Non Communicable Diseases

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Non Communicable Diseases
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Columbus and Nicot
1492 - Christopher Columbus sets off to discover
India and bring spices to Europe He reaches
America and discovers Tobacco

• 1560 - Jean Nicot introduces tobacco to France

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Tobacco smoking spreads in India
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Fast foods
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NCD risk factors in Ayurveda

• Diabetes (Prameha)
• Ashtanga hrudaya
• Charaka samhita
• Heart disease (Hrudroga)
• Madhava Nidana
• Charaka Samhita

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Cardiovascular system
17th Century William Harvey Blood pumped by the
heart
130 AD Claudius Galen Existence of circulatory
system Blood created by the heart / liver
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• 1847 Karl Ludwig
• Kymograph arterial catheter
• 18th century Stephen Hales
• Measuring blood pressure of dogs, horses
• 1855 Karl Vierordt
• Cuff for arresting / releasing blood flow
• 1860 Etienne Jules Mary
• Sphygmograph

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• 1881 Samuel Siegfried Kaul Ritter von Basch
• Water sphygmomanometry
• 1896 Scipione Riva Rocci
• Mercury sphygmomanometry
• Auenbragger Corvisart Laennec
• Stethoscope
• 1905 Nikolai Korotkoff
• Use of stethoscope to measure bp systolic and
  diastolic
• A major physiological biomarker of NCD is born

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• 1913 - Nikolai Anitschkow
• Feeding rabbits cholesterol could induce symptoms
  similar to atherosclerosis
• 1951 - Duff and McMillian
• Formulated the lipid hypothesis in its modern
  form
• Serological biomarkers are born
• 1949 Berenblum and Shubik
• Carcinogenesis - a multistage process
• Chronic disease as a continuum of events search
  for earlier events in natural history.

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• Chronic diseases
• Not seen as a crisis and the pay-off for
  prevention efforts occurs in future years
• More concern in general about involuntary risks
  (e.g., potential exposure to a waste site) than
  about voluntary risks (e.g., cigarette smoking)
• Lack of chronic disease and risk factor data
• Public health funding is disproportionately low

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• Mortality reduction achieved in CVD and cancers -
  
• 1935 First population-based cancer registry.
• 1949 The Framingham Heart Study beginsamong the
  first cohort studies.
• 1950 Doll and Hill, Levin et al., Schreck et al.,
  and Wynder and Graham publish the first
  case-control studies of cigarette smoking and
  lung cancer.
• 1964 The U.S. Surgeon Generals Advisory
  Committee on Smoking and Health publishes the
  first Surgeon Generals Report on Smoking and
  Health establishes criteria for evaluation of
  causality in epidemiologic studies.

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• 19711972 North Karelia Project and Stanford
  Three Community studies are launchedthe first
  community-based cardiovascular disease prevention
  programs.
• 1972 NHLBI launches the National High Blood
  Pressure Education Program.
• 1984 CDC establishes the Behavioral Risk Factor
  Surveillance System
• 1988 Release of the first Surgeon Generals
  Report on Nutrition and Health.

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Take home message

• Global NCD risk factor incursions into
  populations are
• centuries old
• rapid in spread across continents
• can be controlled or reversed
• Experiences in Framingham, North Karelia
• are sustainable
• have been successfully replicated in other areas
• were used to develop NCD risk factor control
  programmes

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Characteristic Features

• Multiplicity of agents
• Long latent period with indefinite onset
• Permanent
• Nonreversible pathological alterations
• Residual effects
• Trained lifestyle modifications
• Long term care

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Levels of Prevention

• Primordial
• prevent emergence of risk factor by maintaining
  existing healthy practices eg smoking habit of
  women
• Primary
• Health promotion
• Specific protection
• Secondary
• Early diagnosis and treatment (Screening)
• Tertiary
• Disability limitation
• Rehabilitation

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Cardiovascular Diseases

• Hypertension
• Dyslipidemia
• Coronary Diseases
• Cerebrovascular diseases / Stroke

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Hypertension

• WHO / JNC VII criteria
• Components of lifestyle modifications include
  weight reduction, DASH (Dietary Approaches to
  Stop Hypertension 8S whole grains, 5S FV, 2S
  low fat milk, 2S fish/lean meat, nuts
  occasionally and other foods sparingly) eating
  plan, dietary sodium reduction, aerobic physical
  activity, and moderation of alcohol consumption.

