Professional Documents
Culture Documents
PRESENTED BY:
DR RIPIKA SHARMA
PG STUDENT
DEPATMENT OF PUBLIC HEALTH DENTISTRY
Contents:
INTRODUCTION..
INDIAN SCENARIO
GLOBAL BURDEN OF CHRONIC DISEASES
DEFINATIONS
SURVILLANCE
GAPS IN NATURAL HISTORY OF NCDS
RESOLUTIONS ADOPTED BY WHA
ACTION PLAN FOR GLOBAL STRATEGY FOR PREVENTION AND CONTROL OF NON
COMMUNICABLE DISEASES
RISK FACTORS
COMMON RISK FACTOR APPROACH
SOCIAL AND ECONOMIC IMPLICATIONS OF NON COMMUNICABLE DISEASES
PATHWAY ILLUSTRATING THE INCREASED PREVALENCE OF NCDS HAS AN IMPACT
ON SES AND HEALTH OUTCOMES.
Microeconomic, Health System and Macroeconomic Impact of NCDs in
India.
Financing for NCD
Financial impact of NCDs on households
Impact of ncds on health system and GDP
PREVENTION OF NON-COMMUNICABLE DISEASES
WHO BEST BUYS FOR CONTROL OF NON-COMMUNICABLE DISEASES
Cardiovascular diseases
CORONARY HEART DISEASES
ORAL HEALTH IMPLICATION
STROKE
HYPERTENSION
Why non communicable diseases are
important:
For most populations, the last century has witnessed the most dramatic
improvements in health in history.
Life expectancy at birth has increased from a global average of 46 years in 1950
to 66 years in 1998.
The health status and disease profile of human societies have historically been
linked to the level of their economic development and social organization.
With industrialization, the major causes of death and disability, in the more
advanced societies, have shifted from a predominance of nutritional deficiencies
and infectious diseases, to those classified as degenerative [chronic diseases such
as cardiovascular disease (CVD), cancer, and diabetes]. This shift has been
termed “the epidemiologic transition.”
Global burden of shifted from
communicable to noncommunicable diseases
(NCDs)
NCDs caused an estimated 36 million deaths in 2008. This figure represents
almost two thirds of all deaths globally, with nearly 80% of deaths due to
NCDs occurring in low- and middle-income countries, and approximately 29%
of deaths involving people less than 69 years of age .
The NCD burden is projected to increase disproportionately in lower income
countries and populations over the next 10 years .
Current epidemiological evidence indicates that four major NCDs – CVD,
cancer, chronic respiratory disease and diabetes – make the largest
contribution to the NCD burden in low- and middle-income countries.
Indian scenario of NCDS
In India alone, rapid changes in the country’s society and lifestyles have
caused NCDs to become responsible for two-thirds of the total morbidity
burden and about 53% of total deaths (up from 40.4% in 1990, and expected
to increase to 59% by 2015) .
This change is an example of the widespread urbanization that has occurred
during the last century.
In 2004, deaths due to non-communicable diseases in India were twice those
from communicable diseases.
In 2004, the people of India spent USD9.1 billion out-of pocket on tests,
treatments and medical devices to manage their non communicable diseases
(equal to 3.3% of India’s GDP for that year and 4 times the total spent by all
governments on healthcare.)
As a low-middle income country it is not surprising that India’s expenditure on
healthcare is also quite low. In 2007, India spent 4.1% of its Gross Domestic
Product (GDP) on health services, only 26% of which was government funding.
The major risk factors for non-communicable diseases are smoking, alcohol
abuse, a sedentary lifestyle, and an unhealthy diet. As a result, 40-50% of
non-communicable disease-related, premature deaths are preventable.
By 2020, heart disease and stroke will become the leading causes of death
and disability worldwide, with the number of fatalities projected to increase
to more than 24 million by 2030
The global burden of chronic diseases:
Approximately 58 million death occurred in the year 2005.
14%
chronic respiratory diseases
33% diabetes
One DALY can be thought of, under a number of conditions, as one lost
healthy year of life(Murray and Lopez 1996).
SURVEILLANCE
Public health surveillance
The term “surveillance” is derived from the French word meaning “to watch over”
In 1968 the 21st World Health Assembly described surveillance as the “systematic
collection and use of epidemiologic information for the planning,
implementation, and assessment of disease control”; in this sense, surveillance
implies “information for action”
The distinction between monitoring and surveillance of NCDs is
blurred and the terms are often used interchangeably.
Surveillance implies an integrated approach connecting the data to
development and evaluation of programmes whereas monitoring is
not always associated with programmes of action.
