Public Health 150
Non-communicable Diseases
Zuo-Feng Zhang, MD, PhD
Professor of Epidemiology
November 5, 2012
What are NCDs?
• NCD is a medical condition or disease, which is
not infectious
• NCDs are diseases or medical conditions with
long duration and relatively slow progression
• NCDs are usually called “Chronic Diseases”
Why NCDs Are Important in Public Health?
• 57 million deaths that occurred globally in
2008
• 36 million – 63.2%, almost two thirds – were
due to NCDs
• 9 million death that occurred among people
under age 60
• mainly cardiovascular diseases, cancers,
diabetes and chronic lung diseases
UN High-Level meeting on NCDs,
September 19-20, 2011
Number of deaths for leading causes
of death in the US
•
•
•
•
•
•
•
•
•
•
Heart disease: 631,636
Cancer: 559,888
Stroke (cerebrovascular diseases): 137,119
Chronic lower respiratory diseases: 124,583
Accidents (unintentional injuries): 121,599
Diabetes: 72,449
Alzheimer's disease: 72,432
Influenza and Pneumonia: 56,326
Nephritis, nephrotic syndrome, and nephrosis: 45,344
Septicemia: 34,234
US
Cardiovascular Diseases
• CVDs include diseases of the heart, vascular
diseases of the brain and diseases of blood
vessels.
• CVDs are responsible for over 17.3 million
deaths per year and are the leading causes of
death in the world
WHO. Global Atlas on Cardiovascular Disease Prevention and Control. Mendis S, Puska P, Norrving
B editors. World Health Organization, Geneva 2011
Heart and Brain
WHO. Global Atlas on Cardiovascular Disease Prevention and Control. Mendis S, Puska P, Norrving
B editors. World Health Organization, Geneva 2011
Proportion of Death caused by
CVDs
WHO. Global Atlas on Cardiovascular Disease Prevention and Control.
Mendis S, Puska P, Norrving
B editors. World Health Organization, Geneva 2011
Distribution of CVDs
What Is Tumor/Cancer?
Tumor is a disorder of cells
• A neoplasm (Greek, Neo-New, plasma, thing formed)
is the autonomous growth of tissue that have
escaped the normal restraints on cell proliferation
and exhibit varying degrees of fidelity to their
precursors.
• It is usually appears as a tumor ( a swelling) made of
mass of cells.“Abnormal growth of cells”, “Unlimited
growth of cells”.
Tumors
• In general, neoplasms are irreversible, and
their growth is for the most part,
autonomous.
Benign versus Malignant Tumors
• Benign tumors do not penetrate (invade)
adjacent tissue borders, nor do they spread
(metastasize) to distant sites.
• They remain localize overgrowths in the area
in which they arise
• Benign tumors are more differentiated than
malignant tumors, that is, they are more
closely resemble their tissue of origin.
Invasion and Metastasis
• Malignant tumors (cancer) are capable of
invasion (spread of the neoplasms into
adjacent structures) and metastasis
(implantation of the neoplasms into
noncontiguous sites).
