4. In Sri Lanka;
47%
10%
8%
10%
11%
14%
CVD & DM
Cancers
Respiratory Diseases
Other NCDs
Communicable diseases
Injuries
Percentage of mortality by cause in Sri Lanka 2014
8. Prevalence of four main behavioral risk factors
for NCDs in Sri Lanka
15%
72.50%
7.40%
22.50%
Smoking
Non consuming
fruits/vegetables
Alcohol consumption
Physical inactivity
9. Why ?? NCD Screening
• Long pre symptomatic phase before diagnosis
• Simple test to detect pre clinical disease are
readily available
• The duration of the disease is a strong
predictor of adverse outcomes
• Effective interventions are available to prevent
disease progression & reduce the
complication
10. Who should be screened ?
• Individuals who are ≥ 35 years of age
• Between 20-35 years of age
*Overweight
*Smoking
*Symptoms suggestive of diabetes
*Raised blood pressure
*History of premature CVD or Diabetes in
first degree relatives
*Familial Dyslipidemia
11. How do you screen ?
History : Inquiry about risk factors, past
illnesses, family history
Examination : Check height, weight and waist
circumference , measure blood
pressure
Calculate body mass index (BMI)
BMI = Body Weight (Kg)
(Height)2 m
12. Prevention of NCDs
Main areas to target in the prevention of NCDs;
Healthy diet
Physical activity
Stop smoking and alcohol use
Healthy body image
This is achieved though health education, continued support
and making facilities and resources available to the individual
and society, free access to essential healthcare
14. Diabetes Mellitus
Is a ;
group of metabolic diseases characterized by
hyperglycemia resulting from defects in insulin
secretion, insulin action, or both.
Can be classified;
• Type 1-diabetes :-autoimmune beta-cell
dysfunction
• Type 2-diabetes :-progressive loss of beta-cell
• Gestational diabetes :-diagnosed in the second or
third trimester of pregnancy
• Specific types of diabetes due to other causes
15. Diabetes can be diagnosed ;
Diagnosis FBS(FBG)
mg/dl mmol/L
2 hour PPBS
mg/dl mmol/L
HbA1C
Normal <100 <5.5 <140 <7.8 <5.7
Diabetes ≥126 ≥ 7.0 ≥200 ≥11.1 ≥6.5
Pre diabetes 100-125 5.5-6.9 140-199 7.8-11 5.7-6.4
18. What is GDM?
• Due to Hormonal changes in pregnancy
• Diabetes onset or first recognition during
pregnancy, is called gestational diabetes
mellitus
• Usually diagnosed between 24th and 28th
week of pregnancy
• Normal blood glucose levels before pregnancy
and after delivery
19. Adverse effects of diabetes
on baby
• Congenital malformations such as congenital
heart diseases, anencephaly and microcephaly
• Spontaneous miscarriages
• Sudden fetal death
• Macrosomia leading to birth injury
• Premature delivery
• Neonatal hypoglycaemia
• Neonatal jaundice
• Childhood obesity and metabolic syndrome
• Increased risk of developing diabetes in early life
20. Adverse effects of diabetes
on mother
• Increased risk of pre-eclampsia
• Worsening of pre-existing diabetic retinopathy
and nephropathy
• Increased tendency to develop infections such
as urinary tract infections
• Increase in the need for caesarean delivery
• Increased risk of developing type 2 diabetes
mellitus later in life
21. Tips for management of a female with
diabetes planning a pregnancy
• Diabetes needs to be optimized at least three months prior to planning
pregnancy
• Metformin and insulin are preferred
• Satisfactory blood glucose control is essential prior to conceiving (HbA1c
to a value of <7% and closer to 6%)
• Maintain ideal body weight
• Folic acid 5 mg per day at least one month prior to conception , after first
trimester reduced to1 mg
• Statins, ACE inhibitors, angiotensin receptor blockers are contraindicated
• Diabetic retinopathy and nephropathy screening (urine
albumin:creatinine ratio and serum creatinine) prior to conception
22. Screening for diabetes in pregnancy
• All pregnant females should be screened for diabetes
in pregnancy at the first contact
• If the screening test becomes negative, retest at a POA
of 24 -28 weeks
• Screening need not be done in already diagnosed
patients with diabetes mellitus.
