GLOBAL BURDEN OF CHRONIC DISEASES
GAPS IN NATURAL HISTORY OF NCDS
RESOLUTIONS ADOPTED BY WHA
ACTION PLAN FOR GLOBAL STRATEGY FOR PREVENTION AND CONTROL OF NON
COMMON RISK FACTOR APPROACH
4. 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
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
6. Why non communicable diseases are
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.”
8. 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.
9. 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.
10. 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.
11. 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
12. The global burden of chronic diseases:
Approximately 58 million death occurred in the year 2005.
Projected main cause of death world wide
comunicable diseases, maternal
and perinatal conditions, and
chronic respiratory diseases
other chronic diseases
The study of the distribution and determinants of health related
states or events in specified population, and the application of this
study to the control of health problems
17. Definition of Chronic diseases
“An impairment of bodily structure and/or function that
necessitates a modification of the patient’s normal life,
and has persisted over an extended period of time.”
(Euro Symposium 1957)
18. Definition of Chronic diseases
“comprising of all impairments or deviations from normal
which have one or more of the following characteristics :
Leave residual disability
Are caused by non reversible pathological alteration
Require special training of the patient for rehabilitation
May be expected to require a long period of supervision,
observation or care.”
(Commission on Chronic Illness USA )
19. No international definition of what duration should be
Duration of at least 3 months
The most widely used measure of burden of diseases is DALY.
Combines number of years of healthy life lost to premature death with
time spent in less than full health.
One DALY can be thought of, under a number of conditions, as one lost
healthy year of life(Murray and Lopez 1996).
25. 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.
26. 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.”
27. The role of public health surveillance
To detect sudden changes in disease occurrence and
To follow secular (long-term) trends and patterns of
To identify changes in agents and host factors
To detect changes in health care practices
Surveillance is based on a public health agenda, not a
research agenda. Data need to be collected in a timely
way and should be of direct relevance to the health needs
of a population.
28. Active surveillance: a system employing staff members to regularly contact
heath care providers or the population to seek information about health
conditions. Active surveillance provides the most accurate and timely
information, but it is also expensive.
Passive surveillance: a system by which a health jurisdiction receives reports
submitted from hospitals, clinics, public health units, or other sources. Passive
surveillance is a relatively inexpensive strategy to cover large areas, and it
provides critical information for monitoring a community’s health. However,
because passive surveillance depends on people in different institutions to
provide data, data quality and timeliness are difficult to control.
29. Categorical surveillance: an active or passive system that focuses on one or more
diseases or behaviors of interest to an intervention program. These systems are
useful for program managers.
Integrated surveillance: a combination of active and passive systems using a
single infrastructure that gathers information about multiple diseases or
behaviors of interest to several intervention programs (for example, a
health facility–based system may gather information on multiple infectious
diseases and injuries).
Behavioral risk factor surveillance system (BRFSS): an active system of
repeated surveys that measure behaviors that are known to cause disease or
injury (for example, tobacco or alcohol use, unprotected sex, or lack of physical
exercise). Because the aim of many intervention program strategies is to prevent
disease by preventing unhealthy behavior, these surveys provide a direct
measure of their effect in the population.It is useful for providing timely
measures of program effectiveness for both communicable and
noncommunicable disease interventions.
Text book of Disease Control Priorities in Developing Countries ; Peter
Nsubuga, Mark E. White, Stephen B. Thacker, and others
30. The potential usefulness of surveillance as a public health tool to
address problems beyond infectious disease was emphasized in
1968 when the 21st World Health Assembly recommended the
application of surveillance principles to a wider scope of
problems, including cancer, atherosclerosis, and social problems
such as drug addiction .
31. From health surveys to surveillance of risk
Properly conducted, surveillance ensures that countries have the information
they need to control disease immediately or to plan strategies to prevent
disease and adverse health events in the future.
The distribution of the major common risk factors for chronic diseases within
the population is the key item of information required by countries for
planning health promotion and primary prevention programmes.
Because of the relatively long time that elapses between exposure to a causal
agent and manifestation of disease, monitoring and surveillance of chronic
diseases can be a costly exercise involving disease registers and legislation to
ensure disease reporting.
For this reason most of the focus for surveillance of chronic disease,
including oral diseases, involves surveillance of modifiable risk factors. As
emphasized by the World oral health report, 2003.
33. The WHO Global InfoBase
To predict the future burden of chronic disease, including oral disease,data
collection and reporting standards are needed to ensure that the data can be
used effectively to inform policy, prevention and control activities for health.
The WHO Global InfoBase stores the country data being collected as part of
the STEPS approach.
The data entered may also derive from a range of sources such as reports
published in the literature or ministry of health reports.
The database brings together existing country-level data stratified by age and
sex, with complete source and survey information.
The InfoBase makes use of the compiled data to produce comparable country
estimates for risk factors and selected diseases.
34. The WHO Global Oral Health Data Bank was recently updated on the basis of the
available national reports (ministry of health and other), dental scientific literature
(obtained through PubMed), information available in the Country/Area Profile
Programme (CAPP) and data provided by WHO Collaborating Centres and the
International Agency of Cancer Research.
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
35. Most of these noncommunicable diseases share common preventable risk
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.
36. 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.
37. 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.
38. The key feature of the STEPS framework is the distinction between the different levels of risk-
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:
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-
In India the survey was conducted from april 2003 to march 2005 in 6 sites and
again in 2007 in 7 states.
39. 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
WHO does not recommend such advanced
for countries with limited resources.
41. Oral health indicators within the frame
WHO Oral Health Programme designed a risk factor model which provided the
conceptual framework for inclusion of oral health modules within STEPS.
42. The indicators comprise both determinants of health and common modifiable
risk factors such as diet/nutrition, tobacco use and excessive alcohol
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.
43. The WHO Oral Health Programme has developed standardized questions for
obtaining Step 1 data.
44. 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).
45. 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
those most in need.
