AFMC WHO Textbook Community Medicine

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2. Section 10 : Non Communicable Diseases
209 General Principles & Practice of Healthy Lifestyle RajVir Bhalwar 1180
210 Nutrition and the Diseases of Lifestyle Rajul K Gupta 1193
Ischaemic Heart Disease (IHD) Syn: Coronary Heart
211 RajVir Bhalwar 1201
Disease (CHD); Coronary Artery Disease (CAD)
212 Systemic Arterial Hypertension & Stroke Rajvir Bhalwar 1213
213 Diabetes Mellitus Rajvir Bhalwar 1217
214 Cancers RajVir Bhalwar 1221
Mental Health and Stress Management RajVir Bhalwar 1232
215
Mental Health; Prevention and Management of Mental Stress RajVir Bhalwar, VSSR Ryali 1235
216 Unintentional Injuries R K Khajuria 1239
217 Intentional Injuries (Including Inter-Personal and Domestic Violence) RajVir Bhalwar 1246
218 Chronic Obstructive Pulmonary Diseases R K Khajuria 1249
219 Visual Impairment & Blindness RajVir Bhalwar 1254
220 Hearing Impairment & Deafness RajVir Bhalwar 1256
221 Dental and Oral Health Ramen Sinha 1259
222 Rheumatic Heart Disease Ashok K Verma 1267

3. including health educators.
General Principles & Practice of
209 Healthy Lifestyle
What are the major components of “Lifestyle” : As said
earlier, lifestyle is more of attitudes and behaviours, about
“predispositions”. Thus, there would be a large number of
RajVir Bhalwar components of “lifestyle” which affect health, in the form of
the way we exercise, to sexual mores to habitual hand washing
“….The Japanese smoke a lot and suffer fewer heart attacks before eating meals. However, from preventive point of view,
than Australians or New Zealanders; The French eat a lot of fat the major facets of lifestyle are summarized in Box - 2.
and also suffer fewer heart attacks than Australians or New
Zealanders; The Italians drink a lot of wine and also suffer Box - 2 : The Major Components of Unhealthy Lifestyle
fewer heart attacks than Australians or New Zealanders…..” ●● Lack of physical activity
(Conclusion : Eat, drink, Smoke and enjoy the way Japanese, ●● Faulty dietary habits
French and Italians do; Actually it is speaking English that gives ●● Tobacco use
so many heart attacks to Australians & New Zealanders!) ●● Excessive alcohol intake
With rapid urbanization, industrialization and increasing level ●● Mental Stress
of affluence (the so called “modernization”), the price that the ●● Disregard to personal safety regarding
society is paying is a tremendous load of “Non - Communicable” - Accidents
diseases, also referred to as “Chronic” diseases” and, often, - Personal hygiene
as “Lifestyle Diseases”. The list of major lifestyle diseases is - Promiscuous Sex
displayed in the Box - 1. The issue is a global phenomena and
- Insect Vectors of Diseases
not simply restricted to the developed, rich countries. In the
context of our country, too, the problem of lifestyle and its
The National Scenario : India is experiencing a rapid health
consequent diseases needs to be addressed vigorously by all
transition, with large and rising burdens of chronic diseases,
public health care personnel.
which were estimated to account for 53% of all deaths in
2005. Earlier estimates projected that the number of deaths
Box - 1 : Major “Lifestyle Diseases” attributable to chronic diseases would rise from 3·78 million in
Obesity Heart Disease 1990 (40·4% of all deaths) to 7·63 million in 2020 (66·7% of all
Hypertension Diabetes Mellitus deaths) (1). Many of these deaths occur at relatively early ages.
Compared with all other countries, India suffers the highest
Oral cancer Lung cancer loss in potentially productive years of life, due to deaths from
Breast cancer Colonic cancer cardiovascular disease in people aged 35 - 64 years (9·2 million
Other cancers Sexually Transmitted Diseases years lost in 2000). By 2030, this loss is expected to rise to 17·9
million years - 940% greater than the corresponding loss in the
HIV & AIDS Mental Stress and its sequelae USA, which has a population a third the size of India’s (2).
Osteoarthritis Osteoporosis The estimated prevalence of coronary heart disease is around
Liver Disease Asthma and Bronchitis 3 - 4% in rural areas and 8 - 10% in urban areas among adults
older than 20 years, representing a two - fold rise in rural areas
Road accidents
and a six - fold rise in urban areas over the past four decades.
About 29·8 million people were estimated to have coronary
What is “Lifestyle”
heart disease in India in 2003; 14·1 million in urban areas
“Lifestyle”, in the context of preventive health care, indicates and 15·7 million in rural areas (3). The prevalence of stroke is
the behavioural patterns which we routinely adopt and the way thought to be 203 per 1,00,000 population among people older
we tend to (involuntarily) live our daily life, unless coerced to than 20 years (4).
change by some external stimulus. Lifestyle is thus mainly
Data on cancer mortality are available from six centres across
dependent on psycho - social and environmental factors and, to
the country, which are part of the National Cancer Registry
a smaller extent, on genetic influences. Lifestyle is developed
Programme of the Indian Council of Medical Research (ICMR).
in the form of a set pattern of behaviour, very gradually, over
About 8 Lac new cases of cancer are estimated to occur every
many years, in the way we eat, drink, exercise, use intoxicants,
year. The age - adjusted incidence rates in men vary from 44 per
are predisposed to own health care and personal protection,
1,00,000 in rural Maharashtra to 121 per 1,00,000 in Delhi (5).
sexual practices and so on. Since these behavioural patterns
The major cancers in men are mostly tobacco - related (lung,
are acquired very gradually, changing them becomes a difficult
oral cavity, larynx, oesophagus, and pharynx). In women, the
proposition and needs a lot of persuasiveness as well as
leading cancer sites include those related to tobacco (oral cavity,
persistent approach on the part of the health care providers
oesophagus, and lung), and cervix, breast, and ovary cancer.
Lifestyle diseases or “Non-Communicable Diseases” have common risk factors as listed in Box-2. Thus, by becoming physically
active, eating a healthy diet, avoiding alcohol and tobacco and by managing mental stress, we will not only prevent IHD; we
will prevent IHD, diabetes, hypertension, cancers, road accidents and stroke, since the determinants are common.
• 1180 •

4. India has the largest number of oral cancers in the world, due years to 71·5% in the 51 - 60 year age group (20). Many cross
to the widespread habit of chewing tobacco. - sectional surveys have recorded a high urban prevalence of
India also has the largest number of people with diabetes in the central obesity and overweight (especially when the lower
world, with an estimated 19·3 million in 1995 and projected thresholds recommended by WHO for Asian people are used).