• The recommended screening test is 2-hour oral glucose
tolerance test (OGTT)
23. Assessment
• Pre pregnancy BMI
• Pre pregnancy and Current weight
• Weight gain during pregnancy and rate of
weight gain
• 24 Hour dietary recall +/- food
• Frequency questionnaire to determine meal
trends, food
• Preferences and nutritional adequacy
• Physical activity
24. How do you perform an OGTT?
• No diet restriction in the previous 3 days
• Overnight fasting
• Minimum time required for fasting is 8 hours and
should not exceed 14 hours.
• On arrival, a blood sample is drawn for FBS
• 75 grams of glucose powder dissolved in a 300 ml
of water, should be taken within 5 minutes.
• Blood samples are drawn at one hour and two
hours, after the glucose load
25. How to diagnose pre-gestational
DM/GDM based on blood tests?
•Booking visit
FBS ≥ 126 mg/dL
PPBS ≥ 200 mg/dL
HbA1c ≥ 6.5%
If, FBS is 100 -125mg/dL OR PPBS is 140-199 mg/dL proceed to OGTT
•24 -28 weeks (GDM)
•If any one of the three cut-off values are exceeded, GDM can be
diagnosed .
Diagnose Pre gestational
DM
Fasting 1 hour 2 hour
Plasma glucose
cut-offs
≥100mg/dL
(5.1 mmol/L)
≥180mg/dL
(10.0 mmol/L)
≥140mg/dL
(8.5 mmol/L)
26. Management of diabetes during
pregnancy
• Educate the mother
• Refer to VOG for antenatal care
• Involves multi-disciplinary care
• GDM care has three stages
(a) before delivery,
(b) during delivery/immediate postpartum and
(c) after delivery.
27. Care before delivery
Management initiated with medical nutrition therapy (MNT).
Keep the blood sugar levels within the target range
Fasting PG : < 95mg/dL
2h postprandial PG : <120mg/dL
Check blood glucose (SMBG)
fasting state
two hours after each meal on daily basis.
Failing to do SMBG, both FBS and PPBS should be carried out.
28. MNT
Diet-based approach to patients, considering their medical,
psychological and dietary history, body weight and POA
Goals of MNT
• Adequate caloric and nutrients intake
• healthy and steady weight gain,
• glycaemic control
• healthy habits and lifestyle modification after delivery
Factors o be considered with MNT
• The current nutritional status
(Underweight/normal/Overweight/obese)
• Nutritional needs during pregnancy
• Dietary habits and food preferences
29. Tips on MNT
• An ideal dietary composition
45-55% carbohydrates ,15-20% protein , 20-30 % fat, less than 10% of saturated fat
• Consistent carbohydrate diet throughout the day
• Adjusting the type and amount of carbohydrate to achieve
the desired postprandial blood glucose is important
• Complex carbohydrates are preferred.
• Plate model
• Calorie allowance varied according to the nutritional status
• To space out food throughout the day
• Meal plan with 3 main meals alternating with 2-3 snacks
• To consume smaller portions of meals or snacks
• To avoid skipping main meals.
• To allow a variety of food every day from each food group.
• Limit foods with simple sugars.
31. Management of Diabetes
• Non pharmacological management
Lifestyle modification
• Pharmacological management
Oral drugs therapy and Insulin therapy
32. Important component of patient
education
• Nutritional management
• Physical activity
• How to use antidiabetic medication
• Monitoring blood glucose
• Preventing, detecting and treating acute
complications. Ex: Hypoglycemia
• Chronic complications such as Eye, foot problems
• Integrating psychological adjustment to daily living
• Promoting care prior to and during pregnancy
35. Dietary advices in Diabetes
S Simple
MMeasurable plate method
A Acceptable culturally
R Reproducible over a long time
T Time bounded to able to maintain
over a long period of time
36. Glycaemic Index and Glycaemic load
• Glycaemic index (GI) is;
foods according to their potential for
raising blood glucose or it is an index of
postprandial glycaemia
• Glycaemic load (GL) is ;
estimates the impact of carbohydrate
consumption using the GI while taking into
account the amount of carbohydrate that
is consumed.