Surveillance systems are often considered information loops
or cycles involving health care providers, public health
agencies, and the public
The cycle is not completed until information about these cases is relayed to those responsible for
disease prevention and control and others “who need to know.”
The role of public health surveillance
The updated information on dentate status, dental caries, periodontal disease and
incidence of oral cancer has now been entered into the WHO Global InfoBase and the
databank will allow for cross-analysis of oral health status with general health
(chronic disease) and common risk factors.
Such analysis will provide valuable information for integrated prevention of chronic
disease and for the integration of oral health promotion into national and
community health programmes.
Systematic surveillance data also allow for time series analysis of oral disease,
chronic disease and common risk factors, and the health information system may
also provide a means for systematic evaluation of the effect of public health
intervention programmes.
Most of these noncommunicable diseases share common preventable risk
factors.
To anticipate the epidemic in non communicable diseases, WHO has initiated
the worldwide surveillance of risk factors using the WHO STEPwise approach
to Surveillance (STEPS) of risk factors for noncommunicable diseases.
The WHO STEPwise approach to Surveillance of
noncommunicable diseases (STEPS)
Is the WHO recommended NCD surveillance tool.
This framework unifies all WHO approaches to defining core variables for
population-based surveys, surveillance and monitoring instruments.
The goal is to achieve data comparability over time and between countries.
STEPS offers an entry point for low and middle income countries to get
started in NCD activities.
STEPS for NCD risk factors is based on the concept that surveillance systems
require standardised data collection as well as sufficient flexibility to be
appropriate in a variety of country situations and settings.
The STEPwise approach, therefore, allows for the development of an
increasingly comprehensive and complex surveillance system depending on
local needs and resources.
For surveillance to be sustainable, the STEPwise approach advocates that
small amounts of good quality data are more valuable than large amounts of
poor quality data.
A strong argument can also be made for the benefits of monitoring a few
modifiable NCD risk factors since they reflect both a large part of future NCD
burden as well as indicating the success of interventions considered to be
beneficial to a wide range of NCDs.
The key feature of the STEPS framework is the distinction between the different levels of risk-
factor assessment:
self report information by QUESTIONNAIRE (Step 1),
objective information by PHYSICAL MEASUREMENTS (Step 2), or
objective information by blood samples for BIOCHEMICAL ANALYSES (Step 3);
the three modules involved in describing each risk factor:
CORE
EXPANDED CORE
OPTIONAL
The STEPS approach moves along a sequential process.
The key premise is that, by using the same standardized questions and protocols, all countries
can use the information not only for informing within-country trends, but also for between-
country comparisons.
In India the survey was conducted from april 2003 to march 2005 in 6 sites and
again in 2007 in 7 states.
Steps 1 and 2 are desirable and appropriate
for most countries.
An important feature of the STEPwise
approach is that it allows expansion of the
key variables by the addition of optional
modules if there is strong (local) interest in
them.
WHO does not recommend such advanced
measurements
for countries with limited resources.
Oral health indicators within the frame
of STEPS
WHO Oral Health Programme designed a risk factor model which provided the
conceptual framework for inclusion of oral health modules within STEPS.
The indicators comprise both determinants of health and common modifiable
risk factors such as diet/nutrition, tobacco use and excessive alcohol
consumption.
In addition, oral hygiene practices and use of available oral health services are
considered. Most of the risk indicators are Step 1 variables (i.e. ascertained by
questionnaire), but oral health also lends itself to Step 2 (physical
measurements made during clinical examination).
Step 3 measurements in oral health may imply laboratory tests such as
microbial assessment (e.g. Streptococcus mutans) or buffer capacity of saliva.
The WHO Oral Health Programme has developed standardized questions for
obtaining Step 1 data.
These oral health modules are currently being field-tested in several
developing and developed countries. The results may help to identify
variables to form part of the core, expanded core and optional modules for
countries. An additional simplified questionnaire for assessment of the oral
health system has been prepared to examine systems orientation (i.e.
emergency or curative care only, prevention and health promotion).
Surveillance systems have been in operation for several years in certain developing
countries such as Madagascar and Thailand, where data from the evaluation of
child populations are used for targeting school-based oral health activities towards
global strategy for prevention and control of these diseases, endorsed in 2000
by the 53rd World Health Assembly (resolution WHA 53.17). Priority is given to
Obesity hypertension
Myocardial
infarction
Gaps in the natural history of NCD………..
3. Long latent period: it is the period between the first exposure to
suspected cause and the eventual development of disease. This makes
it difficult to link suspected causes with outcomes.
