Non communicable diseases

1. Chronic Non-Communicable
Diseases (NCD) and Conditions
&
Lifestyle Diseases
Dr. Jeevan Yadav
Professor,
Community Medicine,
D. Y. Patil Medical College, Kolhapur

2. National Burden
• Advancing epidemics of LIFESTYLE Diseases are
– propelled by demographic, economic and social factors,
– of which urbanisation, industrialisation, and
globalisation, are the main determinants.
• The Indian economy is
– growing at approx. 7% per year.
– With increasing life expectancy,
– the proportion of the population older than 35 years is
expected to rise from 28% in 1981 to 42% in 2021.

3. National Burden
– NCDs contribute to 62% of total disease (Morbidity) burden,
52% of deaths (Mortality) are associated,
while 43% (Disability) DALYs lost due to NCDs in India.
– Urbanisation and industrialisation are changing the patterns of
living in ways that increase behavioural and biological risk factor
levels in the population.
• For these social reasons,
– the lifestyle epidemic is not simply restricted to NCDs in our
country;
– related to sexual lifestyle and have resulted in HIV - AIDS
epidemic that has reached concerning proportions.

4. Major NCDs / Lifestyle Diseases

5. Gaps in natural H/o NCD
• There are many gaps in our knowledge about the
natural H/o chronic NCDs
• These gaps cause difficulties in aetiological
investigations and research .
• These are
• 1) Absence of a known agent –
• 2) Multiple Risk factors than single cause-
• 3) Long latent period-
• 4) Indefinite onset-

6. • 1). Absence of a known agent -
• There is much to learn about causes of chronic
diseases.
• Whereas in some chronic diseases the cause is
known (e.g., silica in silicosis, asbestos in
mesothelioma),
• For many chronic diseases causative agent is
not known.
• The absence of a known agent makes both
diagnosis and specific prevention difficult.

7. • 2) Multiple Risk factors than single cause-
• Chronic diseases appear to result from
cumulative effects of multiple risk factors.
• These factors may be both environmental and
behavioural, constitutional.
• Epidemiology has contributed massively in the
identification of risk factors of chronic diseases.
• Many more are yet to be identified and
evaluated.

8. • 3) Long latent period-
• A further obstacle in natural history of chronic disease is
the long latent (or incubation) period between the first
exposure to "suspected cause" and the eventual
development of disease (e.g., cervical cancer).
• This makes it difficult to link suspected causes (antecedent
events) with outcomes, e.g., the possible relation between
oral contraceptives and the occurrence of cervical cancer.
• Now it is increasingly evident that the factors favoring the
development of chronic disease are often present early in
life, preceding the appearance of chronic disease by many
years.
• e.g. include-hypertension. diabetes, stroke, etc.

9. • 4) Indefinite onset-
• Most chronic diseases are slow in onset and
development, the distinction between diseased and
non-diseased states may be difficult to establish
(e.g., diabetes and hypertension).
• In many chronic diseases (e.g. cancer) the underlying
pathological processes are well established long before
the disease manifests itself.
• By the time the patient seeks medical advice, the
damage already caused may be irreversible or
difficult to treat.

10. OBESITY

11. Obesity
• Is one of the commonest expressions of
– unhealthy diet, often combined with
– lack of physical activity.
• Indeed, we are amidst an epidemic of obesity.
• Over past 2 decades there has been a dramatic rise in
prevalence of obesity throughout the world.
• It is estimated by the WHO that globally,
– over 1 billion (16%) adults are overweight and
– 300 million (5%) are obese.

12. • The highest rise in the number of obese is noted in the countries
with fast growing economies especially of South East Asia.
• As many as 250 million people in the third world countries suffer
from obesity.
• In India the prevalence of obesity is-
– 12.6% in women and 9.3% in men .
– In other words, > 100 million individuals are obese in India.
• We are truly in the midst of an obesity epidemic, which has
serious health ramifications

13. Epidemiological Determinants of Obesity
1) Obesogenic Environment :
• Today the shared environmental factors like-
– affluent lifestyle, rich food, sedentary home environment,
– vanishing old family traditions (with regards to eating,
exercise and outdoor activities),
– the ‘couch - potato’ culture etc. substantially contribute to
obesity.
• This environment is moulded towards a very favourable milieu
for obesity.