57·2 million in 2025 (6). The prevalence of type 2 diabetes in Though the prevalence of obesity (BMI 30) is usually lower
urban Indian adults has been reported to have increased from than that observed in the western population, the overweight
less than 3·0% in 1970 to about 12·0% in 2000 (7). On the basis category (BMI 25) includes almost a third to half the population
of recent surveys, the ICMR estimates the prevalence of diabetes in every survey. Women and men are equally affected (21, 22).
in adults to be 3·8% in rural areas and 11·8% in urban areas. Small birth size, with rebound obesity in early childhood,
The prevalence of hypertension has been reported to range predicted diabetes and glucose intolerance in adulthood occurs
between 20 - 40% in urban adults and 12 - 17% among rural in an Indian cohort (23).
adults (8). The number of people with hypertension is expected The few available standardised studies of physical activity
to increase from 118·2 million in 2000 to 213·5 million in 2025, revealed low levels in urban areas (compared with rural) and
with nearly equal numbers of men and women (9). in the upper - income and middle - income groups (compared
These advancing epidemics are propelled by demographic, with low - income). Low levels of physical activity have been
economic and social factors, of which urbanisation, reported in 61 - 66% of men and 51 - 75% of women, in urban
industrialisation, and globalisation, are the main determinants. surveys (22, 24). Most surveys have also shown higher mean
The Indian economy is growing at 7% per year. With increasing concentrations of plasma cholesterol in urban population
life expectancy, the proportion of the population older than 35 groups (4·6 - 5·2 mmol/L) compared with rural groups (4·3 -
years is expected to rise from 28% in 1981 to 42% in 2021 (10). 4·6 mmol/L), with a low mean concentration of HDL cholesterol
During the decade 1991 - 2001, the population grew by 18% in (25). The ICMR surveillance project observed that the prevalence
the rural areas and 31% in urban regions (11). Urbanisation and of dyslipidaemia (ratio of total cholesterol to HDL cholesterol
industrialisation are changing the patterns of living in ways 4·5) was 37·5% in individuals aged 15 - 64 years. Even in a
that increase behavioural and biological risk factor levels in relatively young industrial population (20 - 59 years), 62·0%
the population. For these social reasons, the lifestyle epidemic had dyslipidaemia (26). Levels of awareness, treatment, and
is not simply restricted to non - communicable diseases in adequate control are low for hypertension, diabetes, and
our country; the same social changes are leading to other dyslipidaemia, especially in rural areas (26, 27).
forms of lifestyle diseases, related to sexual lifestyle and have With advancing health transition, the poor are increasingly
resulted in an HIV - AIDS epidemic that has reached concerning affected by chronic diseases and their risk factors. Low levels
proportions. of education and income now predict not only higher levels of
An excess risk of death from coronary disease has been observed tobacco consumption, but also increased risk of coronary heart
in men and women of south - Asian origin, by comparison disease (19, 28). Since India’s daily consumption of fruits and
with other ethnic groups, and there is a progressive rise in vegetables is 130 g per person per day, poor people may also
risk from rural to urban migrant environments (12, 13). The have deficiencies of protective phytonutrients. Urban slums in
increased risk of cardiovascular problems noted in Indian Delhi have high rates of diabetes and dyslipidaemia (29).
migrants is a portent of the further rise in risk that Indians Lack of awareness of risk factors and diseases, and inadequate
are likely to experience alongside the developmental transition access to health care, increase the risk of early death or severe
of their country. A high frequency of diabetes, central obesity, disability in such disadvantaged groups. The major socio -
and other features of the metabolic syndrome (especially the economic determinants of unhealthy lifestyle in populations
characteristic dyslipidaemia of reduced HDL cholesterol and are listed in Box - 3.
raised triglycerides) have been reported in migrant and urban World - wide Magnitude of the Problem : Chronic diseases
Indian population groups (14, 15). The INTERHEART study (16) represent a huge proportion of human illness. They include
found that the cluster of nine coronary risk factors identified cardiovascular disease (30% of projected total worldwide deaths
in the global population was also applicable to south Asians in 2005), cancer (13%), chronic respiratory diseases (7%), and
as a group. diabetes (2%). Three risk factors underlying these conditions are
In the past few years, two surveillance systems have been key to any population - wide strategy of control - tobacco use,
established to provide risk factor data from different parts of physical inactivity and obesity. These risks and the diseases
the country (17). In 2002, ICMR, with technical assistance from they engender are not the exclusive preserve of rich nations. An
WHO, established a community - based surveillance system estimated total of 58 million deaths worldwide in a year, heart
involving five centres. The prevalence of tobacco use has been disease, stroke, cancer, and other chronic diseases will account
estimated in the National Sample Survey and the National for 35 million, more than 15 million of which will occur in
Family Health Survey (18). In the Global Youth Tobacco Survey people younger than 70 years. Approximately four out of five
25·1% of the students aged 13 - 15 years reported that they of all deaths from chronic disease now occur in low - income
had ever used tobacco, whereas current use was reported by and middle - income countries, and the death rates are highest
17·5% (19). A national survey in 2002, reported that the overall in middle - aged people in these countries (30).
prevalence of current tobacco use in men and boys aged 12 - We shall discuss the major components of healthy lifestyle and
60 years was 55·8%, ranging from 21·6% in those aged 12 - 18 the methods of addressing them from the preventive angle.
• 1181 •

5. should be ‘Any exercise is good; more the better’ (32 -
Box - 3 : What Socio-Environmental Changes have Led to
35). In fact, people who have not been exercising for
Increasingly Unhealthy Lifestyles in Populations
a long time should be encouraged to start with low
Rapid Industrialisation / Market economy intensity exercises or even by bringing about “life style
Increased global earnings changes” so that they become more active. Coaxing
them to undertake more strenuous exercises from the
Materialism / consumerism
very outset could be counter - productive. Subsequently,
Mechanisation as they progress, they may be encouraged to gradually
Ad - Driven Competitive Food Industry increase the level of exercise intensity.
TV, Cables, VCDs Benefits of Exercise and Diseases Due to
Computers, Internet
Physical Inactivity
It is often thought that physical exercise is a very
Increasing market of tobacco and alcohol, more so driven by ads
good way of reducing the body weight and that is all
Academic competitiveness among children which is good about physical exercise. This notion is
Career Competitiveness correct only to a very small extent which should be
emphasised upon the individuals and communities
Migration towards urban areas
so that they draw the maximum benefits of physical
Loss of traditional “cushion” provided by traditional family life exercise. Alone and by itself physical exercise is not a
Prove your capabilities by pushing the files! Compounded by InfoTech very efficient method of reducing weight. The major
emphasis, if weight reduction is the issue, should be
Lack of Physical Fitness & Physical control on diet. Physical exercise can only be a useful
adjunct. For example, just one average sized slice of bread will
Inactivity give 65 to 70 Kilocalories (Kcal), to burn off which, one would
Substantial progress has been made during the past decades need to go running for a Kilometer. Just four innocuous looking
in scientifically substantiating the role of physical exercise and slices of bread, or a small sized “Samosa” will push in 300 Kcal,
fitness in a number of human diseases and more recently, the which would need 4 kilometers of running/ walking to burn off
role of physical exercise & fitness in positive lifestyle. Indeed, these calories. If one doesn’t do that, these 300 additional Kcal
of all the lifestyle factors, physical exercise seems to be one per day will finally result into an extra 1 kg every month or an
of the most important in relation to health. It has been quite additional dozen of Kgs at the end of a year. Thus, to reiterate,
aptly said that physical exercise is the nature’s panacea for if the major objective is weight loss or weight maintenance,
preventing ill health. proper diet should be the mainstay; physical exercise can be
‘Physical Activity’ and ‘Physical Fitness’ are two distinct used only as a supplementary modality. Notwithstanding the
entities. One may be physically active but may still not achieve above, there are large number of health benefits of physical
a high level of fitness. For instance, if a 70 Kg man walks exercise and fitness, which are over and above the issue of
slowly, covering 8 kilometers in 3 hours, he would burn off weight maintenance, as shown in Box - 4.
almost 550 kilocalories (Kcal); however he may not achieve Epidemiological Evidence - Hazards of Physical
‘fitness’ by such activity, since the ‘Intensity’ is quite low. Inactivity
On the other hand if the same person does a ‘Walk and Jog’
WHO estimates indicate that globally, physical inactivity
schedule, overcoming half the distance (4 km) in half an hour,
accounts for more than one fifth of the IHD, one tenth each
he may burn off only half the numbers of calories, but will
of stroke and breast cancer and one sixth of all colon cancers.