4. Indefinite onset : Most (NCD) are slow in onset and development.
Distinction between diseased and non diseased may be difficult to
establish.
In response to the rising burden of chronic diseases, the world
health assembly has adopted many resolution's:
First in 1956- calling for increased action to be taken to prevent and control the
growing burden of chronic diseases.
WHA has adopted a series of related resolutions which amplify WHO’s mandate
in the area of chronic diseases:
NCDs are largely caused by a cluster of risk factors: tobacco, unhealthy diet,
particularly sugars, physical inactivity and harmful use of alcohol.
Those risk factors also cause oral diseases. Indeed, the UN Political
Declaration recognized in Paragraph 19, "that renal, oral and eye diseases
pose a major health burden for many countries and that these diseases share
common risk factors and can benefit from common responses to non-
communicable diseases".
Oral Disease Added to United Nations Declaration on Non communicable
Diseases, Oral Disease Added to United Nations Declaration on Non
communicable Diseases | JCDA | Essential Dental Knowledge
World Oral Health Day (WOHD) is celebrated every year on the 20th March. It
is an international day to celebrate the benefits of a healthy mouth and to
promote worldwide awareness of the issues around oral health and the
importance of looking after oral hygiene to everyone old and young.
Because 90% of the world’s population will suffer from oral diseases in their
lifetime and many of them can be avoided with increased governmental,
health association and society support and funding for prevention, detection
and treatment programmes.
Recently WHO, jointly with the FDI and the International Association for
Dental Research (IADR), formulated goals for oral health to be achieved by
the year 2020
Global Goals for Oral Health
Rationale
The FDI and the WHO established the first Global Oral Health Goals jointly in
1981 to be achieved by the year 2000.
They had been useful and, for many populations, had been achieved or
exceeded.
Global Oral Health Goals, Objectives and Targets for the
Year 2020 Goals
To promote oral health and to minimise the impact of diseases of oral
and craniofacial origin on general health and psychosocial
development, giving emphasis to promoting oral health in populations
with the greatest burden of such conditions and diseases;
To minimise the impact of oral and craniofacial manifestations of
general diseases on individuals and society, and to use these
manifestations for early diagnosis, prevention and effective
management of systemic diseases.
Targets
The targets should be selected to match predetermined oral health priorities
at a national or local level. Consideration should be given to the following
areas when selecting targets, based on local priorities:
Pain, functional disorders, infectious diseases, oro-pharyngeal cancer, oral
manifestations of HIV-infection, noma, trauma, cranio-facial anomalies,
dental caries, developmental anomalies of teeth, periodontal diseases, oral
mucosal diseases, salivary gland disorders, tooth loss, health care services,
health care information systems.
The Common Risk Factor Approach (CRFA) addresses risk
factors common to many chronic conditions and prevention of
oral disease needs to be integrated with preventing other NCDs
The CRFA will be a guiding principle for FDI when giving advice
to NDAs on prevention, tobacco cessation and caries and
periodontal disease management and should start early in the life
course.
IADRS GROUP RECOMMENDATIONS
NON-
MODIFIABLE
MODIFIABLE
RISK FACTORS,
RISK FACTORS
AND
INTERMEDIATE
RISK FACTORS. 83
Modifiable Risk Factors
Tobacco Use
Mathers CD, Loncar D. Projections of global mortality and burden of disease from
2002 to 2030. PLoS Medicine, 2006, 3(11): e442.
Tobacco Use: Health Effects (cont.)
http://www.who.int/substance_abuse/publications/global_alcohol_report/m
sbgsruprofiles.pdf
Global Alcohol Consumption
Total adult per capita consumption, unrecorded APC and proportion
of unrecorded APC of total APC, in litres of pure alcohol, by WHO
region, 2005
Five-year change in recorded adult per
capita consumption, 2001–2005
Harmful Use of Alcohol: Effects
Immediate effects: Long-term effects:
http://www.pitt.edu/~super4/41011-42001/41171.pdf
Physical Inactivity
31% of the world’s population does not get enough physical activity.
Many social and economic changes contribute to this trend:
Aging populations,
Transportation, and
Communication technology.
http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html
http://www.sciencedirect.com/science/article/pii/S0140673612608988
Global Changes in Physical Activity (cont.)
STRESS FACTORS
Acute and chronic stresses such as Homelessness, Stressful work conditions and
Situations as in Natural and Manmade Disasters are major causes for many
physiological and psychological disorders.
NON MODIFIABLE RISK FACTORS
Non modifiable risk factors
The Risk factors, which cannot be modified:
Age: Elderly and children are the vulnerable group to get the diseases
basically.