14. • Aggressive advertising, marketing and universal
accessibility of chips, wafers and colas have made them
not only a household item but also must for any outing or
birthday party!
• These are some of the reasons of urban obesity.
• Subconsciously we are imparting the same ‘unhealthy’
eating - behaviour to the children, ensuring that the next
generation too falls in the same vicious cycle of no return.

15. 2) Age : The incidence of obesity increases with age till about 60 yrs.
• The vulnerability is maximum in the middle age (around 40 years
of age), owing to certain hormonal changes, affluence and a
more sedentary lifestyle at this age.
3) Gender : Females are more likely to be obese as compared to
males, owing to inherent hormonal differences.
4) Ethnicity : There are large unexplained variations in the prevalence
of obesity in the people from different ethnic groups.

16. 5) Education levels : Indian setting, people with a higher education
level, are more likely to be obese, as compared to less educated.
• It is because the educated are likely to be more affluent.
• In the west, however, the educated might be in a better state of
health, as they are more aware and concerned about health
issues.
6) Income : The effect of income too is varied, in India and in the
West. Just like education, those with higher income are more
likely to be obese in India, but not so in the West.

17. 7) Marital status :
• Those who are married are more likely to be obese as
compared to those who are not.
8) Parity :
• Women with higher parity are more likely to be obese.
an average the woman gains 1kg weight with each pregnancy

18. 9) Diet : A diet rich in fats, refined sugar & carbohydrates
predisposes to obesity.
• Excessive consumption of
– sweets, cold drinks,
– fried food, baked items,
– pickles and chutneys, fast foods, alcohol etc.
– is responsible for obesity.
• Consumption of as little as 100 extra calories per day would
increase the weight of an individual by 4 kg in one year.

19. 10) Smoking : Is mostly clubbed with tea/coffee/cold
drink/alcohol/etc. gives more calories.
(Smoking per se reduces the likelihood of obesity, by virtue of nicotine being an
anorexic agent). But this positive effect of smoking can by no means
be endorsed for its promotion.
11) Physical Inactivity : High physical activity is a vital component
that keeps accumulation of fat and obesity under check.
• One who is undertaking minimal activity and is leading a
sedentary life is at a risk of obesity.

20. 12) Alcohol :
• Alcohol provides 7kcal per gm, which is almost double the
calorie content of carbohydrates or proteins (4kcal). Such a
high calorific value in itself is a risk factor for obesity
• The snacks consumed along with an alcoholic drink are
invariably nutritionally rich (fried, fatty and oily), which add
many more calories and predisposing the individual to
obesity.

21. Causes of Obesity
• Obesity results from
– an excess of dietary energy intake as compared to
energy expenditure and
– thus both an increase in intake and a decrease in
energy expenditure will lead to excess calories
being stored as fat and, ultimately to obesity.
1) Increased energy intake :
– due to lifestyle changes and affluence as seen in
urban areas seems to be fuelling the obesity
epidemic.

22. 2) Passive overeating :
– The term passive overeating is applied to the
practice of eating without a biological need, and
not expending the calories thus gained.
– Such a situation is commonly seen in the urban
setting today where one relishes French fries,
wafers and other high calorie snacks while
watching TV or using a computer.

23. 3) Binge eating :
• It is the practice of overindulging in eating in a short time.
• This might occur in a party, on a weekend or with drinks.
• In binge eating occasions become rather frequent;
it certainly is a cause of obesity.
4) Decreased energy expenditure :
• There is a rapid decline in energy expenditure
• i.e. in manual labour resulting from vehicle ownership,
availability of labour - saving devices,
• shunning outdoor sports and watching television and
computer use for long hours.
• These factors contribute to obesity.

24. 5) Metabolic factors :
• In some individuals endocrine disorders such as Cushing’s
syndrome and hypothyroidism, Prader – Willi syndrome etc.
are the cause of obesity.
6) Genetic factors :
• Obesity tends to run in families.
• Obesogenic genes are under study, which alter the metabolism
or alter response to obesity limiting hormones like Leptins etc.
7) Fetal programming :
• The Barker’s hypothesis proposes that under nutrition during
pregnancy may increase the susceptibility of that individual to
obesity in adulthood.