Improved quality of oral health information systems worldwide may help to
strengthen health systems and operational research may assist in
translating sound knowledge about prevention programmes and health promotion
for the benefit of the poor and disadvantaged population groups
47. STRATEGIES AND APPROACHES IN ORAL DISEASE
PREVENTION AND HEALTH PROMOTION
The threat posed by noncommunicable diseases and the need to provide
urgent and effective public health responses led to the formulation of a
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
diseases linked by common, preventable and lifestyle related risk factors
(e.g. unhealthy diet, tobacco use), including oral health.
49. Gaps in the natural history of NCD
1. Absence of known agent: in most of NCD the cause is not known.
2. Multifactorial causation: in absence of causative agents, risk factors
An attribute or exposure that is significantly associated with
development of disease.
If determinant is modified by intervention, it reduces possibility of
occurrence of disease.
Risk factors can be causative, contributory or predictive.
They can be modifiable or non-modifiable
They can be individual or community risk factors
Epidemiological studies are needed to identify risk factors
At-risk approach, at-risk groups, risk factors with diseases
50. Gaps in the natural history of NCD
Web of causation
Changes in life style stress
Abundance of food lack of physical activity smoking emotional
Hyperlipidemia thrombotic tendency
Coronary arthrosclerosis coronary occlusion
51. 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
52. 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:
Resolution WHA 56.1: on the WHO framework of tobacco control.
Resolution WHA 57.16: on health promotion and healthy lifestyles.
Resolution WHA 57.17: on the global strategy on diet, physical activity
Resolution WHA 58.22: on cancer prevention and control,
Resolution WHA 58.26: on public health problem caused by harmful
use of alcohol;
Resolution WHA 60.23: on prevention and control of non
54. On May 27, 2013, ministers from 194 WHO member states adopted the Global
Action Plan for the Prevention and Control of NCDs 2013 to 2020 at the 66th
World Health Assembly.
Two months later, the United Nations (U.N.) Economic and Social Council
adopted a resolution requesting that the U.N. secretary general establish an
interagency task force on the prevention and control of NCDs.
Fuster V,Global Burden of Cardiovascular Disease JACC VOL. 64, NO. 5, 2014
AUGUST 5, 2014:520 – 2
55. 2013-2020 Action Plan for the Global Strategy for
the Prevention and Control of Noncommunicable
Working in partnership to prevent and control the 4 noncommunicable
diseases — cardiovascular diseases, diabetes, cancers and chronic
respiratory diseases and the 4 shared risk factors — tobacco use,
physical inactivity, unhealthy diets and the harmful use of alcohol.
56. The six objectives of the 2013-2020 Action
. To raise the priority accorded to
the prevention and control of
noncommunicable diseases in
global, regional and national
agendas and internationally
agreed development goals,
international cooperation and
To strengthen national
action and partnerships to
accelerate country response
for the prevention and control
of noncommunicable diseases.
To reduce modifiable risk
factors for noncommunicable
diseases and underlying social
determinants through creation
57. To strengthen and orient health
systems to address the
prevention and control of
noncommunicable diseases and
the underlying social
determinants through people-
centred primary health care
and universal health coverage.
To promote and support national
capacity for high-quality
research and development for
the prevention and control of
To monitor the trends and
noncommunicable diseases and
evaluate progress in their
prevention and control.
61. Oral health
The theme for World Health Day (April 7, 1994), “Oral Health for a Healthy
The UN assembly in 1995 recognized the fact that oral disease burden is high
globally and share common risk factors with other NCDS.
Hence oral health was recommended to be included in NCDS for its prevention
The 8th world congress of preventive dentistry in September 2005 in Liverpool
jointly organized by WHO , IADR and European association for dental public
health with 43 countries participation emphasized oral health an integral part
of general health and wellbeing as a basic human right.
Their impact on individuals and communities is considerable in terms of pain
and suffering, impairment of function and reduced quality of life and cost of
treatment. The extent of inequalities in oral health outcomes is
62. Strategies and management of oral diseases
in the context of NCDs
A 2007 WHO resolution called for oral health to be integrated with chronic
disease prevention programs. Commonly used approaches to prevention and
control of oral diseases have been relatively ineffective. However, methods
exist to prevent a very large proportion of oral diseases.
Therefore, FDI will encourage:
1. Reducing the “knowledge- implementation gap” by
recommending guidelines for evidence based health
2. Applying the principles outlined in the Ottawa Charter for
Health Promotion, which recommends a shift from a vertical
to a more horizontal approach and involves more integration
with others involved in tackling NCDs.
64. UN High level meeting on Non –Communicable
Diseases (19-20 September 2011 in New York)
Political declaration on the prevention and control of non-communicable
diseases (ncds) was adopted by 193 member states
In particular the declaration called for interventions affecting upstream social
determinants of health and illness.
The increasing global burden of NCDs is a major barrier to development and
achievement of the Millennium Development Goals.
NCDs are a contributing factor to poverty and hunger.
65. Implications for oral health
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-
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
66. 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
67. Global Goals for Oral Health
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
68. 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.
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.
71. 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
75. IADRS GROUP RECOMMENDATIONS
A shift from the current downstream approaches by
integrating oral health strategies with those directed at
the major NCDS ( “best buys” are midstream and
76. Oral diseases burden is increasing and majority of dental
decay remains untreated across all countries, evidence of
failure of vertical approach.
Evidence shows population wide prevention strategies
that are no longer vertical , but horizontal can tackle
common risk factors effectively.
77. Oral disease burden is increasing and a majority of dental
decay is untreated across all the countries , evidence of
the failure of vertical approach
80. Risk factors for NCD
The risk factors for NCDs are classified in terms of their amenability to
interventions as :
82. Tobacco Use
Tobacco consumed in any form, whether smoked or chewed and second-hand
tobacco smoke exposures are associated with adverse health effects. It is
associated with cardiovascular diseases, cancers, chronic respiratory disease,
and other communicable and non communicable diseases.
Tobacco kills up to half of its users.
•Tobacco kills nearly 6 million people each year.
•Annual death toll could rise to more than 8 million by 2030.
