CONTRIBUTORS: Jenny Proimos, MB BS, MPH, FRACP,a,b and Jonathan D.

Klein, MD, MPH, FAAPc,d

a
Department of Pediatrics, University of Melbourne, Centre for Adolescent
Health, Royal Children’s Hospital, Parkville, Victoria, Australia; bVictoria
Department of Education and Early Childhood Development, Victoria, Australia;
c
American Academy of Pediatrics, Elk Grove Village, Illinois; and dUniversity of
Rochester School of Medicine, Rochester, New York
Dr Proimos is a member and Dr Klein is chair of the International Pediatric
Association Technical Advisory Group on Noncommunicable Diseases. The
International Pediatric Association is a nongovernmental organization of 144
national, regional, and international specialty pediatric societies.
Accepted for publication Jun 4, 2012
ABBREVIATION
NCD—noncommunicable disease
doi:10.1542/peds.2012-1475

Noncommunicable Diseases in Children and

Adolescents
We have made great progress in
preventing and managing commu-
nicable diseases worldwide. Non-
communicable diseases (NCDs), which
result from noninfectious and non-
transmissible factors, are often
caused by factors that are modifiable.
Children are the frequent victims of
air pollution and behaviors such as
tobacco use, physical inactivity, and
unhealthy diets leading to the de-
velopment of the NCDs discussed in
this global health perspectives com-
mentary. The worldwide burden of
NCDs is enormous, actually account-
ing for the majority of all deaths.
Risk factors such as high blood
pressure, raised cholesterol, tobacco
use, alcohol consumption, and over-
weight coupled with poor economic
and social conditions create a per-
fect storm for many of the world’s
chronic illnesses diseases. Drs Proimos
and Klein bring new focus to
the pediatric perspective and sug-
gest an approach to developing
strategies internationally to combat
these most common health issues of
our time.
—Jay E. Berkelhamer, MD
Editor, Global Health Perspectives
Recent global attention has focused on
NCDs and their impact on global mor-
bidity and mortality. NCDs are medical
conditions or diseases that are non-
transmissible and often enduring. Of
the 57 million deaths worldwide in 2008,
NCDs accounted for 36 million, mainly
due to cardiovascular disease, cancers,
diabetes, and chronic lung diseases.1
Eighty percent of NCD deaths occur in
low and middle income countries.2
NCDs often result from modifiable life-
style risk factors, such as tobacco use,
problem alcohol use, unhealthy diet, and
lack of physical activity, leading to
overweight, raised blood pressure, and
cholesterol. Left unchecked, NCDs will
continue to lower global productivity,
threaten quality of life, and cost trillions
of dollars.3 Systematic efforts to prevent
NCDs, and ameliorate their burden, are
now part of a global health strategy.4
In September 2011, the United Nations
General Assembly declaration on pre-
vention and control of NCDs first ac-
knowledged the increasing impact of
NCDs on children and adolescents and
recognized the need to protect them
from NCDs.5
CHILDREN AND ADOLESCENTS ARE
HEAVILY IMPACTED BY NCDS
• 1.2 million children and youth under
age 20 died of NCDs in 20026
• More than 25% of obese adolescents
have signs of diabetes by age 157
• Despite improvements in survival for
some childhood cancers,8 survival is
much lower in resource-poor coun-
tries
• 90% of the 1 million children born
each year with congenital heart dis-
ease live in areas without adequate
medical care9
• Tobacco smoke causes asthma, oti-
tis, and respiratory infections in
children10