Oral Premalignant Lesions
Oral Leukoplakia
Invasive oral
cancer
Oral submucous
fibrosis
Erythroplakia
Second Primary Cancers
following a first primary
oral cancer
Esophageal Cancer
Oral Cancer
Lung Cancer
Cancer Statistics
• 12.7 million new cases in 2008
• 7.6 million deaths from cancer (13.3% of
overall deaths) in 2008
INCIDENCE BY SEX AND CANCER SITE, WORLD 2008
28.1
1.5
5.2
9.1
3.9
1.5
1.2
6.0
1.7
5.9
3.41
0.12
0.61
1.02
0.39
0.15
0.10
0.64
0.19
0.55
FEMALES
BOTH SEX
ASR Cum. risk
ASR Cum. risk
Cases
Cases
(World) (age 0-74)
(World) (age 0-74)
92,958
2.6
0.29
263,861
3.9
0.45
26,621
0.8
0.08
84,434
1.2
0.13
27,744
0.8
0.09
135,685
2.0
0.24
155,664
4.2
0.50
482,239
7.0
0.86
349,042
9.1
1.03
989,598
14.1
1.68
570,099 14.6
1.63
1,233,711 17.3
1.97
225,916
6.0
0.69
748,271
10.8
1.24
86,940
2.2
0.25
145,662
2.0
0.23
133,406
3.3
0.37
277,668
3.9
0.44
20,145
0.6
0.07
151,219
2.3
0.28
513,637 13.5
1.60
1,608,823 23.0
2.78
197,402
2.8
0.30
96,369
2.6
0.27
1,383,523 39.0
4.14
1,383,523 39.0
4.14
529,828
15.3
1.57
529,828 15.3
1.57
287,107
8.2
0.96
287,107
8.2
0.96
225,484
6.3
0.69
225,484
6.3
0.69
903,452
28.1
3.41
52,549
1.5
0.12
271,384
3.9
0.46
103,401
2.8
0.32
386,365
5.3
0.61
89,027
2.2
0.24
110,938
3.1
0.32
238,796
3.5
0.35
163,020
4.7
0.47
212,033
3.1
0.31
27,673
0.8
0.07
67,887
1.0
0.08
156,275
4.2
0.44
355,844
5.1
0.54
47,971
1.2
0.14
102,762
1.4
0.17
155,469
4.3
0.39
351,412
5.1
0.47
6,629,112 204.1
21.18
6,038,358 164.9
Cases
Lip, oral cavity
Nasopharynx
Other pharynx
Esophagus
Stomach
Colorectum
Liver
Gallbladder
Pancreas
Larynx
Lung
Melanoma of skin
Breast
Cervix uteri
Corpus uteri
Ovary
Prostate
Testis
Kidney
Bladder
Brain, nervous system
Thyroid
Hodgkin lymphoma
Non-Hodgkin lymphoma
Multiple myeloma
Leukaemia
All cancers (excludes
non-melanoma skin cancer)
170,903
57,813
107,941
326,575
640,556
663,612
522,355
58,722
144,262
130,174
1,095,186
101,033
903,452
52,549
167,947
297,338
127,858
49,013
40,214
199,556
54,791
195,943
MALES
ASR Cum. risk
(World) (age 0-74)
5.3
0.62
1.7
0.19
3.4
0.41
10.2
1.25
19.8
2.38
20.4
2.35
16.0
1.83
1.8
0.20
4.4
0.52
4.1
0.51
34.0
4.07
3.1
0.33
16.52
12,667,470 181.6
18.69
MORTALITY BY SEX AND CANCER SITE, WORLD 2008
MALES
FEMALES
ASR Cum. risk
ASR Cum. risk
Cases
Cases
(World) (age 0-74)
(World) (age 0-74)
83,254
2.6
0.30
44,697
1.2
0.14
35,977
1.1
0.12
15,609
0.4
0.05
76,363
2.4
0.28
19,095
0.5
0.06
276,129
8.6
1.03
130,677
3.4
0.40
464,435 14.3
1.67
273,634
6.9
0.76
320,595
9.7
1.05
288,049
7.0
0.72
478,275 14.6
1.67
217,568
5.7
0.65
42,938
1.3
0.14
66,540
1.7
0.18
138,080
4.2
0.49
127,949
3.1
0.34
70,722
2.2
0.27
11,552
0.3
0.04
951,023 29.4
3.45
427,392 11.0
1.27
25,663
0.8
0.08
20,427
0.5
0.06
458,367 12.5
1.34
275,128
7.8
0.87
74,005
2.0
0.23
140,153
3.8
0.43
258,381
7.5
0.64
9,906
0.3
0.02
72,030
2.2
0.24
44,279
1.1
0.12
112,255
3.3
0.34
37,910
0.9
0.08
97,054
3.0
0.31
77,791
2.2
0.23
11,249
0.3
0.04
24,222
0.6
0.08
18,396
0.5
0.05
11,809
0.3
0.03
109,465
3.3
0.34
81,921
2.1
0.21
37,776
1.2
0.13
34,817
0.9
0.10
143,669
4.3
0.39