Sex: There will be some difference between the disease ratios among the
gender.
Family History of Genetic Factors: Genetic factors are major risk factors
which cannot be modified.
2. Low density lipoproteins; often called “bad cholesterol” .High levels of (LDL-C) is positively correlated
with CHD mortality
High saturated fat dietary intake can raise cholesterol levels 108
Risk Factors…..
CHD risk prediction based on serum lipid levels a total “cholesterol/HDL ratio” has been
developed.
A ratio less than 3.5 has been recommended as a clinical goal for CHD prevention.
With newer technique HDL and LDL are further subdivided into sub fractions.
Recent evidences indicates that Plasma Apolipoprotein A1 (the major HDL protein) and
apolipoprotein B (the major LDL protein) are better predictors. Therefore measurements of
109
Global Burden of Raised Total Cholesterol
Increases risks of heart disease and stroke Globally, 1/3 of ischaemic heart disease
is attributable to high cholesterol
A 10% reduction in serum cholesterol in men aged 40 has been reported to result in a 50%
reduction in heart disease within 5 years
A 10% reduction in serum cholesterol in men aged 70 years can result in an average 20%
reduction in heart disease occurrence in the next 5 years
http://www.who.int/gho/ncd/risk_factors/cholesterol_text/en/
Raised blood Pressure (>120/80 mmhg)
Raised blood pressure is considered as modern life style disorder in the present
scenario. It is a major risk factor for cardiovascular diseases.
8.5 million deaths could be prevented over 10 years if sodium intake were reduced by 15%.
Sources of Sodium
People are unaware of how much dietary sodium they are eating.
In the U.S. 75% of sodium consumed comes from processed and restaurant
foods.
In China and Japan, 75% of sodium consumed comes from cooking with high
sodium products.
Recommendations and Actual Intakes WHO
Recommendations A population salt intake of less than 5 grams or
approximately 2,000 milligrams of sodium, per person per day is
recommended to reach national targets or in their absence. This level was
recommended for the prevention of cardiovascular diseases.
Actual Intake Latest global estimates show that average sodium intake varies
from 2,000 to 7,200 milligrams of sodium per person per day.
Raised Blood Glucose(>120 mg/dl)
Global Burden of Elevated Glucose
In 2004, it was estimated that elevated glucose resulted in 3.4 million deaths
(5.8% of all deaths).
Globally, approximately 9% of adults aged 25 and over had elevated blood
glucose in 2008.
Elevated Glucose: Health Effects
Elevated glucose levels can lead to type 2 diabetes. Diabetes: leading cause
of renal failure
Lower limb amputations are at least 10 times more common in people with
diabetes than in non-diabetic people
•Raised glucose is a major cause of heart disease and renal disease.
WHO also identifies the six leading risk factors that are associated with non-
communicable diseases as being the leading global risk factors for death
today:
http://www.who.int/nmh/events/2012/4November2012_PPT_RevPaper_TA.pdf
COMPARATIVE HEALTH CARE SPENDING:
Social and economic implications of non
communicable diseases….. Thakur, et al.: Socio-
economics of NCD
134
Secondary prevention: Action which halts the progress of the disease at its
incipient stage and prevents complications.
Tertiary prevention: All measures available to reduce impairments and
disabilities minimize suffering due to departure from good health and
promote patient’s adjustment to irremediable conditions. Effort will be done
through disability limitations and rehabilitation
WHO BEST BUYS FOR CONTROL OF NON-
COMMUNICABLE DISEASES
World Health Organization has led global efforts to address NCDs through
development of different instruments. Those are Population level interventions
and Individual Level Interventions.
Population level Interventions
NCDs can best be addressed by a combination of primary prevention, targeting
whole population, by measures that targeting high-risk individuals and by
improved access to essential health-care interventions for people with NCDs.
Enforcing bans on tobacco advertising, promotion and sponsorship.
Raising taxes on tobacco.
Strong legislative effort for tobacco control: Government of India had ratified
the National Anti-Tobacco Legislation in 2007, which bans smoking in public
places throughout the country.
Restricting access to retailed alcohol.
Enforcing bans on alcohol advertising.
Raising taxes on alcohol.
Promoting salt reduction in the community through awareness generation and
reducing salt content of processed foods.
Regulatory mechanism for fruits and vegetable prices.
Promoting public awareness about diet (Replacing trans-fat in food with
polyunsaturated fat) and physical activity, through mass media.