PEDIATRICS Volume 130, Number 3, September 2012 379

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• Mental health disorders,11 motor
vehicle trauma, homicide, and sui-
cide12 cause significant morbidity
and mortality in children and
youth
RISK FACTORS AND BEHAVIORS
LEADING TO ADULT NCDS START IN
CHILDHOOD
Prenatal exposure to tobacco and al-
cohol, prematurity and low birth weight,
nutritional deficiency, and diabetes have
long-term impacts on health and de-
velopment, including increased risk of
adult cardiovascular disease, diabetes,
and other social and medical problems
later in life.13 It is important to focus
on prenatal care, healthy nutrition in
pregnancy, and breastfeeding. Safe
deliveries, effective resuscitation, and
postnatal care with adequate immuni-
zations and safe, smoke-free environ-
ments also help prevent the burden of
chronic care for children and their
families.
The onset of risk behaviors predis-
posing to NCDs often occurs in chil-
dren and adolescents. Globally, 100 000
young people start smoking each
day,14 and over 90% of adults who
smoke started as children or youth.15
Adolescent alcohol consumption is com-
mon, risking brain development, nonin-
tentional injury and violence, and alcohol
dependence in adulthood.16,17 Overweight
and obesity are increasing in high-income
countries and in low- and middle-
income countries,10,18 with increased
risk of diabetes and cardiovascular
disease.19
A life course approach to preventive
efforts addressing NCDs and their risk
factors and behaviors will improve
child and adolescent health but also
decrease lifetime health care costs.20
This approach recognizes that adult
health and disease risk develops early
in life and can affect disease states
and risks across generations.20 Vaccine-
preventable NCD programs (eg, human
380 PROIMOS and KLEIN
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papilloma virus and hepatitis B) are
examples of effective primary pre-
vention that have successfully mobi-
lized international resources to help
the world’s poorest countries.21 NCD
efforts must collaborate with maternal,
newborn, and child health systems
to achieve efficiency and effective-
ness and must also address the
social determinants of health and
disease. This includes promoting ed-
ucation, which benefits both lifestyle
choices and health outcomes, and
also community productivity and
social stability.22 Living conditions, air
and water pollution, and adequate
sanitation and open spaces all should
be considered by governments in
developing policies to promote child
health.
Strengthening child and adolescent
health systems is essential if low- and
middle-income countries are to de-
velop comprehensive approaches
to prevention and management of
NCDs. Comprehensive family centered
“medical home” based care systems
(www.medicalhomeinfo.org), integrat-
ing primary care for children and
youth with community public health
systems, are a useful model for a
comprehensive, multilevel approach to
NCD prevention and management. In-
creasingly, young people themselves
have also been engaged as active par-
ticipants in promoting community
health and social services that meet
their needs.23
The United Nations global strategy
calls for comprehensive monitoring of
trends and progress in implementation
of national plans and recommendations
for voluntary global targets for pre-
vention and control of NCDs.24,25 Mon-
itoring is crucial to inform policy;
however, many countries do not col-
lect comparable mortality and NCD
data.26 Only one-third of the world’s
population lives in areas where births
and deaths are accurately registered.
Advocacy for child and adolescent
NCD efforts must encourage coun-
tries to develop and implement ef-
fective monitoring and surveillance
systems. Advocacy is also needed to
ensure that child and adolescent
health targets are included in the
monitoring framework and targets
being set by the United Nations for
NCDs. The International Pediatric As-
sociation, American Academy of Pe-
diatrics, and other national pediatric
societies have called on countries to
pay specific attention to children and
adolescents in developing national to-
bacco, alcohol, mental health, chronic
illness, nutrition and physical activity,
and reproductive health goals. A broad
coalition of family advocates and clin-
ical groups, the NCD Child Network,
has also called on the global com-
munity to (1) focus attention on NCDs
in children and adolescents, (2) ad-
vance policies and interventions that
ensure maternal and child health sys-
tems become engaged in development
of NCD prevention and management,
and (3) assist nations in addressing a
life-course approach to the prevention
and management of NCDs among chil-
dren and adolescents at all levels of
the health care system.27
CONCLUSIONS
Childhood and adolescence are crucial
times for the prevention of NCDs. A life-
course approach to prevention, di-
agnosis, and management may result
in significant gains in health outcomes,
global productivity, and health care
savings. Measuring progress in health
outcome trends is a first step to being
able to monitor the impact of NCD
prevention. Advocacy by child health
leaders for equitable inclusion of
children and adolescents in NCD goals
by countries is critically needed to
ensure that countries’ NCD efforts in-
clude support for child and adoles-
cent health.