113,802
3.1
0.28
Lip, oral cavity
Nasopharynx
Other pharynx
Esophagus
Stomach
Colorectum
Liver
Gallbladder
Pancreas
Larynx
Lung
Melanoma of skin
Breast
Cervix uteri
Corpus uteri
Ovary
Prostate
Testis
Kidney
Bladder
Brain, nervous system
Thyroid
Hodgkin lymphoma
Non-Hodgkin lymphoma
Multiple myeloma
Leukaemia
All cancers (excludes
4,225,662 128.8
Non-melanoma skin cancer)
13.45
3,346,839
87.6
9.10
BOTH SEX
ASR Cum. risk
Cases
(World) (age 0-74)
127,951
1.9
0.22
51,586
0.8
0.08
95,458
1.4
0.17
406,806
5.8
0.70
738,069 10.3
1.19
608,644
8.2
0.88
695,843 10.0
1.14
109,478
1.5
0.16
266,029
3.7
0.41
82,274
1.2
0.15
1,378,415 19.4
2.31
46,090
0.6
0.07
458,367 12.5
1.34
275,128
7.8
0.87
74,005
2.0
0.23
140,153
3.8
0.43
258,381
7.5
0.64
9,906
0.3
0.02
116,309
1.6
0.18
150,165
2.0
0.20
174,845
2.5
0.27
35,471
0.5
0.06
30,205
0.4
0.04
191,386
2.7
0.27
72,593
1.0
0.11
257,471
3.6
0.33
7,571,501 106.2
11.17
Incidence and Mortality, World 2008
Cancer
Cancer
Cancer
Projected demographic effects on cancer incidence and
mortality
New cancers (in 1,000,000s) of all cancers
Region
2008 2010 2020
World
12.67 13.30 16.93
More developed regions 5.56
5.72
6.59
Less developed regions
7.11
7.52
9.92
Africa
0.68
0.72
0.95
Asia (Japan)
0.62
0.64
0.74
Asia (Other)
5.48
5.75
7.60
Europe
3.21
3.29
3.67
Latin America/Caribbean 0.91
0.96
1.28
North America
1.60
1.67
2.08
Oceania
0.14
0.14
0.18
New deaths (in 1,000,000s) of all cancers
Region
2008 2010 2020
World
7.57
7.96 10.22
More developed regions 2.75
2.84
3.32
Less developed regions
4.82
5.11
6.83
Africa
0.51
0.54
0.72
Asia (Japan)
0.34
0.36
0.43
Asia (Other)
3.73
3.92
5.24
Europe
1.72
1.77
1.99
Latin America/Caribbean 0.54
0.58
0.78
North America
0.64
0.66
0.84
Oceania
0.06
0.06
0.08
2008
2030
21.37
7.43
12.88
1.28
0.79
9.89
4.06
1.69
2.50
0.23
2020
2030
Africa
Asia (Japan)
Asia (Other)
Europe
Latin America
North America
0
1
2
3
4
5
6
7
Number of new cases (in millions)
2008
2030
13.16
3.86
9.10
0.97
0.47
6.98
2.26
1.05
1.06
0.10
2010
2010
2020
8
9
10
8
9
10
2030
Africa
Asia (Japan)
Asia (Other)
Europe
Latin America
North America
0
1
2
3
4
5
6
Number of deaths (in millions)
7
Projected demographic effects on cancer incidence and
mortality
2008
New cancers (in 100,000s)
2010
2020
2030
Lung
Cancer site
2008
2010
2020
2030
Lung
16.1
17.0
22.1
28.7
Colon/rectum
Breast
13.8
14.5
17.9
21.7
Stomach
Colon/rectum
12.3
13.0
16.8
21.9
Prostate
Stomach
9.9
10.4
13.5
17.4
Liver
Prostate
9.0
9.5
12.8
17.1
Cervix
Liver
7.5
7.9
10.0
12.5
Esophagus
Cervix
5.3
5.5
6.6
7.8
Esophagus
4.8
5.1
6.6
8.4
Breast
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
2,500,000
3,000,000
Number of new cases
2008
New deaths (in 100,000s)
2010
2020
2030
Lung
Cancer site
2008
2010
2020
2030
Lung
13.8
14.5
19.0
24.9
Stomach
7.4
7.8
10.1
13.2
Liver
7.0
7.3
9.3
11.8
Breast
Colon/rectum
6.1
6.4
8.3
11.0
Esophagus
Breast
4.6
4.8
6.0
7.5
Cervix
Esophagus
4.1
4.3
5.6
7.2
Prostate
Cervix
2.8
2.9
3.6
4.3
Prostate
2.6
2.7
3.6
5.0
Stomach
Liver
Colon/rectum
0
500,000
1,000,000
1,500,000