25. • Critical Periods for Weight Gain
– Weight gained during certain critical periods, usually
lead to an increased number of fat cells and makes
obesity difficult to treat.
– It is important to be on guard during these critical
periods, with an aim of preventing almost irreversible
weight gain
• These periods include :
– Age range of 12 to 18 months •
– Age range of 12 to 16 years •
– Gain of 60% (or more) of his ideal weight by an adult •
– Weight gain during pregnancy •

26. Quantifying Obesity
1) Body Mass Index (BMI) :
• Overweight is usually determined by the Body Mass
Index (BMI), which is a relationship of the person’s
weight to his height.
• BMI is computed by taking the body weight in kilograms and dividing it by
the square of the height in meters.
• Body Mass Index (BMI) = Weight (Kg) / [Height (m)]2
• BMI does not measure the body fat but relates well
with the degree of obesity.

27. 2) Waist circumference :
• Measurement of the waist circumference is a practical method to assess
obesity, esp. the degree of abdominal adiposity and the cardiovascular
disease risk.
• Waist is measured at mid point of lower border of rib cage
and iliac crest (at the level of umbilicus).
• A measure of less than or equal to 90 cm for men and 80
cm for women is considered healthy.
3) Waist - Hip Ratio (WHR) :
• It is another measure of abdominal adiposity and the cardiovascular
disease risk of the individual.
• A ratio of < 0.9 for men and < 0.8 for women is considered
normal.

29. Types of obesity
 Gynoid / ‘Pear shaped’ :
• The fat is evenly distributed (globally distributed).
 Android/‘Apple shaped’ :
• In this type of obesity, the fat is centrally distributed or deposited
preferentially in the abdominal region.
• This expresses the peritoneal (visceral) distribution of fat in the
individual.
• This type of obesity is commonly seen in men of the South East
Asian region, including India.
• Such distribution is higher risk factor for coronary artery disease as
compared to the global distribution of fat in the body.
• Higher waist circumference or higher WHR is a indicator of visceral
(peritoneal) deposition of fat.

30. Hazards of obesity
• Obesity is associated with higher risk of mortality &
morbidity.
• The life expectancy of a morbidly obese individual is
about a decade lower than one with normal BMI.
• Most overweight and obese individuals exhibit
certain symptoms like
– difficulty in walking,
– heavy breathing while walking,
– joint pains, snoring, morning headaches and
– shortness of breath.

31. • Some specific clinical consequences of obesity :
• Metabolic & Degenerative :
– Diabetes type 2 (50 to 100 times more common in obese),
– hyperlipidaemia, ischaemic heart disease, hypertension (5 to 6 times
commoner),
– stroke (2.5 to 6 times commoner),
– gall stones, breast and colon cancer,
– infertility (men and women),gout and
– polycystic ovary syndrome are seen more often in obese.
• Physical :
– Osteoarthritis, chronic back pain,
– respiratory problems, limited mobility,
– higher accidents, sleep apnoea and skin problems.
• Psychological :
– Depression, low self - esteem, social isolation,
– poor employment status, impaired relationships and discrimination.

32. Prevention of Obesity
• “Most obese people- won’t enter treatment,
most who do- won’t lose weight and
most who lose weight- regain it” ~ Stukard
• The quotation by Stukard , clearly summarizes,
the importance of prevention of obesity over
treatment.
• Prevention is the only viable long term
strategy for many reasons.

33. Prevention of Obesity
• 1. Universal Prevention :
• 2. Selective Prevention :
• 3. Indicated Prevention :

34. • 1. Universal Prevention :
• As the name suggests, universal preventive measures are
meant for all the individuals in the community, irrespective
of their weight status.
• Theses measures include
– healthy lifestyle practices,
– like consuming a prudent and healthy diet,
– low consumption of fat and refined carbohydrates.
– Active physical activity and
– shunning sedentary lifestyle also forms a part of this strategy.
• Health and nutritional education is also imparted to
everyone in order to create awareness amongst masses for
prevention of obesity.

35. • 2. Selective Prevention :
• High risk individuals are targeted.
• These include-
– affluent people especially adolescents,
– pregnant women, middle aged people and
– those with rich sedentary lifestyle consuming high energy food (fats)
– those under psychological stress,
– those with a hormonal disorder,
– family history of obesity or on certain drugs like Lithium, Sodium
valproate, hormones etc.
– are also at a high risk of obesity.
• 3. Indicated Prevention :
• Indicated Prevention or the Secondary preventive measures are to
be taken for those with existing problems of overweight and
obesity.