Comprehensive policies on food production, nutrition, marketing, and
transport to promote primordial prevention of CVDs. (Cardio-vascular
diseases)
Modifying the environment (building the play grounds & parks for
relaxation).
Promoting use of cleaner alternate fuels in kitchens.
Improved monitoring and strict enforcement of air quality norms in urban
as well as rural areas.
Public education on air-quality and measures to reduce air pollution.
Developing alternative financing models that protect citizens from the
catastrophic financial impact of chronic diseases including CVDs.(Cardio-
vascular diseases)
A major initiative in CVD control has been the launch of the National Programme for
Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke
[NPCDCS) in 2010. This envisages early diagnosis, risk reduction, and appropriate
management of these diseases at primary health care level.
Protection from occupational carcinogens
Protection against HBV( Hepatitis B virus) and HPV (Human papilloma virus) by
vaccination
Individual Level Interventions
Screening and early diagnosis of disease in all health care settings
Individual health education towards prevention of diseases and promotion of
health.
Counselling, drug therapy, specific treatment and rehabilitations.
“Cardiovascular disease has the same meaning for health care
today as the epidemics of centuries had for medicine in earlier
times: 50% of the population in developed countries die of
cardiovascular disease”
(Pal Kertai)
142
Historical Perspectives of CVD Epidemiology
144
Cardiovascular diseases
CVD comprise of a group of diseases of the heart and the vascular system.
Hypertension
Cerebrovascular disease
145
Cardiovascular diseases
Problem Statement
World
32 million deaths NCD
16.7 million CVD
> 1/3 of these deaths in middle aged adults.
Heart disease and stroke are the 1st and 2nd leading cause of death for adult men
and women.
Cardiovascular diseases (CVDs) account for >17 million deaths globally each year
(30% of all deaths), 80% of which occur in low-income and middle-income
countries, and this figure is expected to grow to 23.6 million by 2030.
Ischaemic heart disease alone caused 7 million deaths worldwide in 2010, an
increase of 35% since 1990.
146
The projected trends in CVD mortality and the expected shifts from infectious
to chronic diseases over the next few decades are shown in Figure .
Deaths caused by CVD at 4 different stages of
epidemiologic transition
149
Cardiovascular Diseases
Problem Statement
India
150
Hospital based data:
Thirty year trends of (1960 -1990) hospital admissions reveal that admissions
due to coronary disease have increased from 5% of hospital admission to
almost 30%.
Projections based on modeling:
In a response to a systematic review by Ghaffar et al, Gupta projected a more
than two fold increase in CHD mortality by the year 2020 as compared to the
numbers in 1990 (the projected mortality in 2020 is 2584000 as compared to
1175000 deaths in 1990).
Murray and Lopez in their Global Burden of Disease study project 4.8 million
CVD deaths by the year 2020 AD, with majority of deaths occurring in middle
age (47.7% of all CVD deaths). India will have lost 43.5 million DALYs by the
year 2020 due to CVD.
Characteristics of CVD in Indians
The risk of death due to CHD is substantially higher among Indians and this is
evident from ‘migrant’ studies which report a 1.5-3.8 CHD mortality ratio
among migrant Indians when compared to the local populations.
MORTALITY FROM CHD IN SOUTH ASIANS OVERSEAS
The INTERHEART study, a large case-control study, involving 15152 patients of
incident AMI and 14820 age & sex matched controls from 52 countries across
the globe demonstrated that the risk imposed by conventional risk factors for
AMI among South Asians is similar to the Western populations
. However, given the background high prevalence of diabetes, impaired
glucose tolerance, insulin resistance and metabolic syndrome, the population
attributable risk and the individual-absolute risk get magnified manifold.
157
Coronary Heart Disease
Myocardial infarction
Irregularities of heart
Cardiac Failure
Sudden death
158
Epidemicity
Over 300 risk factors have been associated with coronary heart disease and
stroke.
The major established risk factors meet three criteria:
A high prevalence in many populations; a significant
Independent impact on the risk of coronary heart disease or stroke;
And their treatment and control result in reduced risk
http://www.who.int/cardiovascular_diseases/en/cvd_atlas_03_risk_factors.
pdf
Risk Factors
1. Smoking
2. Increases risks of cardiovascular disease, especially in people who started young, and heavy
smokers.
3. Passive smoking an additional risk
Mechanisms:
Carbon monoxide induced atherogenesis
Nicotine stimulation of adrenergic drive raising BP nd myocardial oxygen demand
Lipid metabolism (decrease in HDL)
168
Risk Factors
Tobacco use
• Smoking is estimated to cause nearly 10 per cent of all CVD.