2,000,000
Number of deaths
Cancer Incidence and Mortality in China
and World, 2008
China
New Cases
Incidence
Deaths
Mortality
Male
1,622,502
(24.5%)
211.0
1,222,199
(28.9%)
158.6
Female
1,194,708
(19.8%)
152.4
736,148
(22.0%)
91.6
Total
2,817,210
(22.2%)
181.0
1,958,347
(25.88%)
124.6
Male
6,617,844
203.8
4,219,626
128.6
Female
6,044,710
165.1
3,345,176
87.6
12,662,554
181.6
7,564,802
106.1
World
Total
Incidence and Mortality are per 100,000
Population: China: 1,331,460,000; World: 6,775,235,700; China/World: 19.65%
Globocan, 2008
Age Standardized Incidence Rates of
Cancer
US
Lung
More developed
regions
Less developed
regions
Males
Females
Males
Females
Males
Females
49.5
36.2
47.4
18.6
27.8
11.1
Breast
76.0
66.4
27.3
Colorectum
34.1
25.0
37.6
24.2
12.1
9.4
Stomach
5.7
2.8
16.7
7.3
21.1
10.0
Liver
7.0
2.2
8.1
2.7
18.9
7.6
Prostate
83.8
Cervix
Esophagus
62.0
5.7
5.8
Source: GLOBOCAN 2008
1.2
12.0
9.0
6.5
1.2
17.8
11.8
5.7
Age Standardized Incidence Rates (/100,000)
US
Site
China
World
Males
Females
Males
Females
Males
Females
Stomach
7.2
3.3
41.4
19.2
22.0
10.3
Lung
61.9
36.1
42.4
19.0
35.5
12.1
Liver
5.5
2.0
37.9
14.2
15.7
5.8
Esophagus
4.9
1.3
27.4
12.0
11.5
4.7
Colon/Rectum
44.6
33.1
13.6
9.2
20.1
14.6
─
101.1
─
18.7
─
37.5
Leukemia
11.2
7.4
5.7
4.1
5.9
4.1
Pancreas
8.3
6.3
3.9
2.6
4.6
3.3
Cervix
0
7.7
0
6.8
0
16.2
Brain
6.5
4.5
3.9
2.8
3.7
2.6
124.8
0
1.6
0
25.3
0
Breast
Prostate
Source: GLOBOCAN 2002
Leading Causes of Death in
the U.S.: 2008
Source: US Mortality Data, National Center for Health Statistics, Centers for Disease Control and Prevention
Source: US Mortality Data, National Center for Health Statistics, Centers for Disease Control and Prevention
Ten Leading Cancers in the U.S.: 2012 Estimates
Number of New Cases
Site
Prostate
Breast
Lung & Bronchus
Colorectum
Skin Melanoma
Urinary Bladder
Non-Hodgkin Lymphoma
Kidney
Thyroid
Leukemia
All Sites
Both
241,740
229,060
226,160
143,460
76,250
73,510
70,130
64,770
56,460
47,150
Male
Female
241,740
2,190 226,870
116,470 109,690
73,420 70,040
44,250 32,000
55,600 17,910
38,160 31,970
40,250 24,520
13,250 43,210
26,830 20,320
1,638,910 848,170 790,740
Attributed to the reductions
in the use of menopausal
hormone therapy (MHT),
following the publication of
results from the Women’s
Health Initiative in 2002.
Ten Leading Cancer Types for Cancer Deaths
2012 Estimates
Number of Deaths
Site
Both
Male
Female
Lung & Bronchus
Colorectum
Breast
Pancreas
160,340
51,690
39,920
37,390
87,750
26,470
410
18,850
72,590
25,220
39,510
18,540
Prostate
28,170
28,170
Leukemia
Liver
Non-Hodgkin Lymphoma
Ovary
Esophagus
All Sites
23,540
20,550
18,940
15,500
15,070
577,190
13,500
13,980
10,320
12,040
301,820
10,040
6,570
8,620
15,500
3,030
275,370
Decreasing rate but
increasing number
because of the aging
and growth of the US
population.
732,900+ 291,500 = 1,024,400
cancer deaths prevented
COPD
• Chronic obstructive pulmonary disease (COPD) is a life-threatening lung
disease that interferes with normal breathing – it is more than a “smoker’s
cough”.