36. How to Reduce Weight?
• Nearly 2500 years ago, Socrates had very aptly
said :
• ‘Eat only when hungry and drink only when
thirsty, and never to leave the table with a
feeling of satiety’.
• The aim should be to maintain --
 BMI below 25 kg/m2 (preferably below 23.5) and
 waist circumference below 90 and 80 cm in adult men
& women respectively,
 by a prudent combination of diet and physical activity
 and avoid weight gain in adulthood.

37. • Being overweight, a high BMI is probably first indication of fact that our
diet is off - course and needs correction.
• If ignored at this stage other more sinister lifestyle diseases might soon
follow.
• Many modalities for treatment/prevention of obesity are available.
• (a) The dietary therapy (commonly known as ‘dieting’) remains the
most practical and effective measure.
• Other measures are :
– (b) Behaviour therapy
– (c) Drug therapy
– (d) Surgical intervention
– (e) Genetic approach.
• Presently we concentrate only on the dietary therapy.

38. • Reducing weight through dietary therapy (dieting) :
• The first step to adopt a healthy lifestyle is to get educated on
nutritional and health aspects.
• Understanding the nutritive values of Indian foods is perhaps a good
beginning.
• One must learn about calorie content of different foods, food
composition (fats, carbohydrates and proteins), nutrition labels, types
of foods to buy and details on cooking procedures.
• Correct dieting technique involves instructions on how to make safe,
sensible and gradual change in eating patterns.
• Moderate reduction in calorie intake is essential to achieve a slow but
steady weight loss.
• This strategy also helps in maintaining this weight loss.

39. • There are four areas to be considered in the use
of dieting and nutritional education in treating
obesity.
• 1) Ascertain the activity status :
– sedentary, moderate or hard •worker.
– Assess the present BMI and the desired BMI (20 to 25
kg/m2).
– This would indicate the weight (in Kg) to be reduced.
• 2) Set a practical time frame for weight reduction.
– It has to been achieved at a rate of around 1 to 1.5 kg
per month.

40. • 3) Assess the daily calorie intake from fats,
proteins and •carbohydrates.
– The weight to be reduced is then translated to the
calorie restriction.
– These calories are distributed between carbohydrates,
protein and fat so as to cut down calories preferably
from fats and carbohydrates (in that order).
– This also helps balance all nutrients.
• 4) Suitable substitutions should be made.
– The frequency with •which the foods are to be eaten
and the situation in which the food is ingested is also
to be looked into.
• An example is illustrated in Box - 4.

42. substitutions

46. Fad diets and their role in weight reduction :
• Fad diets stress either absence or presence of
particular foods or combination of foods. These
are commonly aimed at weight reduction.
• A fad diet is a set of menus advocated generally
by people, who have little or no knowledge of
nutrition or on the basis of inadequate evidence
by nutritionist as well.
• Even though such diets fail to meet the healthy
diet specifications, they turn out to be beneficial
for a short duration.

47. • They are so different from customary foods and are so
unpleasant to follow that they are used for a short
duration, generally not long enough to cause deficiency.
• People taking up fad diets skip from one such diet to
other, which again saves them from deficiency states.
• The secret of the short - lived success of such diets is
that, weight is rapidly lost, but is regained little later,
once the former eating habits are resumed.

48. Commercial ‘Weight Reducing’ Diets
• Either the sheer number of obese and weight conscious people is so large or there
is such a glamorization of good physique that today dieting is not only
‘commercialized’ but dieting and ‘slimming centres’ have
attained industrial proportions.
• Visiting a well - known slimming centre is
considered a prestige symbol for the affluent.
• Popular diets have become increasingly prevalent and controversial.
• More than 1000 diet books are now available, with many popular ones departing
substantially from mainstream medical advice.
• Public interest is being fuelled by cover stories of
popular magazines and televised debates.
• Out of the thousands of structured commercial diets, probably the more
popular ones are the Atkins diet, Ornish diet, Weight watchers
diet and the Zone diet.

49. Study Exercises
• Long Questions :
• (1) Describe the epidemiology of obesity. How would you advice a
middle aged man of 90 kg and 170 cms tall to reduce weight?
• (2) Discuss the principles of a healthy diet in context of lifestyle
diseases.
• Short Notes :
• (1) Fad diets
• (2) Food pyramid
• (3) BMI
• (4) Benefits of weight loss
• (5) Dietary fiber
• (6) Gaps in natural history of NCD

50. THANKS