand smoke.
  • Encourage people to eat less salt.
  • Promote physical activity.

Other WHO recommendations include:

  • Integrating NCD intervention and treatment for youth into basic primary health care services.
  • Organizing sports programs and events to promote exercise.
  • Educating and counseling people in schools and workplaces on nutrition to increase fruit and vegetable intake.
  • Providing tobacco cessation support (even mobile phone-based services) to everyone who wants to quit.

Collect and Disseminate More Data and Evidence

Up-to-date data on young people’s risk behaviors and trends, including those relating to mental health, are essential for identifying needs and setting priority areas, tracking progress, and developing appropriate responses. Data availability, however, varies substantially across countries and world regions. Even when data exist, they may vary in frequency, scope, and methodology, making comparisons across countries difficult.

Regular population-level surveillance of the risk factors among youth using cross-culturally comparable measures, along with prompt and wide dissemination of the results in accessible formats, is essential for monitoring progress and ensuring that the best policies and programs to address the current needs of youth are implemented. More up-to-date intervention studies and rigorous evaluations of existing policies and programs, especially in low- and middle-income countries, are also needed to understand what works in what contexts, and which approaches are most cost-effective and sustainable. As the evidence base improves, we can better identify areas requiring immediate attention, prioritize actions, and develop best practices for addressing NCD risk behaviors among young people in different parts of the world.



Read more about youth and NCDs in the latest report supported by the AstraZeneca Young Health Programme and the regional reports in Africa, Asia, Latin American and the Caribbean, and the Middle East and North Africa.

Visit the Data Center

Jeffrey Drope et al., The Tobacco Atlas, Sixth Edition (Atlanta: American Cancer Society and Vital Strategies, 2018).
Jo Inchley et al., ed. Adolescent Obesity and Related Behaviours: Trends and Inequalities in the WHO European Region, 2002-2014. Observations From the Health Behavior in School-Aged Children (HBSC) WHO Collaborative Cross-National Study (Copenhagen: WHO Regional Office for Europe, 2017).
Jo Inchley et al., ed. Growing Up Unequal: Gender and Socioeconomic Differences in Young People's Health and Well-Being, Health Behaviour in School-Aged Children (HBSC) Study: International Report From the 2013/2014 Survey (Copenhagen: WHO Regional Office for Europe, 2016).
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http://www.who.int/news- room/fact-sheets/detail/noncommunicable-diseases
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WHO, Report on the Global Tobacco Epidemic, 2017: Monitoring Tobacco Use and Prevention Policies (Geneva: WHO, 2017).
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Acknowledgments

This web feature was produced by Toshiko Kaneda, Ph.D., senior research associate and Michael Orcutt, the Fletcher Summer Intern in International Programs at the Population Reference Bureau (PRB). The authors thank Liam Sollis at Plan International UK for his helpful comments. The Youth and NCDs Data Center and related analytical work were funded by the AstraZeneca Young Health Programme (YHP). YHP is a disease prevention programme with a unique focus on adolescents. It was founded in partnership with Johns Hopkins Bloomberg School of Public Health and Plan International, with local NGO partners implementing YHP programs on the ground. The YHP mission is to positively impact the health of adolescents in marginalized communities worldwide through research, advocacy, and on-the-ground programs focused on NCD prevention.

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