• The risk of developing CVD is higher in female smokers, young men, and
heavy smokers.
• There are currently about 1 billion smokers in the world today.
• Within two years of quitting, the risk of coronary heart disease is
substantially reduced, and within 15 years the risk of CVD returns to that of a
non-smoker
169
Risk Factors
2. Hypertension
BP is single most useful test for identifying individual at high risk of developing CHD
Hypertension accelerates atherosclerotic processes especially if hyperlipidemia is also
present.
Both systolic Blood pressure(SBP) and diastolic blood pressure(DBP) are important risk factors.
170
Risk Factors
Serum Cholesterol
A high blood cholesterol level is called hyperlipidaemia.
Increases risks of heart disease and stroke Globally, 1/3 of ischaemic heart disease is attributable to high cholesterol
A 10% reduction in serum cholesterol in men aged 40 has been reported to result in a 50% reduction in heart disease within 5
years
A 10% reduction in serum cholesterol in men aged 70 years can result in an average 20% reduction in heart disease occurrence in
the next 5 years
171
Other Risk Factors
CHD responsible for 30-50% deaths in diabetics over 40 yrs. in industrialized countries.
Framingham Study:
Men with type 2 diabetes have a two to fourfold greater annual risk of CHD, with an even higher
Genetic Factors : a family history of CHD is known to increase the risk of premature death.
Genetic factors are probably the most important determinants of a given individual’s TC and
LDL levels. but the importance of genetic factors in the majority of cases is largely unknown.
172
Other Risk Factors
Physical activity : Sedentary lifestyle is associated with a greater risk of development of
early CHD.
Hormones : the pronounced difference in the mortality rates for CHD between male and
female subjects .
it has been hypothesized that hyperoestrogenemia may be the common underlying factor
that leads both to atherosclerosis and its complications such as CHD, stroke and
173
Type A personality
preoccupation with deadlines and time urgency. Data in 1980s found that type A
Framingham study.
Alcohol : high alcohol intake, defined as 75g or more per day is an independent risk factor for CHD ,
3. The effect of alcohol on hemostatic factors including fibrinogen , platelet aggregation and fibrinolysis.
The evidence of moderate alcohol intake leads to a reduction in the risk of CHD is un substantiated.
Oral contraceptives :
Women using oral contraceptives have higher systolic and diastolic blood pressure. The risk of myocardial
infarction in women seems to be increased by oral contraceptives , and the risk is compounded by cigarette
smoking
Dyspnoea on exertion and low vital capacity have also been cited as possible risk factors.
Prevention of CHD the Identification of Risk
Factors
1951 – Framingham Heart Study has played a major role in establishing the nature of
CHD risk factors and their relative importance.
177
Seven Countries Study
1958-1970
The link between diet, serum cholesterol and coronary artery disease.
Prospective cohort study of 11,575 healthy men in seven countries.
They found that the following varied considerably among the countries:
Diet: esp the amount of sat. fat
Serum cholesterol levels
Death rates due to CHD
Findings
As % of saturated fat in each country’s diet increased, the average cholesterol
increased
As the average serum cholesterol increased the death rate due to coronary heart
disease increased
Seven Countries Study
1958-1970
Lowest cholesterol levels and lowest incidence of coronary artery
disease in countries with a “Mediterranean diet”
180
North Keralia Project
Follow up surveys at 5 yrs demonstrated a significant reduction in all 3 major risk factor.
1979 – mortality declined by 24% in men and 51% in women in North Keralia compared with
12% in men and 26% in women in rest of Finland.
1982 –more than twice the reduction achieved in the rest of Finland. (Rose’s 10 yr
incubation period)
181
Multiple Risk Factor Intervention Trial
(MRFIT)
MRFIT – USA
Half the group – Intensive intervention prog, being seen every 4 months
Other half received medical examination yearly without any specific advice.
Over 7 year follow up period, IHD mortality was reduced by 22% more in intervention
group (NS)
Reason: Control group had also changed their lifestyle to far greater extent.
182
Oslo diet/smoking Intervention Study
1973- 16,202 Norwegian men aged 40-49 years were screened for coronary risk factors.
1232 normotensive at high risk (cholesterol 290-379 mg/dl) were selected for a 5 year
randomized trial
Aim was to determine whether lowering of serum lipids and cessation of smoking would reduce
incidence of 1st attack of CHD.
Intervention group underwent techniques to lower serum cholesterol level through dietary
means and to decrease or eliminate smoking.
5 yrs – 47% decrease in incidence of MI in intervention group.