• An estimated 64 million people have COPD worldwide in 2004.1
• More than 3 million people died of COPD in 2005, which is equal to 5% of
all deaths globally that year.
• Almost 90% of COPD deaths occur in low- and middle-income countries.
• The primary cause of COPD is tobacco smoke (through tobacco use or
second-hand smoke).
• The disease now affects men and women almost equally, due in part to
increased tobacco use among women in high-income countries.
• COPD is not curable, but treatment can slow the progress of the disease.
• Total deaths from COPD are projected to increase by more than 30% in the
next 10 years without interventions to cut risks, particularly exposure to
tobacco smoke.
COPD
Diabetes
Diabetes
• More than 346 million people worldwide
have diabetes.
• There is an emerging global epidemic of
diabetes that can be traced back to rapid
increases in overweight, obesity and physical
inactivity.
Diabetes
Diabetes is predicted to become the seventh
leading cause of death in the world by the
year 2030.
• Total deaths from diabetes are projected to
rise by more than 50% in the next 10 years.
Diabetes
There are two major forms of diabetes.
• Type 1 diabetes is characterized by a lack of
insulin production and type 2 diabetes results
from the body's ineffective use of insulin.
A third type of diabetes is gestational diabetes.
• This type is characterized by hyperglycaemia,
or raised blood sugar, which has first appeared
or been recognized during pregnancy.
Diabetes
Type 2 diabetes is much more common than
type 1 diabetes.
• Type 2 accounts for around 90% of all diabetes
worldwide. Reports of type 2 diabetes in
children – previously rare – have increased
worldwide. In some countries, it accounts for
almost half of newly diagnosed cases in
children and adolescents.
Diabetes
• Cardiovascular disease is responsible for
between 50% and 80% of deaths in people
with diabetes.
• Diabetes has become one of the major causes
of premature illness and death in most
countries, mainly through the increased risk of
cardiovascular disease (CVD).
Diabetes
Diabetes is a leading cause of blindness,
amputation and kidney failure.
• Lack of awareness about diabetes, combined
with insufficient access to health services and
essential medicines, can lead to complications
such as blindness, amputation and kidney
failure.
Diabetes
Type 2 diabetes can be prevented.
• Thirty minutes of moderate-intensity physical
activity on most days and a healthy diet can
drastically reduce the risk of developing type 2
diabetes. Type 1 diabetes cannot be
prevented.
Percentage of Cancer Deaths Attributed to Various Factors
(Doll R and Peto R, JNCI, 1981)
•
•
•
•
•
•
•
•
•
•
•
•
Tobacco Use: 30% (25%-40%)
Diet:35% (10%-70%)
Infection: 10%? (1%-?)
Reproductive & Sexual Behavior: 7% (1%-13%)
Occupation: 4% (<2%-8%)
Alcohol: 3% (2%-4%)
Geophysical factors (natural radiation): 3% (2-4%)
Pollution: 2% (<1% – 5%)
Food additive: <1% (-5% – 2%)
Medicines and Medical Procedures: 1% (0.5%-3%)
Industrial consumer products <1% (<1%-2%)
Unknown: ?, ?
Lichtenstein P, Holm NV, Verkasalo PK, Iliadou A, Kaprio J, Koskenvuo M, Pukkala E, Skytthe
Study Design in GWA Studies
• Multistage approach to reduce the amount of genotyping required,
without sacrificing power.
• In stage 1, a full set of SNPs is genotyped, and a p-value threshold is used
to identify a subset of SNPs with putative associations.
Joel N. Hirschhorn & Mark J. Daly
Nature Reviews Genetics 6, 95-108,
Published Genome-Wide Associations through
06/2011,
1,449 published GWA at p≤5x10-8 for 237 traits
National Human Genome Research Institute (NHGRI) GWA
Catalog
Tobacco causes 10% of CVD death
Diseases Caused by Tobacco Use
Cigarette smoking increases the risk of:
 Coronary heart disease
 Atherosclerotic peripheral vascular disease
 Cerebrovascular disease
 Cancers of the lung, larynx, mouth, esophagus, bladder, pancreas,
kidney, and cervix
 Chronic obstructive pulmonary disease
 Intrauterine growth retardation, premature rupture of membranes
 Low-birthweight babies, perinatal mortality
 Cataract, macular degeneration; hip fracture
 Peptic ulcer disease
 Possibly liver, stomach, and colorectal cancers and acute myelocytic leukemia
Disease Caused by Tobacco Use
Involuntary smoking (environmental tobacco smoke) is a cause of:
 Lung cancer and coronary heart disease in nonsmokers
 Respiratory infections and symptoms in the children of
parents who smoke
Smokeless tobacco causes:
 Oral Cancer
 Oral leukoplakia
 Dental caries (possibly)
Cigars cause:
 Cancers of the mouth, larynx, and lung
 Coronary heart disease
 COPD
Physical Activities
The Benefits of Physical Activity
Regular physical activity is one of the most
important things you can do for your health.