GL= (GI × grams of carbohydrates) /100
37. Glycaemic Index and Glycaemic load ctd..
• GL is more useful than GI in clinical practice
• Some low GI foods may have relatively high GL
depending on the serving size
• A high GI food consumed in small quantities
would give the same effect as larger quantities
of a low GI food on blood sugar
• So, both quality and quantity of what is eaten
would matter
38. Some food items according to GI ;
Low GI foods Medium GI foods High GI foods
Peanut (14%) Parboiled rice (56%) Popcorn (72%)
Apple (38%) Ice cream (61%) Watermelon (72%)
Pittu (43.7%) White rice (64%) Pumpkin (75%)
Carrot (47%) Macaroni + cheese (64%) Doughnut (75%)
String hoppers (50%) Table sugar (65%) French fries (76%)
Rusk (50%) Samba rice (66.6%) Baked potato (85%)
Banana (52%) Wheat flour bread (68%) Glucose (100%)
40. Carbohydrates
• What are carbohydrates?
Starch, sugar and fiber
Carbohydrates turn into sugar in the body,
which will then raise your blood sugar level
• Limit carbohydrates
42. Grains
•Limit rice to 1-2 tea-cups per meal
•Limit bread to 2-3 slices per meal
•Try to have whole grains (e.g. unpolished rice)
43. Vegetables
•Fill half your plate with vegetables
•Limit starchy vegetables like jack fruit, bread
fruit, potatoes and sweet potatoes
•Have vegetables boiled, steamed, raw or
cooked (without coconut milk),
44. Fruits
• Eat fruits for snacks
• Don’t eat fruits with the main meal
• Limit fruits to the size of one tea-cup per serving
(e.g. one banana)
45. Protein Food
• Include protein foods in each main meal
• Limit red meats (beef and pork)
52. Step 4 – Physical Activity
• Be physically active and limit inactivity
• 30 minutes
• Moderate intensity (e.g. brisk walking)
• 5 days / week
• Can be done in 10-minute bouts
53. Step 5 – Manage your weight
• Maintain your weight
• If BMI >23, Lose 10% weight in 6
months
64. Diabetic Retinopathy
• Commonest cause of blindness among adults
• As diabetic retinopathy is asymptomatic in its
initial period,
• eye screening with dilated fundoscopy is the gold
standard to prevent the loss of vision
• Risk factors for Diabetic retinopathy are; Duration
of diabetes, Chronic hyperglycaemia, High blood
pressure, Renal disease, Hyperlipidaemia,
Pregnancy, Puberty Anaemia
65. Management of diabetic retinopathy
• Optimization of glycemic control
• Treatment of hypertension and
dyslipidaemia
• Ophthalmological referral when
necessary for specific
management.
67. Diabetic Kidney Disease(DKD)
• 20–40% of patients with diabetes
• The leading cause of end-stage renal disease
• The earliest clinical evidence of nephropathy is the
appearance of albuminuria
• Albuminuria is a marker of greatly increased
cardiovascular disease risk as well.
Screening for DKD :-
Assess annually in,
• All Type 2 DM patients since the time of diagnosis
• Type 1 DM patients with duration more or equal to 5
years or from puberty
68. Screening for Diabetic kidney disease
Urine for protein excretion
Urine for Albumin or
Spot urinary Albumin: Creatinine ratio (Urine for
Microalbumin- UMA)
Renal function testing Serum creatinine ± Estimated
GFR
• UACR >30µg/mg creatinine is considered as
microalbuminuria
• UACR 30 -300µg/mg creatinine is albuminuria
Should be repeated and confirmed 3-6 months apart
Exclude other causes of albuminuria
69. Management of DKD
• Optimize BP
• Optimize glycaemic control
* Drugs therapy
* Life style modification
• Oral drugs therapy -ACEI/ARB
71. Diabetic neuropathy
• One of the commonest and troublesome
complication which reduce quality of life in a diabetic
patient
• Screening
type 1- after 5 years
Type 2 – at the time of diagnosis
77. Hypertension is ;
Blood pressure values measured two times above
the cut-offs will need clinical assessment and
management.
SBP mmHg DBP mmHg
Normal blood pressure < 120 < 80
prehypertension 120-139 80-89
Stage 1 140-159 90-99
Stage 2 >160 >100
78. Hypertension can be categorized as…………
• Primary Hypertension (Essential hypertension) (90-95%)
Usually idiopathic, and may indicate a) risk for or b) the
existence of another disease – notably CHD, CVD, renal
disease, diabetes.