•Nearly 80% of the world’s 1 billion smokers live in low- and middle-income
84. Tobacco Use: Health Effects
Mathers CD, Loncar D. Projections of global mortality and burden of disease from
2002 to 2030. PLoS Medicine, 2006, 3(11): e442.
85. Tobacco Use: Health Effects (cont.)
Coronary heart disease
Diseases of the lungs
Peripheral vascular disease
Fetal complications and stillbirth
Second-hand smoke causes
Heart disease, including heart
86. Alcohol Consumption
There is a direct relationship between higher levels of alcohol consumption
and rising risk of cardiovascular diseases and some liver diseases. Heavy
episodic drinking (binge drinking) is especially associated with cardiovascular
87. Global Alcohol Consumption
11.5% of all global drinkers are episodic, heavy users.
2.5 million people die from alcohol consumption per year
The majority of adults consume at low-risk levels.
Estimated worldwide consumption of alcohol has remained relatively stable.
91. Harmful Use of Alcohol: Effects
Diminished brain function
Loss of body heat
Risk for unintentional injuries
Risk for violence
Coma and death
92. Metabolic Risk Factors
the four metabolic risk factors
1. Raised Blood Pressure (Hypertension)
2. Raised Cholesterol
3. Raised Blood Glucose
4. Overweight and Obesity
93. Consumption of Fruits, Vegetables and Processed Food
Inadequate consumption of fruits and vegetables (less than five servings /day)
increases the risk for cardiovascular diseases, stomach cancer and colorectal
The consumption of high levels of high-energy foods, such as processed foods that
are high in fats and sugars, promotes obesity.
Consumption of > 5 gram of dietary salt/ day predisposes to higher blood pressure
levels and increased risk of cardiovascular diseases.
Consumption of high amounts of saturated fats and transfat increases the risk of
coronary heart disease and diabetes.
94. Global Changes in Diet
Most countries have increased overall daily consumption of: Daily
Fat and meats, and
Energy dense and nutrient-poor foods such as: Starches
95. Physical Inactivity
Low physical activity is an important cause of overweight and obesity.
Participation in 150 minutes of moderate physical activity for every week or
equivalent activity is estimated to reduce the risk of cardiovascular disease,
diabetes, breast and colon cancer, and depression.
96. Global Changes in Physical Activity
31% of the world’s population does not get enough physical activity.
Many social and economic changes contribute to this trend:
97. Global Changes in Physical Activity (cont.)
6-10 % OF MAJOR NCDS IS ATTRIBUTABLE TO PHYISCAL INACTIVITY
98. Physical Activity: Health Effects
REDUCES THE RISK OF:
High blood pressure
Adverse lipid profile
Type 2 diabetes
Poverty means that
there is less
purchasing power in
This low purchasing
power results in
compromising on the
choices that is made
at the household
This results in major
behaviors such as
tobacco use, harmful
use of alcohol,
consumption of fruits
and vegetables and
preferential use of
less expensive and
among the vulnerable
groups of people.
Environmental risk factors are contributing to the NCD’s’ like as Air Pollution,
water Pollution, Occupational Hazards and Exposure to Radiation.
INADEQUATE HEALTH SERVICES
Failure and inability to obtain preventive health services such as screening,
regular follow up are major predisposing factors to the NCDs. Also, some late
diagnosis of disease conditions, untreated infections may lead to carcinomas.
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.
102. Non modifiable risk factors
The Risk factors, which cannot be modified:
Age: Elderly and children are the vulnerable group to get the diseases
Sex: There will be some difference between the disease ratios among the
Family History of Genetic Factors: Genetic factors are major risk factors
which cannot be modified.
Personality: Individual personality may contribute in development of the non
104. Intermediate Risk Factors
Obesity and Overweight (overweight (BMI>=25) or
Physical inactivity and inappropriate nutrition are directly
reflected in the growing burden of overweight in the
Indian population predominantly in the urban areas.
Central obesity is an important risk factor for diabetes
and appears to better predict the risk of diabetes among
Indians in Asian region.
105. Hyperlipidemias(>200 mg/dl)
A high blood cholesterol level is called hyperlipidaemia.
Cholesterol can be measured as the level of Total Cholesterol in the blood. National guidelines suggest a
challenging target of total cholesterol of less than 4.0mmol/l for individuals with established cardiovascular
disease, diabetes, or at high risk of developing cardiovascular disease
Total cholesterol has two components;
1.High density lipoproteins; often called “good cholesterol”.it is the fraction of cholesterol that removes
cholesterol (via the liver) from the blood.
Guidelines on HDL-C recommend treatment for those with concentrations below 1.0mmol/l.
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
106. Risk Factors…..
CHD risk prediction based on serum lipid levels a total “cholesterol/HDL ratio” has been
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
Apolipoprotein may replace lipoprotein cholesterol determinations in assessing the risk.
107. Global Burden of Raised Total Cholesterol
In 2008, global prevalence of raised total cholesterol among adults (≥ 5.0
mmol/l) was 39% (37% for males and 40% for females).
Estimated to cause 2.6 million deaths.
The Framingham Heart Study demonstrated the lower the HDL-C and higher
LDL-C levels, the greater is the likelihood of developing coronary artery
disease. The level of risk increases 3 fold when LDL-C is 220mg/dL and HDL-C
is 25mg/dL (or 12.2mmol/l and 1.4mmol/l).
108. Raised Total Cholesterol: Health Effects
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
109. 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.
Hypertension and Excessive Sodium Intake
Sodium, through hypertension, is a major cause of cardiovascular disease deaths and
About 10% of cardiovascular disease is caused by excess sodium intake.
8.5 million deaths could be prevented over 10 years if sodium intake were reduced by 15%.
110. 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
In China and Japan, 75% of sodium consumed comes from cooking with high
111. 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.
112. 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.
113. 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.
114. WHO also identifies the six leading risk factors that are associated with non-
communicable diseases as being the leading global risk factors for death
Tobacco use Physical inactivity Overweight/obesity
High blood pressure
High blood glucose
115. 2012 WHO Global Targets: Reducing Risk
117. Social and economic implications of non
communicable diseases….. Thakur, et al.: Socio-
economics of NCD
The multi-dimensional effect at individual, household, health system, and
macroeconomic level, NCDs are being labeled as a global ‘chronic
Burden and Social Determinants of NCD in India.