REFERENCES
1. Alwan A, Maclean DR, Riley LM, et al.
Monitoring and surveillance of chronic
non-communicable diseases: progress and
capacity in high-burden countries. Lancet.
2010;376(9755):1861–1868
2. World Health Organization. Global Status
Report on Non-Communicable Diseases
2010. Geneva, Switzerland: World Health
Organization; 2011
3. Bloom D, ed. The Global Economic Burden
on Non-Communicable Diseases. Geneva,
Switzerland: World Economic Forum; 2011
4. World Health Organization. Action Plan
for the Global Strategy for the Prevention
and Control of Noncommunicable Dis-
eases. Geneva, Switzerland: World Health
Organization; 2008
5. United Nations. Political declaration of the
high-level meeting of the general assem-
bly on the prevention and control of non-
communicable diseases; September 16, 2011;
New York, NY: United Nations General As-
sembly; 2011
6. Mathers C. Global Burden of Disease
Among Women, Children, and Adolescents.
Maternal and Child Health: Global Chal-
lenges, Programs, and Policies. New York,
NY: Springer; 2009:19–42
7. Goran MI, Ball GD, Cruz ML. Obesity and risk
of type 2 diabetes and cardiovascular dis-
ease in children and adolescents. J Clin
Endocrinol Metab. 2003;88(4):1417–1427
8. Cancer Research UK. Childhood cancer
statistics: survival. Available at: http://
info.cancerresearchuk.org/cancerstats/
childhoodcancer/survival/childhood-cancer-
survival-statistics. Accessed November 5,
2011
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
PEDIATRICS Volume 130, Number 3, September 2012
Downloaded from pediatrics.aappublications.org by guest on May 9, 2015
9. Tchervenkov CI, Jacobs JP, Bernier PL, et al.
The improvement of care for paediatric
and congenital cardiac disease across the
World: a challenge for the World Society for
Pediatric and Congenital Heart Surgery.
Cardiol Young. 2008;18(suppl 2):63–69
10. The NCD Alliance. A Focus on Children and
Adolescents: Key Recommendations on Tar-
gets to Monitor Progress in Reducing the
Burden of Non-Communicable Diseases
(NCDs); 2012. Available at: http://ncdalliance.
org/sites/default/files/rfiles20110627_A_
Focus_on_Children_&_NCDs_FINAL_2.pdf.
Accessed June 19, 2012
11. Patel V, Flisher AJ, Hetrick S, McGorry P. Mental
health of young people: a global public-health
challenge. Lancet. 2007;369(9569):1302–1313
12. Gore FM, Bloem PJ, Patton GC, et al. Global
burden of disease in young people aged 10-
24 years: a systematic analysis. Lancet.
2011;377(9783):2093–2102
13. Gluckman P, Hanson M; University of
Auckland. Developmental Origins of Health
and Disease. Cambridge, UK: Cambridge
University Press; 2006
14. Shafey O. The Tobacco Atlas. 3rd ed.
Atlanta, GA: American Cancer Society; 2010
15. National Centre for Chronic Disease Pre-
vention and Health Promotion. Youth To-
bacco Surveillance - United States. 2000.
MMWR Surveill Summ. 2001;50(SS04):1–84
16. Bonomo YA, Bowes G, Coffey C, Carlin JB,
Patton GC. Teenage drinking and the onset
of alcohol dependence: a cohort study over
seven years. Addiction. 2004;99(12):1520–1528
17. DeWit DJ, Adlaf EM, Offord DR, Ogborne AC.
Age at first alcohol use: a risk factor for
the development of alcohol disorders. Am J
Psychiatry. 2000;157(5):745–750
PEDIATRICS PERSPECTIVES
18. Wang Y, Lobstein T. Worldwide trends in
childhood overweight and obesity. Int J
Pediatr Obes. 2006;1(1):11–25
19. Must A, Strauss RS. Risks and conse-
quences of childhood and adolescent obe-
sity. Int J Obes Relat Metab Disord. 1999;23
(suppl 2):S2–S11
20. Catalano RF, Fagan AA, Gavin LE, et al.
Worldwide application of prevention sci-
ence in adolescent health. Lancet. 2012;379
(9826):1653–1664
21. Monk BJ, Wiley DJ. Will widespread human
papillomavirus prophylactic vaccination
change sexual practices of adolescent and
young adult women in America? Obstet
Gynecol. 2006;108(2):420–424
22. Viner RM, Ozer EM, Denny S, et al. Adoles-
cence and the social determinants of
health. Lancet. 2012;379(9826):1641–1652
23. Adamchak S. Youth Peer Education in Re-
productive Health and HIV/AIDS. Arlington, VA:
Family Health International/YouthNet; 2006.
Available at: http://pdf.usaid.gov/pdf_docs/
PNADI607.pdf. Accessed June 19, 2012
24. World Health Organization. Action Plan for
the Global Strategy for the Prevention and
Control of Noncommunicable Disease Con-
trol. Geneva, Switzerland: World Health Or-
ganization; 2008
25. World Health Organization. WHO Discussion
Paper: A comprehensive global monitoring
framework and voluntary global targets for
the prevention and control of NCDs. Geneva,
Switzerland: World Health Organization;
2011 Updated version December 21, 2011
26. Patton GC, Coffey C, Cappa C, et al. Health of
the world’s adolescents: a synthesis of in-
ternationally comparable data. Lancet.
2012;379(9826):1665–1675
381
 Noncommunicable Diseases in Children and Adolescents
Jenny Proimos and Jonathan D. Klein
Pediatrics 2012;130;379; originally published online August 13, 2012;
DOI: 10.1542/peds.2012-1475
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All
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Downloaded from pediatrics.aappublications.org by guest on May 9, 2015

 Noncommunicable Diseases in Children and Adolescents
Jenny Proimos and Jonathan D. Klein
Pediatrics 2012;130;379; originally published online August 13, 2012;
DOI: 10.1542/peds.2012-1475

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/130/3/379.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on May 9, 2015