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Dyslipidemia

• National Cholesterol Education Program (NCEP)
  Adult Treatment Panel (ATP III)
• Serum HDL gt 40 Serum Triglyceride lt 150
• Diet, exercise smoking cessation

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Coronary Heart Disease

• Community based study ECG Rose questionnaire
• Hospital based cardiac enzymes, cardiac
  function, vascular studies

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Stroke

• TIA
• Stroke
• Thromboembolic
• Haemorrhagic
• Young stroke
• Stroke management at secondary level
• Stroke surveillance STEPwise approach

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STEPS-stroke

• WHO has developed an international stroke
  surveillance system the STEPwise approach to
  stroke surveillance
• Information on stroke patients admitted to heath
  facilities (Step 1)
• Identification of community-based fatal stroke
  events (Step 2)
• Estimates of community-based non-fatal stroke
  events (Step 3)

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Health System Issues

• Promptness of diagnosis
• Nonpharmacological aspects of treatment
• Diet
• Exercise
• Tobacco
• Management of acute event secondary care
  facilities to be developed

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Diabetes Mellitus

• Diabetes mellitus positive findings from any
  two of the following tests on different days
• Symptoms of diabetes mellitus
• Casual plasma glucose concentration gt200 mg per
  dL (11.1 mmol per L)
• FPG gt126 mg per dL (7.0 mmol per L)
• 2hrPPG gt200 mg per dL (11.1 mmol per L) after a
  75-g glucose load
• Impaired glucose homeostasis
• FPG from 110 to lt126 (6.1 to 7.0 mmol per L)
• 2hrPPG from 140 to lt200 (7.75 to lt11.1 mmol per
  L)
• Normal
• FPG lt110 mg per dL (6.1 mmol per L)
• 2hrPPG lt140 mg per dL (7.75 mmol per L)

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Risk of Type II Diabetes Mellitus

• Convincing
• Overweight and Obesity
• Abdominal Obesity
• Physical inactivity
• Maternal diabetes
• Probable
• Saturated fats
• IUGR Barkers hypothesis
• Possible
• Total fat intake
• Trans-fatty acids

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Health System Issues

• Promptness of diagnosis
• Nonpharmacological aspects of treatment
• Diet
• Exercise
• Tobacco
• Management of complications every discipline
  involved

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Obesity

• Body Mass Index
• Abdominal Obesity (Waist Circumference Waist
  Hip ratio)

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Overweight and ObesitySocially accepted
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Risk Factor Modification - Biomarkers
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Risk Factor Modification Behavioural Risk
Factors

• Five servings of fruits / vegetables
• High sugar / salt / fat foods to be used
  sparingly
• 30 minutes of moderate physical activity daily
• Tobacco cessation / control

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Acute MI in North Kerala, 1967-1988
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Acute MI in North Kerala, 1967-1988
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Prevalence of CHD in the rural Trivandrum
population, 1990-91
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Random capillary blood sugar and coronary risk
factors in Trivandrum, 1998
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Related studies

• Hypertension prevalence among Individuals gt30
  years was 36.7
• Thankappan KR, Sivasankaran S, Sarma PS at al
  Prevalence-correlates-awareness-treatment and
  control of hypertension in Kumarakom, Kerala
  baseline results of a community-based
  intervention program, Indian Heart J. 2006
  Jan-Feb58(1)28-33
• Prevalence of DM
• Overall DM 16.3 IGT 3.
• Age-standardized for 30-64 years 13.7.
• Kutty VR, Joseph A, Soman CR. High prevalence of
  type 2 diabetes in an urban settlement in Kerala,
  India. Ethnicity and health. 1999, 4(4) 231-239.
• Tobacco related cancers among all cancers 46
  in males, 14 in Females
• Hospital Based Cancer Registry, Regional Cancer
  Centre, Thiruvananthapuram, 2002

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• Thank you!