A recent report by the World Bank for South-East Asia Region estimated NCDs
to account for 62% of DALY losses in India in 2004.
While most of the developed countries witnessed a rise in NCD at a time when
the communicable diseases had reached significantly lower levels; India is one
of the developing countries which has witnessed a ‘double burden’
epidemiological transition with high rates of NCD morbidity and mortality at a
time when the communicable diseases have yet not been controlled.
118. Indians contribute to 2.7 million CVD cases, 62.4 million diabetes, 1.5 million
stroke, more than 30 million chronic respiratory diseases and 0.95 million
incident cancer cases.
As per latest projections, the number of diabetics in India are estimated to
62.4 million, which is the second largest in the world after China.
The prevalence of CVD has increased by nearly two times in rural areas, it
has increased by six times in urban areas during the past four decades.
This rate of increase has been estimated to be twice the rate at which CVDs
increased in the developed countries.
119. CVD was initially regarded as a disease of the affluent classes in INDIA.
As the epidemic is maturing, a graded reversal of social gradient, with socio-
economically disadvantaged groups becoming increasingly vulnerable.
CVD risk is increasing among poor in slum and rural areas.
In selected urban, rural and slum communities of north India, prevalence of
hypertension was found to be statistically similar after controlling for age,
gender and education (P>0.05).
Prevalence of physical inactivity, central obesity, overweight and
hypertension were found to be statistically similar among illiterate and
literate population after controlling the effect of age, sex and place of
120. As per Million Death Study (2001-03) in India, CVDs are already at the top
among top 10 causes of adult deaths (25–69 years) in urban and rural India
contributing to 32.8% and 23% of deaths, respectively.
Such numbers are compounded by the barriers to care for the rural poor with
NCDs. In addition, technology for NCD care is usually concentrated in
hospitals, making it harder to reach for rural dwellers.
Few study found that use of key treatments also differed by socioeconomic
122. Socioeconomic inequalities affect health through more than one mechanism and
involve material, psychosocial and behavioral factors. Low income may affect
A study which estimated causes of premature mortality in US found that 40% of
premature mortality in the US is the result of behavioral factors, compared
with 30% arising from genetic predisposition, 20% from social and
environmental factors and 10% from healthcare deficiencies.
Marmot et al have shown that the role of social determinants in the causation of
NCDs seems to be more important than even the role of major behavioral risk
social determinants play a role by altering the way people make their choices
about personal behaviors, which exacerbates NCD prevalence, and hence it makes
an even important case for the Governments to act on these social determinants
123. Microeconomic, Health System and
Macroeconomic Impact of NCDs in India
Health care in India is highly privatized, both in terms of financing and delivery.
More than 80% of outpatient and 40% of inpatient care is sourced from private
India spends about 4.2% of its GDP on health care, with about 30% of this total
health expenditure (THE) is contributed by the public sector. With only about 10%
of the total population under cover of any form of health insurance, nearly 90% of
the total private health expenditure is borne out-of-pocket by the households in
2000, which has reduced to 86.4% in 2009 and is still very high.
124. Financing for NCD
Mahal et al 2010 found that between two study periods (1995–96 and 2004),
the share of NCDs in total out-of-pocket health expenditures in India
increased from 31.6% to 47.3%, (or over 9 billion USD) of total OOP
expenditures, suggesting a growing importance of NCDs in terms of their
financial impact on households.
The average out-of-pocket expense per stay for inpatient treatment for NCDs
is almost two times than for non-NCDs whether the treatment is in public
or private facilities.
It is possible that early detection and treatment of NCDs at outpatient centers
can substantially reduce the visits for inpatient care and reduce the cost of
treatment for NCDs.
125. Financial impact of NCDs on
Study in India showed that about 25% of families with a member with CVD
and 50% with cancer experience catastrophic expenditure and 10% and
25%, respectively, are driven to poverty.
The odds of incurring catastrophic hospitalization expenditure were nearly
160% higher with cancer than the odds of incurring catastrophic spending
when hospitalization was due to a communicable disease.
Overall, NCDs are linked closely with MDG 2, 4, 5, 6 and 8e, so managing NCDs
is of central importance to progress toward achievement of these goals. By
taking away a significant portion of household’s capacity to pay, NCDs leave
little to be spent on education especially female education.
126. Impact of NCDs on health system
Increased prevalence of NCDs has also led to increased pressures on the health
systems for providing treatment care and support.
The proportion of hospitalizations and outpatient consultations as a result of
NCDs rose from 32% to 40% and 22% to 35%, respectively, within a decade from
1995 to 2004. In macroeconomic term, most of the estimates suggest that the
NCDs in India account for an economic burden in the range of 5–10% of GDP,
which is significant and slowing down GDP thus hampering development.
Health and wealth reinforce each other and health systems are a catalyst for
both, so strengthening health system is crucial to address the challenge of NCDs.
127. Impact of NCDs on gross domestic
Mahal et al. 2010 concluded that in the event of elimination of NCDs in 2004,
India’s per capita GDP would be higher than its 2004 value (USD 562) by 5–
10%.From 2005 to 2015, India is projected to lose international $237 billion
(1.5% of GDP) as a result of heart disease, stroke and diabetes
129. PREVENTION OF NON-COMMUNICABLE
Prevention of NCDs can be done through following method 3,11
Primordial prevention: Through the prevention of emergence or development of
risk factors in the population or in the countries in which they have not yet
appeared. Efforts are directed towards discouraging children from adopting
harmful life styles.
Primary prevention: Action taken prior to the onset of disease which removes the
possibility that the disease will ever occur. Effort will be done through health
promotion and specific protection
130. 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
132. WHO BEST BUYS FOR CONTROL OF NON-
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.
133. 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
Modifying the environment (building the play grounds & parks for
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-
134. 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
135. Individual Level Interventions
Screening and early diagnosis of disease in all health care settings
Individual health education towards prevention of diseases and promotion of
Counselling, drug therapy, specific treatment and rehabilitations.