achieve a pretty good level of fitness. The point to be noted is
Physically inactive lifestyle accounts in 3.3% of all deaths (i.e.
that both are important - some work (activity / exercise) needs
1 death out of every 30 deaths in the world can be attributed to
to be performed to burn off calories and, additionally, such
physical inactivity). Physical inactivity also accounts for almost
activities / exercises should be undertaken with reasonable
19 million Disability Adjusted Life Years (DALYs), world - wide.
amount of intensity (vigorousness) so that, in addition to
World wide estimates as per a recent WHO report indicate that,
burning the calories, “fitness” is also achieved. The above point
on a long term average, physical inactivity carries an increased
is important since recent research has pointed out that most of
risk (as measured in terms of RR) of 1.05 to 2.63 for IHD, 1.2
the health benefits of physical exercise (as brought out later in
to 2.89 for hypertension and stroke, 1.08 to 4.31 times for
a separate section) are actually due to the “Fitness” that results
diabetes type - 2, 1.02 to 2.5 for colonic cancer, 1.02 to as much
from the exercise and not from simply burning off the calories
as 5 times for breast cancer and 1.02 to 1.37 for osteoporosis
during such activities (31). For instance, a housewife, during
(36).
the course of her daily chores, or a person playing golf without
carrying the clubs and walking at a slow pace for 2 hours, may In the 1980s and 1990s, various epidemiological studies
burn off substantial amount of calories but may not be able to demonstrated that less intensive physical activity also provides
reap the complete benefits of exercise. considerable health benefits. The focus has therefore shifted
now, to advocate, for the general population at large, to take to
However, for those who are not exercising at all or else cannot
moderate intensity exercise by all adults and children, as brisk
exercise at moderate intensity levels even mild exercises will
walking (5-6.5 kmph), recreational cycling and recreational
help. For planning a physical exercise program, the dictum
• 1182 •

6. Box - 4 : Health Benefits of Physical Exercise & Fitness
Helps keeping body weight in check.
Increases the action of insulin hormone, thereby increasing the insulin sensitivity and the peripheral utilization of glucose,
thus protecting against Insulin Resistance Syndrome (Syndrome X; Metabolic Syndrome) and NIDDM (Type-2 diabetes), both
major risk factors for IHD.
Has a preferential action in mobilizing the fat depots, particularly the “Visceral” (Intra abdominal, peritoneal) fat. By
preferentially mobilizing this dangerous type of accumulated fat, physical exercise protects against dyslipidemias, IHD &
NIDDM.
Has a specific role in altering the lipid profile in a healthy fashion. Various studies have shown that the HDL levels are much
higher while the triglycerides, LDL and Total cholesterol levels are much lower, among those who exercise regularly.
Is associated with lowered levels of systolic and diastolic blood pressure, thereby protecting against hypertension.
Has cardio-protective effect. Besides the improvements in insulin sensitivity, blood pressure, lipid profile and visceral fat
deposition, physical exercise exerts its cardio-protective role by opening up the collateral blood vessels; increases the stroke
volume and maximal ventilatory capacity; reduces myocardial oxygen demand at a given level of work; reduces fibrinogen
levels, platelet aggregation and tendency of thrombus formation.
Brings about a reduction in the level of anxiety and stress and induces a sense of confidence and well-being. To some extent, this
effect is believed to be brought about by the release of “beta endorphins “which are natural occurring, opiate-like chemicals.
Tones up muscles and increases flexibility, thus protecting from injuries and falls.
Helps in maintaining adequate bone mass density, thereby protecting from osteoporosis and its complications.
Protective against cancers of colon, prostate and breast.
Is of use in prevention as well as in rehabilitation of low backache.
swimming. In addition, the focus has also shifted to inculcate “tummy trimmer” and there is none else.
healthy lifestyle, by increasing activity levels in all the four The Exercise Program : A physical exercise and fitness
‘domains’ of life viz., at workplace, in transport, at home and schedule should be incorporated into the daily lifestyle. It
during recreation time. needs to be emphasized that such program does not include
Does past physical activity / fitness help ? : This aspect only walking or jogging or only weight - training. An optimum
needs to be clearly understood by all medical personnel and physical fitness program should cater to three major facets of
explained to the community members. There is enough evidence physical fitness, viz, Endurance (Stamina : Cardio - respiratory
to indicate that the various health related benefits of physical efficiency); Muscular Strength; and Flexibility.
exercise are always due to “current” physical activity and not Endurance : It is the capacity to undertake sustained aerobic
“past” activity. Thus, for one to draw the benefits of exercise, physical exercise using a high proportion of maximal oxygen
one should continue to be active; the benefits will occur only as uptake. The ideal means of improving endurance is by
long as one continues to be active. Physical activity in the past undertaking sustained aerobic training at the near maximal
does not seem to help - one may have been an international level, which a person can tolerate. Gradually, with continued
level athlete during one’s heydays, but that does not protect if training, at near maximal level, the maximal aerobic capacity
one becomes inactive later in life. increases, i.e. the person increases the ‘Stamina’. Concurrently,
Does “Spot - reduction - exercise” works ? : Often, obese with increase in stamina, the level of physical fitness increases
people, especially those with abdominal obesity are led to and the person starts reaping more and more health benefits
believe that abdominal strengthening exercises (as ‘sit ups’ or of physical exercise, as have been cited earlier. Any endurance
equivalent gymnasium gadgets) will “burn off” the fat around training program has three distinct components, viz. :
the abdomen. It needs to be explained that for burning off the Frequency : This is measured by the number of sessions per
fat “around” (actually inside) the abdomen, one has to burn week that are devoted to endurance training. Ideally, there
off overall calories and restrict the diet. Abdominal exercises should be 4 to 5 sessions per week; the minimum recommended
may only slightly help by ‘toning’ up the abdominal muscles is 3 per week.
but the energy spent in such exercises will be too little to have
Intensity : Intensity is measured by the ‘strenuousness’ of the
any impact on overall weight loss. It needs to be emphasised
exercise. We shall deliberate on the measures of strenuousness
that ‘sit ups’ do not, by any chance, push away the fat from the
a little later in a separate section. In general, it is recommended
abdomen. Vibrator belts and massage systems used over the
that to achieve the maximum gains, the physical exercise
abdomen are equally unscientific. The best (and generally the
should be of at least “moderate” intensity. As one becomes
only) way to lose fat from the “tummy’ is to do brisk aerobic
more and more fit, one could (and should) aim to undertake
exercise and cut down on dietary calories - this is the only
• 1183 •

7. more strenuous (high intensity) exercises. 0 to 20, as per Box - 5.
Duration : This is the time spent on exercise, in a given session. To start with, the exercise should be at a level of ‘12’score,
In general, during a session, approximately 60 minutes should i.e. the subject feels that the exercise intensity is between
be devoted for mild intensity exercises, 40 to 45 minutes for “Light” and “Somewhat hard”. This level, in most subjects, is
moderate intensity activities, while 20 to 30 minutes and 10 approximately equal to 60% of MxPHR. As fitness improves,
to 15 minutes are adequate for high intensity and very high the subjects should increase the intensity of exercise so that
intensity exercises, respectively. It also needs to be emphasized they are finally working at a level of 16 i.e. the perception
that the above suggested plans are only recommendations about the exercise they are undertaking is that it is more than
based on overall consensus and evidence. Ultimately, the ‘hard’ but less than ‘Very hard’. This level usually represents
program has to be tailored to meet the individual / community approximately 85% of MxPHR in most subjects.
needs. Measuring exercise intensity using Metabolic Equivalents
Measuring the level of intensity : Out of the 3 components (METs) : Recently the concept of METs is being increasingly
of endurance training, while measuring the duration and used to prescribe the level of exercise for individual subjects. 1
frequency is quite straightforward, measuring the various levels MET is actually equal to a level at which a person will spend 1
of intensity often gets shrouded with confusion, particularly Kcal energy per kg body weight per hour and this level usually
at the level of the user. A summary of various available corresponds to the resting stage. This level also corresponds to
guidelines to measure intensity of exercises and the overall an oxygen uptake level of 3.5 ml / kg body weight per minute
recommendations are given in the succeeding paragraphs. (37). As the level of MET increases, the intensity of exercise
Measuring exercise intensity on the basis of heart rate : increases.