183
Lipid Research Clinics Study
184
STROKE
The term “stroke” is applied to acute severe manifestations of
cerebrovascular disease.
Hypertension :
Main risk factor for cerebral thrombosis as well as cerebral hemorrhage .
Other factors:
Cardiac abnormalities (i.e left ventricular hypertrophy, cardiac dilation),
diabetes, elevated blood lipids, smoking,blood clotting and viscocity, oral
contraceptives.
transient ischemic attack (TIA)
These are episodes of focal , reversible , neurological deficit of sudden onset and
of less than 24 hours duration. They show a tendency to recurrence. They are due
to microemboli, and are warning sign of stroke.
Host factors;
Age;
Incidence rate increases steeply with age.
In india 1/5th of all the stroke occur below the age of 40 (called “stroke in youngs”)
Sex:
Incidence rate are higher in male than in female.
Stroke control programme:
Aim:
To apply community level effective measures for the prevention of stroke.
First priority is the control of hypertension which is main the cause.
TIA are the earlier manifestation of stroke, their earlier detection and
treatment is important for prevention of stroke.
Control of other risk factors like diabetes, smoking etc at the population level
are new approaches.
HYPERTENSION
Hypertension
Accounts for 20-25% of all deaths, and is the major risk factor cardiovascular
mortality
2013 -- The theme for this year's World Health Day, 7 April, is hypertension
195
196
197
Classification of Blood Pressure measurement
198
Classification of hypertension by extent of organ damage
Accurate measurements are essential under standardized conditions for valid comparisons
between persons or groups over time.
Three sources of error have been identified in the recording of blood pressure.
Observer errors : eg hearing acuity, interpretation of korotkow sounds.
Instrumental errors: e.g leakage valve, cuff that do not encircle the arm.
200
Blood pressure measurement
WHO group recommended sitting position than supine position
Uniform policy should be adopted, using either right or left arm consistently
Near the DBP the sound 1st becomes muffled (phase IV) and then disappears (phase V)
Measured at least 3 times over a period of at least 3 mins and lowest reading recorded
201
Hypertension
Classification
Primary (Essential) – 90%
Secondary
202
"Rule of halves"
203
The areas of the circles shown in Fig. correspond to the
actual proportions observed in several population based
studies and number-wise represent the following :
Few population either living at high altitudes or belonging to primitive cultures ( small
no of ethnic groups living in Pacific islands, Asia, Africa and S.America) – exceptionally
low BP
205
Prevalence in India
Data derived from 2 well planned studies
Urban –
59.9/1000 and 69.9/1000 in males and females respectively.
Rural –
35.5/1000 and 35.9/1000 in males and females respectively.
206
Tracking of BP
207
Risk Factors for hypertension
208
Risk Factors for hypertension
209
Risk Factors for hypertension
Modifiable risk factors
Environmental Stress
Potassium also affects BP. It antagonizes the effect of sodium.
Other cations such as calcium, cadmium and magnesium have also been suggested as of importance in
reducing BP
Dietary Fiber: Risk of CHD and hypertension is inversely related to consumption of dietary fiber.
Alcohol : Increases SBP more than DBP, returns to normal after abstinence.
Heart Rate :Higher in hypertensive group, reflects resetting of sympathetic activity at higher level.
210
Risk Factors for hypertension
Socioeconomic Status : Countries that are in post transitional stage, consistently higher levels
of BP have been noted in lower socioeconomic groups.
This inverse relation has been noted with levels of education, income and occupation. In
societies that are transitional or pretransitional – higher prevalence in Upper socioeconomic
status.
211
Prevention of Hypertension
Primary Prevention
Population Strategy
High risk Strategy
Secondary Prevention
212
Prevention of Hypertension
1. Population Strategy:
Nutrition :
213
Prevention of Hypertension
214
Prevention of Hypertension
215
Implication of oral health
Recent studies have found that patients with periodontal disease have a 1.5-
to 2.0-fold greater risk of incurring fatal CVD than patients without
periodontal disease.
In fact, oral infections seem to increase the risk of coronary artery disease to
a degree similar to the classic risk factors.
Periodontal Medicine: A New Paradigm, J Can Dent Assoc 2000; 66:488-91
1989 Mattila and colleagues found an increase
in caries, periodontal disease, pericoronitits and
perapical lesions in patients with recent MI, when
compared to controls.
Many risk factors for MI were the same for Periodontitis,
mainly:
Smoking
Older Male Patients
Lower SES
Effect of periodontal infection
How?