137. “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
Someone has a heart attack every two minutes
(British Heart Foundation)
138. Historical Perspectives of CVD Epidemiology
Concept of “risk factors”, coined by Framingham Heart
Study, involved gaining understanding of factors
predisposing to occurrence of CVD
Framingham Heart Study was the first large-scale
epidemiologic study, begun in 1948
First demonstrated epidemiologic relations of cigarette
smoking, blood pressure, and cholesterol levels to
incidence of CHD.
139. Public Health Significance
Leading cause of mortality in developed countries and a rising
tendency in developing countries (disease of civilization)
A major impact on life expectancy
Significantly contributes to morbidity and death rates in the middle
aged population: potential life years lost, common cause of
premature death, labor force (economic costs), family life
Morbidity: nearly 30% of all disability cases
Contributes to deterioration of the quality of life
140. Cardiovascular diseases
CVD comprise of a group of diseases of the heart and the vascular system.
Major conditions are
Ischemic heart disease
Congenital heart disease
Rheumatic heart disease
141. Cardiovascular diseases
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
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.
143. The projected trends in CVD mortality and the expected shifts from infectious
to chronic diseases over the next few decades are shown in Figure .
146. 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
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.
147. 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
148. 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.
Burden of CVD risk factors in South Asians:
149. Burden of CVD risk factors in South
Several cross-sectional studies were initiated in the late 1980s to obtain CVD
risk factor prevalence among Indians. Studies that were large and well
designed are summarized in table . The cross sectional studies that were
carried out are of three types:
Cross-sectional surveys within India;
Migrant studies comparing South Asian (mainly Indians) to other local
Comparison of migrants and their relatives living within India.
152. Coronary Heart Disease
Defined as “impairment of heart function due to inadequate blood flow to the
heart compared to its needs caused by obstructive changes in the coronary
circulation in the heart”.
Cause of 25-30% of the deaths in industrialized countries.
The WHO has drawn attention to the fact that CHD is our modern
“epidemic”, i.e., a disease that affects populations, not an unavoidable
attribute of ageing.
153. Coronary Heart Disease
CHD may manifest itself in many presentations :
Angina Pectoris of effort
Irregularities of heart
Epidemics of CHD began at different times in different
US - epidemics began in 1920- now declining
Britain – 1930
Developing countries are catching up.
Singapore – Doubled in 20 yrs.
Countries where the epidemic began earlier are now
showing a decline
Initially it was disease of higher socioeconomic status.
In recent years socioeconomic status is inversely related to CHD
in developed countries.
Even in countries showing decline, CHD is still the most
frequent single cause of death.
155. Coronary Heart Disease in India
Coronary heart disease is assuming serious dimension in developing
It is expected to be the single most important cause of death in India
by the year 2015.
There is a considerable increase in prevalence of CHD in urban areas
in India during the last decade.
Although there is increase in prevalence of CHD in rural areas also, but
it is not that steep because life-style changes have affected people in
urban areas more than in rural areas.
The pooled estimates from studies carried out in 1990s upto 2002
shows the prevalent rate of CHD in urban areas as 6.4 per cent and 2.5
per cent in rural areas.
In urban areas the pooled estimate was 6.1 per cent for males and 6.7
per cent for females.
156. Coronary Heart Disease in India……
According to medical certification of cause of death data, 25.1 per cent
of total deaths in urban areas are attributable to diseases of the
158. Risk factor
Over 300 risk factors have been associated with coronary heart disease and
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
163. Risk Factors
2. Increases risks of cardiovascular disease, especially in people who started young, and heavy
3. Passive smoking an additional risk
Carbon monoxide induced atherogenesis
Nicotine stimulation of adrenergic drive raising BP nd myocardial oxygen demand
Lipid metabolism (decrease in HDL)
164. Risk Factors
• 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
• 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
Global Atlas on Cardiovascular Disease Prevention and Control. Mendis S, Puska P,
Norrving B editors. World Health Organization (in collaboration with the World
Heart Federation and World Stroke Organization), Geneva 2011
165. Risk Factors
BP is single most useful test for identifying individual at high risk of developing CHD
Hypertension accelerates atherosclerotic processes especially if hyperlipidemia is also
Both systolic Blood pressure(SBP) and diastolic blood pressure(DBP) are important risk factors.
166. Risk Factors
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
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
167. Other Risk Factors
Diabetes : Risk is 2-3 times higher in diabetic than non diabetic;
CHD responsible for 30-50% deaths in diabetics over 40 yrs. in industrialized countries.
Men with type 2 diabetes have a two to fourfold greater annual risk of CHD, with an even higher
(three to fivefold) risk in women
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.
168. Other Risk Factors
Physical activity : Sedentary lifestyle is associated with a greater risk of development of
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
peripheral vascular disease.
169. Type A personality
Type A behavior is characterized by aggressivenss, competitive drive ,
preoccupation with deadlines and time urgency. Data in 1980s found that type A
is aaociated with CHD in the western collaborative grouop study and
170. Alcohol : high alcohol intake, defined as 75g or more per day is an independent risk factor for CHD ,
hypertension and all cardiovascular diseases.
It has several associations with CHD
1. Association of alcohol with increase BP and the risk for stroke.
2. Association of alcohol consumption with increased HDL-C and levels of triglycerides.
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
Miscellaneous: Dietary fiber, Sucrose and Soft water role is debated
Dyspnoea on exertion and low vital capacity have also been cited as possible risk factors.
171. Prevention of CHD the Identification of Risk
Framingham heart study 1951-
The Seven countries study 1958-70
Stanford Heart disease Prevention Program
North Keralia Project Finland
Multiple Risk factor Intervention Trial
Lipid Research Clinics Study.
The Interheart study 1999-2004
172. Risk Factor Intervention Trials
1951 – Framingham Heart Study has played a major role in establishing the nature of
CHD risk factors and their relative importance.
Major Risk factors identified: elevated serum cholesterol, smoking, hypertension ,
Risk factor trials can be single or multifactorial.