• Secondary hypertension (5-10%)
As part of another disease process (renal failure, drugs)
80. Treatment of hypertension
• To prevent target organ damage and reduce the
overall cardiovascular risk
• Commonly used anti-hypertensive medications are
– thiazide diuretics,
– angiotensin converting enzyme inhibitors (ACEI),
– angiotensin receptor blockers (ARB)
– long acting calcium channel blockers
81. Blood pressure goals
• BP < 140/90 mmHgAge <60
• BP < 150/90 mmHgAge > 60
• BP < 140/90 mmHgAll ages + DM
• BP < 140/90 mmHgAll ages + CKD
+/- DM
82. Tips on management of hypertension
• Screen all patients for active or passive smoking
• Encourage a healthy diet
• Reduce harmful use of alcohol
• Reduce salt intake to less than 5g/day (1 tea spoon)
• Encourage moderate to vigorous physical activity
• Educate patients on harmful effects of uncontrolled high
blood pressure
• Check compliance with anti-hypertensive medications
• Refer Females who are planning for a pregnancy may
need modification of their treatment
83. Blood pressure measurement
1. Seat the patient & Explain
2.Ask patient not to speak
3.Ensure patient’s back is supported
4.Ensure patient’s legs are
uncrossed
5.Ensure patient’s feet are flat on
the floor
6.Ensure patient’s arm is supported
7.Place the cuff mid-arm at heart
level
8.Place bottom of cuff 3 cm from
the fold of the elbow on bare arm
85. Dyslipidaemia
• Dyslipidaemia is one of the major contributors
of acute myocardial infarction (MI)
• Elevated levels of LDL-C are strongly
associated with atherosclerosis and
cardiovascular disease
• Increased levels of HDL have a protective
effect
86. Causes of dyslipidemia
1. Primary (genetic disorders)
2. Diabetes mellitus, hypothyroidism and certain
medications.
3. Sedentary lifestyle
4. Excessive dietary intake of saturated fat, cholesterol
and trans fats.
87. Diagnosis of dyslipidaemia
• Lipid profile ( 12 hours fasting)
• Includes
Total cholesterol (TC)
LDL-C, HDL
TG
Total cholesterol/HDL ratio
89. • several risk factors are taken in collection to
calculate and predict the 10-year risk of future
cardiovascular disease
• Depending on 10 year cardiovascular risk
status, primary preventive strategies are
applied
91. Tips on management of dyslipidaemia
• Educate patients that dyslipidaemia usually
causes no symptoms but leads to serious
outcomes
• Treatment reduces CVD risk
• Healthy diet and adequate physical activity
• Discuss the side effects of their medications
• Statins are contraindicated in pregnancy and
lactation
93. Ischaemic heart disease (IHD)
• Characterized by reduction of blood supply to the
cardiac muscles.
• Usually due to atherosclerosis.
• The greatest single cause of mortality and loss of
disability-adjusted life years worldwide
97. Definition of Stroke / Transient
ischaemic attack (TIA)
Stroke :
A clinical syndrome of rapidly
developing focal (or global)
cerebral dysfunction, lasting
more than 24 hours or leading to
death, of presumed vascular
origin
98. Definition of stroke / Transient
ischaemic attack (TIA)
TIA (Transient Ischaemic Attack):
TIA is traditionally defined as a clinical
syndrome of rapidly developing focal
cerebral or retinal dysfunction, lasting less
than 24 hours, of presumed vascular origin
(A new tissue based definition of ‘a transient episode of
neurological dysfunction caused by focal brain, spinal
cord, or retinal ischaemia, without acute infarction has
been suggested for TIA, but this has not been universally
accepted as it requires immediate MRI scanning of the
brain)
99. Prevention of stroke
Primary Prevention
• Risk assessment and modification of risk
factors.
• Treat Hypertension, diabetes, dyslipidaemia,
other cardiovascular and thrombogenic risk
factors appropriately .
• Anti platelet therapy and anticoagulants
101. Long term follow up of stroke
Rehabilitation.
Minimize overall cardiovascular risk
Prevent second stroke
102. Management of a stroke patient in
primary care level
• BP control
• Glycaemic control
• Drug compliance
• Life style modification
• Disability status: Motor power, speech,
activities of daily living
103. • Pain management
• Psychological status: Depression
• Sexual problems
• Recovery of social/ financial status
• Refer back to specialist care whenever needed
Management of a stroke patient in
primary care level