One of the oldest and quite widely used measure of exercise Thus, a person weighting 70 kg at rest, i.e. at activity level
intensity is based on “Maximum Permissible Heart Rate of 1 MET will spend 70 K cal per hour while the same person
(MxPHR)”. The MxPHR for any individual is calculated as 220 exercising at the level of 6 MET will be spending 6x70 = 420
( - ) Age in years. For example, for a person aged 50 years, the K cal in an hour. Moreover, the level of 6 MET will correspond
MxPHR will be 220 ( - ) 50 = 170 beats per minute. In general, to “moderate” level of exercise intensity. Thus, MET have dual
during an exercise session, this limit should not be exceeded. If advantage, in that in a single value they gave an indication of
a person is exercising at 50% to 60% of his MxPHR, it is taken both, the amount of energy expenditure as well as the intensity
as Low intensity exercise, 60% to 70% is Mild intensity, 70% to of exercise. According to general agreement, the MET levels
80% is Moderate intensity, while 80% to 90% and 90% to 100% corresponding to various intensity levels of exercise are shown
are taken as Severe intensity & Very severe intensity exercises in the Box - 6 and the METs for common physical exercises are
respectively. shown in the Box - 7 (37, 38). For example, let us say a subject
For example, the MxPHR for a 50 years old person would be weighing 70 kg is exercising by cycling at a speed of 16 km/h.
170. If the heart rate achieved by the person during a session He cycled for 8 km in half an hour. He will be exercising at 7
of exercise is 50 to 60% of 170 (i.e. 85 to 102 beats per minute) MET which is the upper limit of ‘moderate intensity’, rather
he is exercising at low intensity level. Accordingly, for this almost touching the level of high intensity exercise. During this
person, the heart rate levels from 103 to 119, 120 - 136, 137 half an hour, he will burn off (70 x 7 x ½) = 245 K cal of energy,
- 153, and 154 to 170 or even more, would qualify for mild, this will be equivalent to burning off 30 grams of body fat.
moderate, severe intensity and very severe intensity exercise
respectively. Box - 6 : MET Levels for Different Exercise Intensities
How to measure the heart rate achieved during an exercise Usual MET level
Level of exercise Intensity
session. A practical method is as follows : Immediately on Men Women
completion of an exercise session and definitely within 5
seconds of completion the individual starts counting the radial Rest 1 1
pulse, for 10 seconds. The first beat is counted as zero. The Very low intensity 1 - 1.5 1 - 1.2
number of beats so counted in 10 seconds is multiplied by ‘6’ Light 1.6 - 3.9 1.2 - 2.7
to obtain the heart rate achieved during exercise.
Moderate 4 - 5.9 2.8 - 4.3
Measuring Exercise intensity according to Borg’s scale of
“Rating of Perceived Exertion (RPE)” : The scale has the Heavy 6 - 7.9 4.4 - 5.9
advantage of simplicity and can be used by anyone in the Very Heavy 8 - 9.9 6.0 - 7.5
general community. The scale rates the intensity of exercise, as
Unduly heavy >10 > 7.6
perceived by the person himself, on a visual analogue scale of
Box - 5
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Almost Nil Somewhat Excruciatingly
Nil Very, Very Light Quite Light Light Hard Very Hard
exercise Hard Hard
• 1184 •

8. Box - 7
Activity MET level Activity MET level
Walking 4.8 km/h (slow pace) 3.0 Badminton leisure 3-6
Walking 5.4 Km / h (slow pace) 3.6 Badminton match 7-9
Walking 6 km / h (brisk pace) 4.3 Dancing social 3-7
Walking 6.4 km/h (brisk pace) 4.6 Dancing aerobic 6-9
Walking 7 km / h (very fast pace) 6.0 Circuit weight training 8-9
Jogging 8 km/h 8.7 Roller skates 5-8
Running 9.6 km/h 10.0 Squash leisure 8 - 10
Running 12 km/h 12.5 Squash match 11 - 12
Bicycling 16 km/h 7.0 Tennis leisure 6-8
Swimming 20 mtr from 6.0 Tennis match 9 - 10
Swimming 40 metre from 12.0 Volleyball 3-6
Golf, walking 4.0 Basket ball match 7 - 12
Golf, walking carrying bag 5-6 Basket ball non game 3-9
Recommendations for Physical Exercise the calories to be burnt off, the duration (generally to indicate
Recommendations based on calorie expenditure : The “how long during a given session”) and frequency (to answer
minimum amounts of calories to be expended in programmed “how many times in a week?”) are also equally important. The
physical exercise by the general population have been recently general guidelines are set out in Box - 8.
forwarded by CDC Atlanta and American College of Sports The good news is that the above mentioned exercise can be
Medicine. These recommendations state that every adult “accumulated” i.e., it is not necessary to undertake a given
should spend at least 200 Kcal per day (i.e. 1400 k cal in a session of exercise in 60 minutes at a stretch, Rather, 2 session
week) by physical exercise and this should be undertaken on of 30 mts each or even 3 session of 20 mts each over the day
“most days” (Preferably all days of a week) (39). This could be may also be good enough. It is generally recommended that for
achieved by having a half - hourly session every day of brisk achieving weight loss and subsequently maintaining it, people
walking. The point to be noted in that these are the minimum should accumulate 60 to 80 minutes of moderate intensity
recommendations and more exercise (in terms of more time or exercise every day. Although, to the general public, devoting
more intensity) is always better. 60 to 80 mts to exercise may sound a bit too much, even
More comprehensive recommendations on adequate calories to impossible; however, once we emphasize on them that these
be spent have come from large scale studies among Harvard 60 to 80 mts of exercise can be accumulated by undertaking
alumni and British civil servants. These recommendations in frequent, short sessions, things seem to become manageable
general suggest that to obtain the maximum health benefits for most individuals.
of physical exercise, individuals should spend about 2500 k Most experts agree that the best schedule is to have 4 to 5
cal per week through regular, (and at least moderate intensity) sessions per week, of moderate intensity exercises of 5 to 8
exercises. To spend these 2500 calories, an average person MET level, with each session lasting for 45 to 60 minutes.