173. Seven Countries Study
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
As % of saturated fat in each country’s diet increased, the average cholesterol
As the average serum cholesterol increased the death rate due to coronary heart
174. Seven Countries Study
Lowest cholesterol levels and lowest incidence of coronary artery
disease in countries with a “Mediterranean diet”
Low in animal products and sat. fat
Principal fat = olive oil (mono sat)
Rich in legumes, fruit, fish
175. Stanford- Three-Community Study
To determine whether community health education can reduce the risk of
cardiovascular disease – Field Trial – 1972
3 North California towns
2 towns – Intensive mass education prog-2 yrs
3rd community – control.
People interviewed at baseline, 1yr and 2yr and also were evaluated for
physiological indicators of risk.
Control – Risk of CVD increased over 2 yrs
Study group – Decrease in CVD risk
Difference in estimated total risk was – 23-28%
176. North Keralia Project
Multiple Risk factor intervention trial was started in 1972
2 aims – to reduce risk factors and to promote the early diagnosis, treatment and
rehabilitation of patients with CVD.
Mass community action against risk factors and advice on their avoidance.
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
177. Multiple Risk Factor Intervention Trial
MRFIT – USA
Aimed at high risk adult males (35-57 years old)
12,866 men without evidence of CHD enrolled.
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
Reason: Control group had also changed their lifestyle to far greater extent.
178. 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
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.
179. Lipid Research Clinics Study
Double blind randomized clinical trial.
3,806 asymptomatic “high risk” American men aged 35-59 yrs with hyperlipoproteinemia.
1st group – cholestyramine
2nd group – Placebo.
Followed for 7.4 yrs
Treatment group – 8.5% and 12.6% greater reduction in total cholesterol and LDL cholesterol
Resulted in 24% reduction in death from definite CHD and 19% reduction in non fatal MI.
181. The term “stroke” is applied to acute severe manifestations of
It causes both physical and mental crippling.
WHO defined stroke as,
“rapidly developed clinical signs of focal disturbance of cerebral function;
lasting more than 24 hours or leading to death, with no apparent cause
other than vascular origin”.
182. The disturbance of cerebral function is caused by three morphological
abnormalities, i.e.. stenosis, occlusion or rupture of the arteries.
Dysfunction of the brain ("neurological deficit") manifests itself by
various neurological signs and symptoms that are related to extent and
site of the area involved and to the underlying causes.
These include coma, hemiplegia, paraplegia, monoplegia, multiple
paralysis, speech disturbances, nerve paresis, sensory impairment, etc.
Of these hemiplegia constitutes the main somatoneurological disorder
in about 90% of the patients
Stroke is a worldwide health problem. It makes an important
contribution to morbidity, mortality and disability in developed as well
as developing countries.
cerebral thrombosis is usually the most frequent form of stroke
encountered in clinical studies, followed by hemorrhage.
184. Morbidity and mortality
In 2008 it was estimated that cerebrovascular disease accounted for 6.1
million deaths world wide, equivalent to 10.8% of all the deaths.
Majority of these death occurred in people living in developing countries and
33.72% of the subjects were aged less than 7o years.
It is the leading cause of disability in adults and each year million of stroke
survivors have to adopt life with restriction in activities of daily living as a
consequence of stroke.
185. the prevalence of stroke appears to be comparatively less in India than
in developed countries, it is likely to increase proportionally with the
increase in life expectancy.
The proportion of stroke in the young population is significantly more in
India than in developed countries;
The prevalence rate of stroke in India is about 1.54 per thousand and
death rate about 0.6 per 1000.
The Disability Adjusted Life Year’s lost is about 597.6 per lac.
The total number of stroke cases in India in the year 2004 were about
1.64 million, and total Disability Adjusted Life Year’s lost in 2004 were
about 6.37 million.
186. Risk factor for stroke
Main risk factor for cerebral thrombosis as well as cerebral hemorrhage .
Cardiac abnormalities (i.e left ventricular hypertrophy, cardiac dilation),
diabetes, elevated blood lipids, smoking,blood clotting and viscocity, oral
187. 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.
Incidence rate increases steeply with age.
In india 1/5th of all the stroke occur below the age of 40 (called “stroke in youngs”)
Incidence rate are higher in male than in female.
188. Stroke control programme:
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 is a chronic condition of concern due to its role in the
causation of coronary heart disease, stroke and other vascular
Commonest cardiovascular disorder, posing a major public health challenge
Accounts for 20-25% of all deaths, and is the major risk factor cardiovascular
Direct relation between cardiovascular risk and BP
2013 -- The theme for this year's World Health Day, 7 April, is hypertension
195. Blood pressure measurement
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.
Subject errors: e.g circumstances of examination.
196. Blood pressure measurement
WHO group recommended sitting position than supine position
Uniform policy should be adopted, using either right or left arm consistently
Pressure at which sounds are 1st heard (Phase I) –SBP
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
"Rule of halves"
Hypertension is an "iceberg" disease.
It became evident in the early 1970s that only
about half of the hypertensive subjects in the
general population of most developed
countries were aware of the condition, only
about half of those aware of the problem were
being treated and only about half of those
treated were considered adequately treated.
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 :
1. The whole community
2. Normotensive subjects
3. Hypertensive subjects
4. Undiagnosed hypertension
5. Diagnosed hypertension
6. Diagnosed but untreated
7. Diagnosed and treated
8. Inadequately treated
9. Adequately treated
Industrialized countries – 25% have DBP above 90 mm Hg
Prevalence in developing countries similar to European countries, ranging from 10-20%
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
201. Prevalence in India
Data derived from 2 well planned studies
59.9/1000 and 69.9/1000 in males and females respectively.
35.5/1000 and 35.9/1000 in males and females respectively.
202. Tracking of BP
If BP levels were followed over a period of years from early childhood
into adult life, then those individuals whose pressures were initially high
in the distribution would probably continue in the same track as adults.
In other words low BP levels tend to remain low and high levels tend to
become higher as individuals grow older.
