Monitoring targets and indicators for the prevention and control of non-communicable diseases in Korea

In order to respond to the increasing burden of non-communicable diseases (NCDs) worldwide, the World Health Organization developed the global action plan (GAP), which included nine targets and 25 indicators to monitor the targets. Owing to space constraints, the article reviewed the status of 17 indicators for seven targets out of nine targets in the GAP in Korea. Most of these 17 indicators required additional analysis with existing national data to evaluate the status in Korea. Based on the result from evaluating indicators, the current NCD policy strategy and resources in Korea seemed unlikely to reach the GAP goals, unless innovative policy changes was planned to reduce NCD risk factors particularly focusing on smoking, excessive drinking, and insufficient physical activity.


INTRODUCTION
The World Health Organization (WHO) developed the global action plan (GAP) to reduce the burden of non-communicable diseases (NCDs) accounted for 65% of global deaths annually. The GAP suggested 25 indicators to monitor progress and to evaluate the nine targets set by GAP to reduce the global NCDs burden to be achieve by 2020 [1].
The monitoring would provide the assessment of NCDs trends between nations over time, which could lay a foundation for policy development and execution, and help increase political responsibility. In addition, the GAP proposed to develop additional indicators to monitor strategy development for NCDs prevention and control within each national and regional context. This included institutional reinforcement to increase the efficiency of data collection to generate indicators and improve the quality and scope of data [2]. The 25 GAP indicators include mortality and morbidity (indicators 1 and 2), NCDs risk factors (indicators 3-17), and national systems response (indicators 18-25). The national system response indicators were mainly patient treatments, drugs, and vaccines. This review focused on sources of data in Korea for the 17 indicators (indicators 1-17) related to NCDs mortality, morbidity and risk factors and highlighted the trend of each indicator.

DATA SOURCE FOR MONITORING GLOBAL ACTION PLAN INDICATORS
Korean sources of data for the 17 indicators to monitor NCDs mortality, morbidity and status of risk factors were shown in Table 1. The major sources of data were the statistics from the Causes of Death Statistics, the National Cancer Registry, the Korea National Health and Nutrition Examination Survey (KN-HANES), and the Korea Youth Risk Behaviors Web-Based Survey (KYRBS).

GLOBAL ACTION PLAN INDICATOR LEVELS AND TRENDS
Premature mortality due to non-communicable diseases -Indicator 1. Unconditional probability of dying between 30 and 70 year-olds from cardiovascular diseases, cancer, dia- Age-standardized premature mortality due to circulatory diseases (I00-I99) between 30-69 years of age Age-standardized premature mortality due to cerebrovascular diseases between 30-69 years of age Age-standardized premature mortality due to cardiovascular diseases between 30-69 years of age Age-standardized premature mortality due to neoplasm (C00-D48) between 30-69 years of age Age-standardized premature mortality due to diabetes (E10-E14) between 30-69 years of age Age-standardized premature mortality due to chronic lower respiratory diseases (J40-J47) between 30-69 years of age Indicator 2. Cancer incidence by type of cancer per 100,000 people National Cancer Registry Total cancer incidence Six major cancer Incidence Cancer incidence by cancer types Age-standardized obesity prevalence among those 19 years or older, based on body mass index Obesity prevalence among those 19 years or older, based on waist circumference Indicator 15. Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18+ years KNHANES (not reported) [6] Intake of saturated fats Indicator 16. Age-standardized prevalence of persons (aged 18+ years) consuming less than five total servings (400 g) of fruit and vegetables per day KNHANES (Appendix 21) [6] Age-standardized daily intake of vegetables (g) among those 1 year of age or older Age-standardized daily intake of fruits (g) among those 1 year of age or older Indicator 17. Age-standardized prevalence of raised total cholesterol among persons aged 18+ years and mean total cholesterol concentration KNHKNANES (Appendix 22) [6] Age-standardized high cholesterol prevalence among those 30 years or older betes or chronic respiratory diseases -Indicator 2. Cancer incidence by type per 100,000 people Indicators of premature mortality due to NCDs could be viewed as age-standardized mortality of individuals 30 to 69 years of age in causes of death statistics from the National Statistical Office of Korea. As the GAP included individuals up to 70 years of age, reanalysis is required. Nevertheless, premature death due to NCDs has been steadily decreasing in the past decade (Appendices 1-4). According to age-standardized cancer incidence by type from National Cancer Registry during the past 10 years, incidences of the six major cancer (gastric, lung, liver, colorectal, breast, and cervical cancer) have gradually increased, whereas the total cancer incidence has increased relatively faster. In particular, incidences of colorectal and breast cancer have increased more rapidly (Appendices 5 and 6).