weighing about 65 kg will need to walk or jog about 35 kms in This will provide recesses for recovering, as also improve
a week or roughly 5 kms every day. compliance, since the exercise - off days (2 - 3 per week) leave
Comprehensive Recommendations Based on Intensity, the participants with ample opportunities for other pursuits
Duration & Frequency : Besides the intensity of exercise and and social obligations. The optimum linear distance to be
Box - 8
Recommended
Target Heart Recommended
Kcalorie spent Frequency
Intensity of Exercise rate as % of Duration (Mts
per mt (sessions
MxPHR per session)
per week)
By Borg’s
By description By MET level
RPE scale
Low Moderate 4 - 5.9 13 70-80% 5 - 7.4 60 - 75 5-6
High Moderate 6 - 7.9 16 80-90% 7.5 - 9.9 45 - 60 4-5
Heavy 8 - 9.9 18 90-95% 10 - 12.4 20 - 30 3-4
• 1185 •

9. covered by brisk walking or jogging in a week is recommended by a reduction of about 5 beats per minute in the exercise heart
to be about 32 km (20 miles). rate at that intensity level of exercise or by a decreased felling
Resistance Training : Weight training and isometrics are often of exertion on the RPE scale or by ability to undertake higher
grouped under a general category of “resistance training”. level of MET exercises), the subject moves to phase - 2, wherein
Current opinion is to encourage mild weight training as a he/she undertakes exercises at MET level of 6 to 7 (see table
part of exercise - fitness program. It is recommended that of MET values, e.g., brisk walk - jogging, covering 7 to 7.5
mild weights (20 - 30 pounds for men and 10 - 20 pounds km in an hour) for about 30 to 45 minutes every session, and
for women) may be used, exercising all major muscle groups maintaining at this level for 4 - 6 weeks. In the last phase, the
(chest, back, shoulders, arms, forearms, glutei, thighs and subject again gradually works up, over 4 - 6 weeks to a level
legs) keeping about 3 sets for each major muscle group and 10 of 8 to 9 MET (Jogging, covering 7.8 to 8.5 km per hour). The
- 15 repetitions in each set. Two or three weekly sessions of the overall recommendations are summarised in Box - 9.
above schedule are recommended. Care should be specifically Bringing about “Physically Active” Lifestyle Changes
taken not to indulge in “valsalva’s maneuver” (breathing “Structured Physical Activity” programmes, as have been
forcefully against closed glottis, as happens while straining at discussed till now, are only one side of inculcating physical
stools), while undertaking resistance training and even while activity among individuals and communities. What is equally
undertaking aerobic exercises. important is to educate and motivate persons and communities
Flexibility : Gentle stretching exercises as forward bending, side to inculcate a “physically active lifestyle” so that physical
bending and calf stretch are ideal. Yoga exercises are excellent activity gets incorporated in each and every action of life.
for flexibility. It is best to incorporate flexibility exercises as Emphasis should not only be towards incorporating “exercise
part of overall exercise plan, during the initial “warming up” sessions” in the daily time table or advising gymnasium
for 5 to 10 minutes and the final “Cool down” phase for another activities. Equal emphasis should be placed on changing the
5 to 10 mts. overall lifestyle from one of luxury and sloth to one of physical
Progressing on the exercise program : It is generally advisable activity at every possible moment, integrating physical activity
to progress in three phases. In the first phase the subject starts into lifestyle with short, frequent bouts of mild or moderate
at a low level of about 3 MET (as walking 4.8 Kms in an hour) intensity exercise. This seems to provide the best answer and
and over the next 4 - 6 weeks, gradually working up to a level of can be even better than structured exercise programmes. Some
4 - 5 MET (eg., brisk walking at speed of 6.5 to 7 km per hour) examples of positive lifestyle habits are shown in Box - 10.
for 30 mts in a session, and having 4 - 5 such sessions per The principal goal of active lifestyle is to increase energy
week. This level should be maintained for 4 - 6 weeks. Once the expenditure without concern for the intensity of activity. The
subject is comfortable at this level for 4 - 6 weeks (as evidenced basic principle is that very mild, even inapparent increases
Box - 9 : Key Messages to be Given to Individuals & Communities
There are two clear components : firstly, a formal, structured exercise and fitness programme; secondly, inculcating “physically
active lifestyle” as a part of day to day life. Both are equally important.
Structured Program
Develop & meticulously follow a structured programme. Include all the three components (Endurance, Strength & Flexibility)
Endurance
- Most minimum : Brisk walking at least 2 miles (3.2 Km) every day or at least most days a week, covering 3.2 Km in 30 to 35
mts.
- Ideal : Exercise at 6 to 8 MET (e.g. walking / jogging covering 7 to 8 Km in an hour), 45 to 60 mts per day, every day or at
least 4 to 5 days a week.
- If you can exercise at even higher intensity or longer duration, the better it is.
- Instead of walking or jogging, substitute any other aerobic exercise (cycling, swimming, sports, etc.) which makes you
happy.
Strength : Advisable to undertake resistance training with light weights (10 to 30 lbs) exercising all major muscle groups 2 or
3 times a week.
Flexibility : Undertake 5 to 10 mts of Yoga or other gentle stretching exercises before and after an exercise session.
Physically Active Lifestyle
Develop the attitude to be physically active always. Use stairs instead of lift, walk instead of driving, Remove the remote
controls of TV, Fetch a glass of water yourself rather than asking your orderly, walk to your colleague’s office and discuss rather
than using the intercom, park your car at the farthest, and so on.
Ensure Compliance
Biggest hurdle in structured physical exercise or active lifestyle program is that you tend to lose out on compliance. Watch
out.
• 1186 •

10. (as going out for shopping rather than ordering for grocery Box - 11 : Motivating the Community Members & Subjects
on telephone) may make much difference. In fact, emphasis : Driving away any Excuses for not Exercising
should be on promoting low - intensity, leisure pursuits, which
are seen as pleasurable (as walking a dog, gardening, etc.) Lack of time
rather than simply stressing on occasional or periodic vigorous ●● Take several spurts of 10 mts each, of exercise during
exercises. Similarly, “structured exercise” should also be lunch, tea time & dinner time.
encouraged but should not be presented as one which requires ●● Park farthest away in the parking lot.
●● Turn off TV/computer for at least 30 minutes and exercise
excessive physical effort; target should be on activities that can
instead.
be easily incorporated in daily schedule.
Bad weather
Box - 10 : Changing the Daily Lifestyle : Examples ●● Get a “treadmill” for home.
●● Try an exercise video at home.
Take stairs instead of the lift; make several trips. ●● Do stationary jogging / walking.
Put away the remote control of TV. Holidays
Stand while answering the telephone. ●● Put a lot of effort into cleaning your house.
●● Wash your car/two wheeler
After every half an hour of office job, go out and walk in the ●● Go shopping and carry your packets of grocery.
corridor for 3 minutes. ●● While going for shopping, park your vehicle far off, so
Park your car at the farthest possible point. that you walk for at least 2 to 3 Kms.
Take a longer way around, to walk to the due destination. Feeling Fatigued
●● Remind yourself that exercise will give you more energy
Don’t use servants / children for “fetch-it’ jobs; do them
●● Try and “force” yourself for just 10 minutes of walk.
yourself. Once you start off, chances are that you with continue
Go out for entertainment (e.g. see a Movie in the theatre) for longer.
rather than sitting before the TV.
Based on the National Family Health Survey - 2 age specific
Wash / mop your car yourself.
data, it is estimated that in the thirty plus age group, smoking
Clean your house on holidays. prevalence among men is 41.2%. Further, 35.4% of men and
18.2% of females use chewing tobacco in this age group.
Practice Advocacy rather than Health Education : The effort
The prevalence of tobacco use among the youth has been
of all health care professionals, whether in public health or
surveyed by the Global Youth Tobacco Survey (GYTS) supported
in clinical domains, should be not simply to educate the
by CDC and WHO. GYTS is a tobacco specific survey to track the
community / individuals / patients, but rather to socially
prevalence of tobacco use among 13 - 15 year age group school
market the concept of physically active lifestyle. Such advocacy
going students. GYTS has been conducted in different states
becomes especially important when dealing with high risk
of India in the period 2000 - 2004. As per this survey, 17.5%
groups or with individual persons or patients.
of 13 - 15 year old students are using tobacco in some form.