203. Risk Factors for hypertension
Non modifiable risk factors
204. Risk Factors for hypertension
Modifiable risk factors
Obesity – Data indicates that individuals with high BP when they lose weight,
their BP generally decreases.
Central Obesity has been correlated with BP
Sodium(salt) intake : High salt intake (7-8 g/d) increases BP proportionately.
High incidence of Hypertension is found in Japan where sodium intake is
above 400 mmol/d, while primitive communities ingesting 60mmol/d have
virtually no hypertension
205. Risk Factors for hypertension
Modifiable risk factors
Physical Activity : By reducing body weight may have an indirect effect on BP
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
Saturated Fat : Increase BP as well as cholesterol
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.
206. Risk Factors for hypertension
Modifiable risk factors
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
208. Prevention of Hypertension
1. Population Strategy:
Reduction of salt intake
Moderate fat intake
Avoidance of high alcohol
Restriction of energy intake
209. Prevention of Hypertension
Weight Reduction : (BMI>25) obesity
Behavioral changes: reduction of stress.
210. Prevention of Hypertension
High risk strategy: Tracking of Blood pressure
Secondary prevention :
Early case detection
211. 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
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
212. 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,
Older Male Patients
213. Effect of periodontal infection
ISCHEMIC HEART DISEASE:
IHD is associated with atherogensis and thrombogenesis
Increased blood viscosity may promote IHD
Increase in FIBRINOGEN ,WBC COUNT,VON WILLEBRAND FACTOR
increases the risk of IHD
OVERALL 25% OF ALL STROKE PATEINTS HAD SIGNIFICANT DENTAL
Gingivitis and Radiographic bone loss independently associated with
risk of a cerebral ischemic event
Active periodontitis increases the prothromotic
state recurrent bacteremia, platelet
activation, increased clotting factors
220. 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
221. 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.
Chronic hyperglycemia, from whatever cause, leads to a number
of complications - cardiovascular, renal, neurological, and ocular
222. There are several types of diabetes:
TYPE I - Body does not produce any insulin.
TYPE II- Body is not making enough or is losing
sensitivity to insulin made.
GESTATIONAL DIABETES- diabetes during
IMPAIRED GLUCOSE TOLERANCE- an
intermediate between normal and diabetes.
Types of Diabetes
223. TYPE 1 OR INSULIN-DEPENDENT DIABETES
Characterized by beta cell destruction caused by an autoimmune process, usually leading to absolute insulin deficiency
Most severe form of the disease
Onset-typically abrupt and is usually seen in individuals<30 years of age
Usually associated with ketosis in its untreated state
Exogenous insulin is required to reverse the catabolic state, prevent ketosis, reduce the hyperglucagonemia and reduce
224. Type 2 or Non-insulin dependent diabetes
Characterized by insulin resistance in peripheral tissue and an insulin secretory defect
of the beta cell
Most common form of diabetes mellitus
Often discovered by chance
Typically gradual in onset and occurs mainly in the middle-aged and elderly, frequently
mild, slow to ketosis and compatible with long survival if given adequate treatment
227. Global scenario
382 million people have diabetes
90% Type II
The greatest number of people with diabetes are between 40 and 59 years of age
Asians shows more vulnerability
80% of people with diabetes live in low and middle income countries
Diabetes caused 5.1 million deaths in 2013
Every six seconds a person dies from diabetes
Diabetes is an "iceberg" disease.
This number is predicted to double by 2025 (a prevalence rate of about 5.4 per cent), with
the greatest number of cases being expected in China and India.
It is estimated that 20 per cent of the current global diabetic population resides in the
South-East Asia Region.
The number of diabetic persons in the countries of the Region is likely to triple by the
year 2025 increasing from the present estimates of about 30 million to 80 million.
Unfavorable modification of life-style and dietary habits that are associated with
urbanization are believed to be the most important factors for the development of diabetes.
230. Diabetes in the World
Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.
231. Diabetes in the World
Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.
235. 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
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.
236. World Capital of the Diabetes - India
The factors for this steep rise include
2. Insulin resistance
3. Central obesity
4. Genetic predisposition
237. Diabetes - a global threat
Diabetes is a global epidemic
It’s devastating effects on
1. Individual Quality of life
2. Social life
3. Economic impact
(a) Individual level
(b) Society & Country
238. MOHANet al: EPIDEMIOLOGY OF TYPE 2
Undiagnosed diabetes - the hidden danger
It is important to note that the studies that have shown an increase
in prevalence of diabetes have also reported a very high
prevalence of undiagnosed diabetes in the community.
In CURES, the prevalence of known diabetes was 6.1 per cent,
that of undiagnosed diabetes was 9.1 per cent.
The Kashmir valley study showed that the that the prevalence of
undiagnosed diabetes was 4.25 percent, which was more than
double to that of the known diabetes (1.9%)
The individuals who are unaware of their disease status are left
untreated and are thus more prone to microvascular as well as
240. Causes of the rise in prevalence of diabetes
Several studies on migrant Indians across the globe have shown that Asian Indians have an
increased risk for developing type 2 diabetes and related metabolic abnormalities compared to
other ethnic groups.
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
241. Fast food culture’ and ‘Sedentarinism’- The maindrivers of diabetes epidemic
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.
242. 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
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)
243. 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%)
249. Types of screening
1. Mass screening : General population
2. Opportunistic screening : A patient is screened for
diabetes while seeking medical attention for an
3. Targeted screening : At-risk population (High
251. 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.
255. Stages in the natural history of Diabetes
Manage the Agony
258. Aims of treatment
Achievement of as near-normal blood sugar levels as possible,
To maintain ideal body weight
Treatment is based on
Diet alone- small balanced meals frequently
Diet and oral antidiabetic drugs
Diet and insulin
Avoidance of the long-term complications : retinopathy, neuropathy, nephropathy,
and atherosclerotic events such as heart attacks, stroke, and peripheral
259. Glycated Hemoglobin
Also known as glycohemoglobin, glycosylated hemoglobin or HbA1c
Used to monitor treatment in patients with diabetes mellitus.