High-risk alcohol intake
-Indicator 3. Total alcohol per capita (15+ year olds) consumption -Indicator 4. Age-standardized prevalence of heavy episodic drinking among adolescents and adults -Indicator 5. Alcohol-related morbidity and mortality among adolescents and adults Drinking-related indicators could be evaluated by data from the KNHANES, the Korea Alcohol Liquor Industry Association, and the Road Traffic Authority of Korea. There has been no major change in per-capita alcohol consumption over the age of 15 since 2007 (Appendix 7). The prevalence of high-risk drinking and the prevalence of alcohol abuse have been steady at about 14% since 2009 (Appendix 8) and 7% since 2008 (Appendix 9), respectively. However, the proportion of deaths due to driving under the influence of alcohol from the total traffic accidents has continuously increased, even though deaths due to traffic accidents have decreased steadily (Appendix 10). Mortality by mental or behavioral disorders caused by alcohol drinking has continuously decreased since 2000 while mortality by alcoholic liver diseases has rapidly increased until early 2000 and has been maintained at 7.5 per 100,000 persons for the last 10 years since 2004 (Appendix 11).
Insufficient physical activity -Indicator 6. Prevalence of insufficiently physically active adolescents -Indicator 7. Age-standardized prevalence of insufficiently physically active persons aged 18+ years Physical activity indicators could be evaluated using data from the KNHANES and KYRBS. Since age groups were differently categorized, reanalysis based on the definition of indicators for insufficient physical activities might be required. Physical activities in youths have gradually increased during the past five years, while physical activities among adults have decreased for the last 5 years (Appendices 12 and 13).

Sodium intake
-Indicator 8. Age-standardized mean population intake of salt (sodium chloride) per day in grams in persons aged 18+ years Sodium intake indicator could be calculated using data from the KNHANES, indicating an average intake of 6.5 g, which was 3 times higher than the 2 g target consumption of WHO. Despite a slight reduction in sodium intake compared to a decade ago, there has been no change during the past five years (Appendix 14). Hypertension and diabetes -Indicator 11. Age-standardized prevalence of raised blood pressure among persons aged 18+ years -Indicator 12. Age-standardized prevalence of raised blood glucose/diabetes among persons aged 18+ years Prevalence of hypertension and diabetes, which are biological risk factors, could be evaluated using the KNHANES data. The reanalysis is required to use 18 years as a starting age. The prevalence of hypertension has been increased during the past five years, while the previous trend of gradual increase in diabetes prevalence was decreased in 2012 (Appendices 17 and 18).
Obesity -Indicator 13. Prevalence of overweight and obesity in adolescents -Indicator 14. Age-standardized prevalence of overweight and obesity in persons aged 18+ years Obesity indicators could be evaluated by data from the KN-HANES and the KYRBS. Although reanalysis of the past 10 years is required to use 18 years as a starting age for obesity in youths and adults and also the definition of obesity is different from that of WHO, obesity prevalence in youths and adults has been increased during the last decade (Appendices 19 and 20). As the KYRBS data was not based on actual measurements, data could be additionally supplemented using student health check-up data (Appendices 19 and 20).

Additional indicators
-Indicator 15. Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18+ years -Indicator 16. Age-standardized prevalence of persons (aged 18+ years) consuming less than five total servings (400 g) of fruit and vegetables per day -Indicator 17. Age-standardized prevalence of raised total cholesterol among persons aged 18+ years and mean total cholesterol concentration Although nutrient intake and dietary habit indicators were recorded in the KNHANES, saturated fatty acid intake was not officially reported until 2014. Recently, the Korea Centers for Disease Control and Prevention have developed methods to calculate intake of saturated fatty acids using the nutrients database by food types and these findings were expected to be presented in the near future. There have been no major changes in vegetables and fruit intake during the past five years. Recently, the KNHANES data has shown a continuous and rapid increase in the prevalence of high cholesterol (Appendices 21 and 22).

EVALUATION OF THE 17 GLOBAL ACTION PLAN INDICATORS
Among the 17 GAP indicators described in the Table 2, five indicators were currently available based on the GAP definitions, but 11 indicators from the sources of data in Korea required the reanalysis based on age standards or GAP defini-tions. For the last indicator, intake rate of saturated fat has not been determined yet. It could be calculated by using the National Health and Nutrition Survey data in the near future.