Active periodontitis increases the prothromotic
state recurrent bacteremia, platelet
activation, increased clotting factors
DIABETES
Definition: DIABETES MELLIETUS
It is a heterogeneous group of disorders characterized by hyperglycemia, and
disturbances of carbohydrate, fat and protein metabolism with absolute or relative
deficiency of insulin action and or secretion.
In 1910, Sir Edward Albert Sharpey-Schafer suggested that people with diabetes were
deficient in a single chemical that was normally produced by the pancreas—he proposed
calling this substance insulin , from the Latin insula , meaning island.
Banting and laboratory director MacLeod received the Nobel Prize in Physiology or
Medicine in 1923 for finding out insulin injection.
Banting is honored by World Diabetes Day which is held on his birthday, November
14.
Once regarded as a single disease entity, diabetes is now seen as a
heterogeneous group of diseases, --characterised by a state of
chronic hyperglycemia, resulting from a diversity of etiologies,
environmental and genetic, acting jointly.
239
Diabetes in the World
Year
31.7 2000 20.8
China
India 17.7
USA
8.4 6.8
Indonesia millions Japan
Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.
Diabetes in the World
Year
79.4 2030 42.3
China
India 30.3
USA
21.3 8.9
Indonesia Japan
millions
Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.
The “TOP 10”
244
245
India is declared as the capital of diabetes because approximately 41 million Indians have
diabetes till date and every fifth diabetic in world is an Indian.
65.1 million individuals with diabetes
Diabetes Prevalence-8.56%
IGT Prevalence-2.83%
More worryingly, this number is set to increase to 87 million by 2030, more than 15 million more than
China, which lies in second place.
World Capital of the Diabetes - India
1. Ethnicity
2. Insulin resistance
3. Central obesity
4. Genetic predisposition
5. Urbanization
Diabetes - a global threat
increased risk for developing type 2 diabetes and related metabolic abnormalities compared to
Although the exact reasons are still not clear, certain unique clinical and biochemical
characteristics of this ethnic group collectively called as the “Asian Indian phenotype” is
considered to be one of the major factors contributing to the increased predilection towards
diabetes .
Fast food culture’ and ‘Sedentarinism’- The maindrivers of diabetes epidemic
in India
Fast food culture which has overwhelmed our cities and towns is also a major
driver of the diabetes epidemic.
As a majority of the immigrants in Indian cities depend on these unhealthy
‘junk’ foods, this may be a major factor in the rising prevalence of diabetes
and cardiovascular diseases in urban slums. One point worth emphasizing is
that diabetes can no longer be considered as a disease of the rich. The
prevalence of diabetes is now rapidly increasing among the poor in the urban
slum dwellers, the middle class and even in the rural areas.
The next factor driving the epidemic is what has been referred to as
‘sedentarinism’ or the adoption of sedentary behaviour. Over the past few
decades, a huge number of the working population has shifted from manual
labor associated with the agriculture sector to physically less demanding
office jobs.
With the advent of highly addictive computer and video games, sedentarinism
is now affecting the children and youth as they tend to spend more time in
front of television sets or computers than playing outdoors
Chennai Urban Population Study (CUPS)
It was observed that the prevalence of diabetes was almost three times
higher in individuals with light physical activity compared to those having
heavy physical activity (23.2 vs. 8.1%)
EPIDEMOLOGICAL DETERMINANTS
AGENT FACTORS
Pancreatic disorders
Defective insulin production
Decreased insulin sensitivity
Genetic defects
Autoimmunity
HOST FACTORS
Age
Sex
Genetic factors
Genetic markers
Immune mechanisms
Obesity
Maternal diabetes
ENVIRONMENTAL RISK FACTORS
Sedentary lifestyle
Diet
Dietary fibre
Malnutrition
Alcohol
Viral infections
Chemical agents
Stress
Socioeconomic status
Occupation
Urbanization
SCREENING FOR
DIABETES MELLITUS
Types of screening
Above 30
Family history
Obese
Pregnant women
Premature atherosclerosis
Symptoms of DM
SCREENING METHODS
1. URINE EXAMINATION
2 hours after a meal
Less sensitive, numerous false negatives.
2. BLOOD GLUCOSE ESTIMATION
Standard oral glucose test.
Cornerstone of diagnosis
Fasting and postprandial should be done.
2 hour value after 75mg glucose.
WHO Diagnostic Criteria
DM ≥ 126 ≥ 200
PREVENTION
Stages in the natural history of Diabetes
1.POPULATION STRATEGY
Prevention programmes to eliminate environmental risk factors.
Primordial –nutrition, exercise
2. 2 – 3 am BG once a week