Role of physicians in improving the lifestyle of subject/ In many states alarmingly high prevalence of use of tobacco
patient : Physicians may play a catalytic role in improving products among the school - going youth has been reported.
the lifestyle of people they come in contact with. An initial North Eastern states like Nagaland (63%), Manipur (46.7%),
counselling session of 5 to 7 minutes by the physician followed Sikkim (46.1%) have reported highest prevalence of tobacco use
by periodic telephone calls or personal interview sessions to among school students.
keep up the motivation have been shown to be quite successful.
As a result of collaborative efforts of Ministry of Health and
Some motivatory examples to be conveyed to the community
WHO, the National Tobacco Control Cell was set up in February
members are shown in Box - 11.
2001 to provide impetus to the tobacco control efforts and to
Diet & Lifestyle coordinate these activities at the national level.
Detailed deliberations have been made regarding diet, nutrition The National Tobacco Control Cell assists in development of
and lifestyle diseases in the next chapter. comprehensive anti - tobacco public awareness plans to provide
health education among the masses; capacity building among
Tobacco & Lifestyle NGOs working in the field of tobacco control; establishment
Tobacco is one of the major causes of deaths and disease in India, and strengthening of tobacco cessation centers and providing
accounting for over eight lakh deaths every year. The variety of key technical inputs on research and policy issues related to
forms of tobacco use is unique to India. Apart from the smoked tobacco. The Cell has been recognized as an innovative approach
forms that include cigarettes, bidis and cigars, a plethora of towards effective tobacco control, which can be replicated by
smokeless forms of consumption exist and they account for other countries.
about 35 percent of the total tobacco consumption. Tobacco has been proven, beyond doubt, to be associated with
According to the National Family Health Survey - 2, the a large number of serious diseases (see Box - 12). In fact, the
prevalence rate among males for chewing tobacco was 28.3% single most important lifestyle factor as a risk for diseases
and for smoking tobacco, 29.4%. For females, the corresponding is tobacco use. Globally, tobacco accounts for 27.8% of all
prevalence rates were 12.4 and 2.5 percent respectively.
• 1187 •

11. cardiovascular deaths, 13.6% of all lung cancer deaths, 6.6% of while the rest is in the form of country liquor. People drink at
upper aerodigestive cancer deaths, 6.6% of other cancer deaths, an earlier age than previously. The mean age of initiation of
27.2% of deaths due to COPD and 12.8% of other respiratory alcohol use has decreased from 23.36 years in 1950 to 1960
deaths. Worldwide, tobacco use causes 4.83 million deaths, to 19.45 years in 1980 to 1990. India has a large proportion
loss of 59 million DALYs and estimated economic loss of $ of lifetime abstainers (89.6%). The female population is largely
200 billion per year. The medical recommendations regarding abstinent with 98.4% as lifetime abstainers. This makes India
tobacco are very clear - individuals and communities should an attractive business proposition for the liquor industry.
completely give up use of tobacco. In public health practice, Changing social norms, urbanization, increased availability,
all functionaries should endeavour to educate and motivate high intensity mass marketing and relaxation of overseas trade
individuals and communities regarding the adversities rules along with poor level of awareness related to alcohol has
associated with tobacco use and to give up tobacco. In addition contributed to increased alcohol use. Taxes generated from
to educating and motivating, we must use all possible means to alcohol production and sale is the major source of revenue in
convince the community leaders, peers, politicians, and social most states (Rs.25,000 crores) and has been cited as a reason
groups to exert influence in this regards, with a view to obtain for permitting alcohol sale. Four states - Gujarat, Mizoram,
the following ends : Manipur and Nagaland - have enforced prohibition. Profile of
●● Make availability difficult (e.g. banning the sale of tobacco clients in addiction treatment centers in 23 states (including
products in major markets, near educational institutions, states with prohibition) showed that alcohol was the first or
in hotels / restaurants, etc). second major drug of abuse in all except one state. The annual
●● Make the smokers feel that his smoking habit is loss due to alcohol was estimated to be Rs.70,000 to 80,000
“undesirable” (e.g. ban smoking in public places, transport million.
systems, auditoria, offices, meetings / gatherings, parties; Habitual alcohol use is another major lifestyle factor associated
create separate restricted areas as earmarked smokers with ill health and a large number of serious diseases, as
rooms for people to smoke). depicted in Box - 13.
●● Exerting influence through influential socio - political
groups Box - 13 : Alcohol Related Diseases
●● Setting of personal example by influential persons as
Hypertension & Stroke (RR 1.4 to 4.1, depending on intake)
doctors, sports and theatre personalities, etc.
●● Enforcement of relevant laws. IHD (mild consumption may be protective (RR = 0.68); heavy
consumption carries risk (RR = 1.33)
Box - 12 : Tobacco Related Diseases Road Accidents
IHD (RR 1.28 to 1.78) Obesity
Stroke (RR 1.17) Diabetes Mellitus type - 2
Lung cancer (RR 12 to 24) Cancers : Female Breast Cancer (RR 1.14 to 1.62); Oral Cancer
Oral cancer (RR 6.95 to 7.87) (RR 1.45 to 5.39);Other cancers (aerodigestive tract, stomach,
Liver Cancer (RR 1.40) pancreas, kidneys, bladder) (RR 1.8 to 4.93 depending on
intake and site)
Cancers of upper aerodigestive tract
Liver disease (RR 1.2 to 13 depending on intake) (cirrhosis,
Peptic Ulcer increased susceptibility to liver infections)
COPD Pancreatitis
Buerger’s Disease Degenerative neurological diseases
Hypertension Social and emotional problems
Amblyopia Psychiatric problems and dependence
Lack of efficiency, productivity and organizational issues.
Alcohol
62.5 million alcohol users are estimated in India. Per capita Besides the diseases, alcohol has additional social and
consumption of alcohol increased by 106.7% over the 15 - year emotional problems, and disrupts family and organizational
period from 1970 to 1996. Due to its large population, India health. A WHO report indicates that alcohol use accounts
has been identified as the potentially third largest market for 3.2% of all global deaths and 4% of all global burden of
for alcoholic beverages in the world which has attracted the diseases; it also accounts for 3.5% of all DALYs lost due to
attention of multi national liquor companies. Sale of alcohol all causes. What is even more concerning is the recent trend
has been growing steadily at 6% and is estimated to grow at wherein lay magazines tend to put across a conveniently
the rate of 8% per year. About 80% of alcohol consumption is distorted version of the medical research findings, which tend
in the form of hard liquor or distilled spirits showing that the to indicate that moderate drinking is good for health. This is,
majority drink beverages with a high concentration of alcohol. in fact, an issue which all public health persons would need to
Branded liquor accounts for about 40% of alcohol consumption counter when talking to individuals and communities. While
• 1188 •

12. it is agreed that “moderate” alcohol intake may be associated quality of life and lowered productivity, the world over. It is
with lower HDL - cholesterol levels and lower IHD mortality, therefore a priority area for all public health systems and
the fact also remains that continued alcohol intake, even in functionaries to develop and implement programs and strategies
mild to moderate quantities, is associated with a number of to combat these major ill - health issues. The following are the
other diseases like road accidents, various cancers, obesity suggested which can be adopted for this purpose.