However, it is not recommended for routine diagnosis of this condition because of a
lack of standardization of tests and results
260. SELF CARE
In following lifestyle modifications
In taking medications regularly.
Self glucose monitoring
Periodic check ups
Recognition of symptoms of glycosuria,hypoglycemia.
Preventive care practices for eyes, kidneys, feet, teeth and gums
266. Objectives of Tertiary Prevention
To organize specialized DIABETIC CLINICS.
To provide diagnostic & management skills.
Clinical and epidemiological research
267. NATIONAL PROGRAMME FOR CONTROL &
PREVENTION OF DM,CVD & STROKE
Launched in January 2008
Prevention & control of NCD’s through integrated approach
Reduction of premature morbidity & mortality
Now integrated with National Cancer Control Programme and now called NPCDCS.
268. Urban health check-up scheme for diabetes
and high blood pressure
To screen urban slum population for diabetes and high blood pressure
To create database for prevalence of diabetes and high blood pressure in urban slums
To sensitize the urban slum population about healthy lifestyle
The blood sugar and blood pressure will be checked for all ≥ 30 years and all pregnant
woman of all age
269. Nalamana Tamizhagam
Government of Tamil Nadu’s Diabetes and Hypertension Prevention Initiative
Aim: To screen the population and identifying the risk factors in the rural populations in
Attained through health promotion, behaviour change in the community.
270. Prevention Awareness Counseling and
Evaluation(PACE) Diabetes programme
Is a large awareness and prevention programme underway in Chennai.
The aim of this programme which is funded by the Chennai Willingdon Corporate
Foundation, a non governmental organization (NGO) in Chennai,
It is to create massive public awareness about diabetes and related disorders
reaching out to about a million people and conduct large scale opportunistic
screening of at least 100,000 people.
Awareness programmes are being organized in public places like banks, shopping
complexes, cinema halls, places of worship, bus stands, railway stations, schools,
The PACE project is already having a large impact in the form of increased
Mass awareness programmes not only help in the prevention of diabetes, but also
help in increasing the awareness about other noncommunicable diseases.
272. PERIODONTAL DISEASE AND DIABETES -A TWO-WAY
STREET BRIAN L. MEALEY, DDS, MS
A large evidence base suggests that diabetes is associated with an increased
prevalence, extent and severity of gingivitis and periodontitis.
Furthermore, numerous mechanisms have been elucidated to explain the impact of
diabetes on the periodontium.
While inflammation plays an obvious role in periodontal diseases, evidence in the
medical literature also supports the role of inflammation as a major component in the
pathogenesis of diabetes and diabetic complications.
Research suggests that, as an infectious process with a prominent inflammatory
component, periodontal disease can adversely affect the metabolic control of diabetes.
Conversely, treatment of periodontal disease and reduction of oral inflammation may
have a positive effect on the diabetic condition, although evidence for this remains
There has recently been much emphasis on the ‘two-way’ relationship between
273. Studies show that the incidences of macroalbuminuria and end-stage renal
disease are increased twofold and threefold, respectively, in diabetic
individuals who also have severe periodontitis.
Furthermore, people with diabetes and severe periodontitis have a three
times higher risk of cardiorenal mortality compared with those without severe
274. Periodontal infection associated with
glycemic control in diabetes
Acute bacterial and viral infections have been shown to increase
insulin resistance and aggravate glycemic control.
Systemic infections increase tissue resistance to insulin,preventing
glucose from entering target cells ,causing elevated blood glucose
Pancreatic insulin production increases to maintain normalglycemia
276. Key points
• People with poorly controlled diabetes (both type 1 and type 2 diabetes mellitus, both
adults and children) must be considered at risk for periodontitis, and people with diabetes
should be informed of this risk.
• Early diagnosis and prevention are of fundamental importance to avoid the largely
irreversible tissue loss that occurs in periodontitis, and early referral of adults and children
with poorly controlled diabetes to dental clinicians is indicated for periodontal screening.
• Periodontal therapy in patients with diabetes is associated with improvements in glycaemic
control (HbA1c reductions of approximately 0.4%) that may be clinically relevant in the
management of diabetes.
• Oral health should be promoted in people with diabetes as an integral component of their
overall diabetes management.
• Closer collaboration between medical and dental clinical teams is necessary for the joint
management of people with diabetes and periodontitis, and contact with dentists is
important after the diagnosis of diabetes
277. DESHPANDEY K ETAL Diabetes and periodontitis, J Indian
Soc Periodontol. 2010 Oct-Dec; 14(4): 207–212
Periodontal disease and diabetes are strongly interrelated and have
Inflammatory events during periodontal disease may play an important
role in development of diabetes and insulin resistance probably facilitates
the progress of periodontal disease.
Diabetes acts as a risk factor in development of periodontitis as
periodontitis is significantly aggravated in patients suffering from
diabetes having long term hyperglycemia.
Different mechanisms underlying the association between the
accelerated periodontal disease and diabetes are emerging but still more
work is needed. Major efforts are required to elucidate the impact of
periodontal diseases on diabetes.
At the same time, patients are needed to be made aware of regular
periodontal maintenance schedule and oral hygiene.
278. Hypothetical model of association between periodontal disease and diabetes
showing the cascade of events contributing to periodontitis in combination with
diabetes with and without periodontal therapy
279. Park’s Textbook of Preventive and Social Medicine-22nd edition
IDF Diabetes Atlas-6th edition
D. Wayne Taylor, The Burden of Non-Communicable Diseases in India,
Hamilton ON: The Cameron Institute, 2010.
FDI POLICY STATEMENT NON COMMUNICABLE DISEASES ;Adopted by the FDI
General Assembly: 31 August 2012 – Hong Kong
Bonita R, deCourten M, Dwyer T, Jamrozik K, Winkelmann R. Surveillance of
risk factors for noncommunicable disease: the WHO STEPwise approach.
Geneva: World Health Organization; 2002. WHO document
Poul Erik Petersen,Denis Bourgeois, Douglas Bratthall, & Hiroshi Ogawa. Oral
health information systems — towards measuring progress in oral health
promotion and disease prevention.Bulletin of the World Health Organization