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Control your weight
Reduce your risk of cardiovascular disease
Reduce your risk for type 2 diabetes and metabolic syndrome
Reduce your risk of some cancers (colon, breast, endomentrial
and lung cancers)
Strengthen your bones and muscles
Improve your mental health and mood
Improve your ability to do daily activities and prevent falls, if
you're an older adult
Increase your chances of living longer
CDC, 2011
Harmful Use of Alcohol
Obesity
Key facts
• Worldwide obesity has more than doubled since
1980.
• In 2008, 1.5 billion adults, 20 and older, were
overweight. Of these over 200 million men and
nearly 300 million women were obese.
• 65% of the world's population live in countries where
overweight and obesity kills more people than
underweight.
• Nearly 43 million children under the age of five were
overweight in 2010.
• Obesity is preventable.
Obesity
• Globally, 44% of diabetes, 23% of ischaemic heart
disease and 7–41% of certain cancers are
attributable to overweight and obesity.
Obesity
• Body Mass Index (BMI) is a number calculated
from a person's weight and height. BMI
provides a reliable indicator of body fatness
for most people and is used to screen for
weight categories that may lead to health
problems.
• http://www.cdc.gov/healthyweight/assessing/
bmi/adult_bmi/english_bmi_calculator/bmi_c
alculator.html
BMI Classification
• Body Mass Index (BMI) is a simple index of
weight-for-height that is commonly used to
classify underweight, overweight and obesity
in adults. It is defined as the weight in
kilograms divided by the square of the height
in metres (kg/m2). For example, an adult who
weighs 70kg and whose height is 1.75m will
have a BMI of 22.9.
• BMI = 70 kg / (1.75 m2) = 70 / 3.06 = 22.9
The International Classification of adult underweight,
overweight and obesity according to BMI
Fattest Countries in the World
Diet
Exhibit 16–1 American Cancer Society (ACS) Guidelines on Nutrition and Physical Activity for
Cancer Prevention
ACS Recommendations for Individual Choices
1. Eat a variety of healthful foods, with an emphasis on plant sources.
 Eat five or more servings of a variety of vegetables and fruits each day.
 Choose whole grains in preference to processed (refined) grains and sugars.
 Limit consumption of red meats, especially those high in fat and processed.
 Choose foods that help maintain a healthful weight.
2. Adopt a physically active lifestyle.
 Adults: engage in at least moderate activity for 30 minutes or more on five or more days
of the week; 45 minutes or more of moderate-to-vigorous activity on five or more days
per weekmay further enhance reductions in the risk of breast and colon cancer.
 Children and adolescents: engage in at least 60 minutes per day of moderate-to-vigorous
physical activity at least five days per week.
3. Maintain a healthful weight throughout life.
 Balance caloric intake with physical activity.
 Lose weight if currently overweight or obese.
4. If you drink alcoholic beverages, limit consumption.
ACS Recommendations for Community Action
Public, private, and community organizations should work to create social and physical
environments that support the adoption and maintenance of healthful nutrition and physical
activity behaviors.
 Increase access to healthful foods in schools, worksites, and communities
 Provide safe, enjoyable, and accessible environments for physical activity in schools, and
for transportation and recreation in communities.
Source: Reprinted with permission from T Byers, et al., American Cancer Society Guidelines on Nutrition
and Physical Activity for Cancer Prevention: Reducing the Risk of Cancer with Healthy Food Choices and
Physical Activity. CA: A Cancer Journal for Clinicians , Vol 52, pp. 92-119, © 2002, Lippincott Williams
& Wilkins.