and hypertension. Secondly, it is quite difficult to maintain Tobacco and Alcohol control issues can be considered together
“moderation” - many of those who are initially moderate may from the preventive point of view since both are highly
become heavy drinkers gradually. Thirdly, there are various addictive substances, are used by a large proportion of human
other more healthy methods (as brisk, regular physical population, and are liable to cause a wide variety of serious
exercise) rather than drinking, to increase the HDL levels. All diseases. The preventive strategy should focus on two levels,
these aspects should be emphasized on the clientele. viz., firstly, the national / large community level and, secondly,
The relationship between even mild drinking and obesity (with at the individual / family level.
all the consequent ill health effects of obesity) is quite logical, Steps at the National / Large Community Level : The
as depicted in Box - 14. In addition, even two small pegs may approach would include a combination of three strategies,
raise the blood alcohol level beyond the legally acceptable in viz. Information, Education and Communication (IEC) steps,
India (30 mg %), and may interfere with the protective reflexes, Statutory (legal or regulative) steps, and Fiscal steps, as
causing road accidents. The hazards of alcohol use should follows :
be well communicated to our clientele and they should be
IEC Steps : These would include the following
motivated to give up alcohol. The recommendations should
be: Developing a nation wide educational strategy and
●● There is nothing like medically prescribed or medically program : A comprehensive policy and programme should
encouraged drinking to get good health; with all its well be developed by nations / states for informing the community
documented resultant diseases, alcohol should not be members regarding the health hazards due to tobacco and
used. alcohol, the seriousness of these diseases and regarding the
●● However, despite the above exhortation, if somebody still potential methods of prevention. Educational programs should
decides to drink, he or she may do so provided there is involve the departments of advertising and audio - visual
no other risk factor (Obesity, Diabetes, hypertension) and media and those concerned with information and broadcasting.
provided one drinks only in “moderation”. The guidelines Educational messages should be adequately pilot tested and
for “moderation” are in Box - 15. should be presented on various channels of mass media, not
●● Besides restricting to moderation, adhere to the following only on governmental but also private channels as well.
principles : firstly, never drive after drinks (even after very Counter - Advertising (Counter - Marketing) Campaigns :
mild drinking); secondly, try not to drink on two consecutive Experience in developed countries has shown that proactively
days; thirdly, try not to drink in daytime; and, fourthly, conducted educational and advertising campaigns to highlight
drink along with food and not on empty stomach. the seriousness of consequences of these substances can actually
help a lot in increasing the proportion of population who would
Box - 14 : Alcohol even in mild quantities, promotes give up their use and reduce the proportion of persons who take
obesity by : up smoking. The strategy is, in fact, to counter the advertising/
Providing “blank” calories - each gram gives 7 Kcal; I small marketing campaigns which are carried out by various liquor/
peg gives 70 Kcal, equal to running 1 Km! tobacco companies and under the influence of which a large
number of young people actually initiate their smoking habit.
Promotes overeating It has also been seen that taking the help of prominent public
Desire to eat rich, fattening food personalities as cine stars and sports - persons may be of
further help in this direction.
Reduces desire of physical activity
School and Youth based IEC programs : The persons who
are most at risk of initiating the tobacco and alcohol habit are
Box - 15 : Defining “Moderate” Drinking teenagers. It is therefore very logical that educational programs
A “unit” of alcohol is defined as equivalent of 10 grams pure be developed, targeting these adolescents in the schools as well
ethanol. as at other youth forum as youth festivals, sports functions,
This will be equal to 1 small peg of hard drink or 100 ml of etc.
Wine or half a bottle of Beer. Quitlines / Helplines : Experience in developed countries has
provided evidence that developing telephonic helplines may
Moderation means maximum of 3 units in a day for men
be quite helpful in reducing the prevalence of smokers and
(and 2 units a day for women)
increasing the duration of cessation. Such telephonic helplines/
quitlines may be part of governmental effort or NGO effort and
The Principles of Public Health Approach for
are designed to provide total assistance to the smoker / alcoholic
Preventing Alcohol and Tobacco Use
who desires to quit smoking, maintain a state of cessation as
As would be apparent from the facts mentioned above, tobacco well as for persons who want education and assistance for not
and alcohol use a major cause of diseases, ill health, reduced initiating tobacco use habit.
• 1189 •

13. Fiscal Measures : Increasing the prices of tobacco and alcoholic include the following :
products definitely reduces the proportion of persons who use ●● Printing of statutory warnings on bottles of alcoholic
these substances; particularly, lesser number of adolescents are drinks
able to initiate these habits. This has been shown in a number ●● Promulgation of “dry state” order by certain state wherein
of countries and has been (privately) acknowledged by tobacco consumption of alcohol is totally banned, except for those
companies. Public Health policy makers should suggest to the having permit to drink
governments to consider an increase on excise on raw material ●● Testing of motor vehicle drivers for breath test and alcohol
and increased taxation on finished product. level in blood. The upper limit for safety in driving, as far
Legislative and Regulatory Measures : To back up as statutory limits in our country are concerned are 30 mg
the educational and fiscal steps, the governments and per 100 ml of blood.
communities would need to develop legal provisions, so as to Steps at the Family and Individual Level : These are directed
make availability of tobacco and alcohol difficult to consumers to educating, motivating and supporting the individuals and
as well as to ensure that users of these substances do not families for, firstly, not initiating the tobacco and alcohol habit
harm the other members of their family / community due to and, secondly, to give up the habit. The following steps are
this habit. In general, the legislative measures focus on the documented to be beneficial :
following provisions : ●● Educating and motivating the family members, especially
●● Printing of statutory warnings regarding the fact that the spouse and parents.
alcohol / tobacco is bad for health, on the packets of ●● Enrolling “peer groups” as religious teachers, school
tobacco/ alcoholic products. teachers, etc., in motivating and playing role model for the
●● Clean indoor air laws and smoke free zone policies, community.
including prohibition of use of these substances in public ●● Developing support groups as “alcoholics anonymous”
places, as railways, airlines and other transportation groups and informing the community members about their
systems, offices, common rooms, restaurants, and such location, ways to contact them and the help that they can
other public places. provide.
●● Prohibition of sale of these substances to vulnerable ●● Pharmaceutical measures as disulfuram for alcohol
groups, especially children and adolescents. cessation and nicotine patches / tablets or bupriopion for
●● Ban on advertisements on promotion of tobacco products. tobacco cessation. However, these measures should be
In our country an extensive law has been promulgated used under medical supervision.
starting with the Cigarettes (Regulation of production, supply Summary
and distribution) Act of 1975 which specified the printing of
statutory warnings on all cigarette packets. Subsequently, With “modernization” there is tremendous increase in “Non -
the statutory provisions were enlarged with the promulgation Communicable” diseases referred to as lifestyle diseases and
of “The cigarettes and other tobacco products (prohibition of this issue is a global phenomenon. “Lifestyle”, in the context
advertisement, regulation of trade and commerce, production, of preventive health care, indicates the behavioural patterns
supply and distribution) Act 2003. The act declares that it is which we routinely adopt. The National Scenario estimated
expedient in public interest that the Union should take control chronic diseases to account for 53% of all deaths in 2005.
of the tobacco industry. The act prohibits smoking in public Mortality due to chronic diseases is expected to rise from 40%
places and provision of a separate smoker’s room in restaurants of all deaths in 1990 to 67% of all deaths in 2020. Prevalence
having seating capacity of 30 or more and in airports (From 02 of coronary heart disease is around 3 - 4% in rural areas and
Oct, 2008, i.e. the birthday of the father of the nation, the Govt 8 - 10% in urban areas among adults older than 20 years.
has extended the promulgation by imposing a blanket ban on Data on cancer mortality estimates about 8 Lac new cases of
all public places). The act also lays down a total prohibition on cancer every year. The major cancers in men are mostly tobacco
advertisements of cigarettes and other tobacco products. The act - related. In women, the leading cancer sites include those
prohibits sale of tobacco products to any person aged less than related to tobacco, and cervix, breast and ovary cancer. Further,
18 years and lays down restrictions on trade and commerce in India also has the largest number of people with diabetes in
and on production, supply and distribution of cigarettes and the world. World - wide estimated deaths due to cardiovascular
tobacco products including printing of statutory warnings on disease is 30% of projected total worldwide deaths in 2005,
the packets of these products, the letter size, language and cancer (13%), chronic respiratory diseases (7%), and diabetes
other specifications of these warnings, and also the powers (2%). Components of healthy lifestyle and addressing them
of searching the premises and confiscation under this act, as through preventive angle. One of the very important facets of
well as the punishment and appeal under this act. The detailed healthy lifestyle is Physical Fitness & Physical activity. Some
rules (2004) for implementation of the act have been published work (activity / exercise) needs to be performed to burn off
vide Govt of India Gazette No. 200 dated 25 Feb 2004. calories and additionally, such activities / exercises should be
undertaken with reasonable amount of intensity (vigorousness)
As regards alcohol, we do not have such well formulated so that, in addition to burning the calories, “fitness” is also
legislative regulations as we have for tobacco, but the effort achieved. For planning a physical exercise program, the dictum
of the Government has been, in recent years, to develop a is ‘Any exercise is good; more the better. Physically inactive
comprehensive policy as well as legislation to reduce alcohol lifestyle accounts for 3.3% of all deaths, the focus has now
intake among communities. The available statutory provisions shifted to inculcate healthy lifestyle, by increasing activity
• 1190 •

14. levels in all the four ‘domains’ of life viz. at workplace, in methods (as brisk, regular physical exercise) rather than
transport, at home and during recreation time. The exercise drinking, to increase the HDL levels. All these aspects should
program should cater to three major facets of physical fitness, be emphasized on the clientele.
viz. Endurance; Muscular Strength; and, Flexibility. Endurance
training program has three distinct components, viz. Frequency.
Study Exercises
(minimum recommended is 3 per week); Intensity, which Long Question : What are the disease of lifestyle. Discuss their
should be of at least “moderate” intensity; and, Duration, epidemiology with specific reference to major lifestyle factors.
which can be tailored to meet the individual / community needs Short Notes : (1) Community based guidelines for physical
but is generally recommended to be 30 to 60 minutes on each exercise (2) Dietary guidelines for prevention of non -
day on which exercise is undertaken. The easily applicable communicable diseases (3) Moderation in alcohol intake (4)
recommendations are that every adult should spend at least Health benefits of physical exercise (5) Measures for community
200 Kcal every day through brisk exercise - this can be achieved prevention and control of tobacco use
by undertaking at least 30 minutes of brisk walking, covering 2 MCQs & Exercises
miles (3.2 Kms) in that time, daily or on most days of the week.
1. Enumerate the major components of unhealthy lifestyle?
Measuring the level of intensity can be based on “Maximum
2. Which of the following is not a life style disease?(a) Breast
Permissible Heart Rate [MxPHR, calculated as 220 ( - ) Age in
cancer (b) Mental Stress (c) Osteoporosis (d) RHD
years], Borg’s scale of “Rating of Perceived Exertion (RPE), or
3. How many new cancer cases are known to occur every year
by Metabolic Equivalents (MET), considering that one MET is
in India? : (a) 1Lac (b) 5 lac (c) 8 lac (d) 10 lac
equal to a level at which a person will spend 1 Kcal energy per kg
4. What is India’s daily consumption of fruits and vegetables
body weight per hour and this level corresponds to the resting
per person per day? (a) 250 g (b) 500g (c) 130 g (d) 350g
stage. In addition to a structured physical exercise programme,
5. If a 70 Kg man walks slowly, covering 8 kilometers in 3
the lifestyle should be made habitually active. Principal goal
hours, he would burn off how many calories?
of active lifestyle is to increase energy expenditure without
6. In above question the activity done will be classified as
concern for the intensity of activity. The basic principle is that
fitness exercise or just an physical activity
very mild, even inapparent increases in physical activity may
7. Those who exercise regularly have higher levels of :
make much difference.
(a) LDL (b) HDL (c) Triglycerides (d) Total cholesterol
Proper diet is as important as physical exercise and fitness, in 8. Physical exercise bring about reduction in the level of
context of lifestyle diseases. A healthy daily diet should provide anxiety and stress by release of which chemicals
calories and all nutrients which are actually required by the 9. Effects of physical activity are long lasting - true/false?
body, depending on age, sex, existing body weight, amount 10. The minimum recommended frequency for endurance
of physical activity and other physiological requirements of training is : (a) 4 - 5/wk (b) 7/wk (c) 3/wk (d) 1 - 2/wk
growth, pregnancy, etc. Dietary fats should provide not more 11. How is Maximum Permissible Heart Rate (MxPHR)
than 30% of the total daily energy intake; within this limit, calculated?
saturated fats should not provide more than 10% of the total 12. Rating of Perceived Exertion (RPE) is for rating which of
dietary energy. Dietary cholesterol should not exceed 300 mg the following : (a) Frequency of exercise (b) Duration of
in a day. Total salt intake should not exceed more than 6 grams exercise (c) Intensity of exercise
a day, while sugars should not provide more than 10% of daily 13. Match the following
dietary energy. Fruits and Vegetables are rich source of Folic
acid, antioxidant vitamins and minerals. In one day, an adult RPE 1Kcal/Kg body wt/hr
should consume about 400 to 500 grams of fresh fruits and
MET 220 - Age in years
vegetables (not including potatoes). Adequate consumption
of dietary fiber has been shown to be protective against MxPHR Visual analogue
cardiovascular diseases, diabetes type - 2, obesity, gall bladder
disease and certain cancers, particularly colonic cancers. 14. Moderate intensity of exercise level is equivalent to what
Dietary consumption of fiber should be at least 30 grams per MET level in men?
day. 15. A subject weighing 60 kg is exercising by Running at
speed of 12 km/h. He ran 6 km in 30 min (MET level 12.5).
In public health practice, all functionaries should endeavor to Calculate the amount of energy in Kcal expended by the
educate individuals and communities regarding the adversities person and the amount of fat burnt off ?
associated with tobacco use and motivate them to give up 16. According to recommendations of CDC Atlanta and
tobacco. American College of Sports Medicine a person should spend
Alcohol intake, even in mild to moderate quantities, is associated how many calories per day by physical exercise?
with a number of other diseases like road accidents, various 17. Saturated fats should not provide more than what
cancers, obesity and hypertension in addition to diseases seen in percentage of the total dietary energy?
chronic alcoholics like liver diseases, pancreatitis, hypertension 18. What is the daily recommendation of salt intake by a
and DM, psychiatric & social problems and dependence. person?
Secondly, it is quite difficult to maintain “moderation” - many 19. Globally what percentage of cardiovascular deaths is
of those who are initially moderate may become heavy drinkers contributed by tobacco intake?
gradually. Thirdly, there are various other more healthy
• 1191 •

15. 20. What is the estimated RR of hypertension and stroke due : World Health Organization, 2003 :
to alcohol intake? 18. International Institute for Population Sciences. National Family Health
Survey 1998 - 1999 (NFHS - 2). Mumbai : IIPS, 2000 : .
21. A “unit” of alcohol is defined as equivalent of how many 19. In : Reddy KS, Gupta PC, eds. Tobacco control in India. New Delhi : Ministry
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