N.C.D Program for Prevention & Control of

Diabetes & Hypertension Status & Strategies

Dr. S.Sajith Kumar MD

Associate Professor in Community Medicine

T.D. Medical College,Alappuzha

Trends & Projections of NCDs in India

Diabetes• 2000: 32 million (WHO)• 2010: 51 million (International Diabetes Federation)• 2030: 80 million (WHO)

Cardio-vascular Diseases• 1998: 19 million (ICMR)• 2005: 38 million (Nat. Com. Macroeconomics & Health)• 2015: 64 million (Nat. Com. Macroeconomics & Health)

Cancer• Estimated number of persons with cancer: 2.8 million• Annual Incidence: 1 million

Percentage of NCD deaths, by cause in WHO Regions, 2008

0%

20%

40%

60%

80%

100%

% o

f De

ath

Other NCDs

Diabetes

Respiratorydiseases

Cancers

Cardiovasculardiseases

Four major NCDs cause 80% of deaths due to NCDs in all WHO RegionsSource: WHO global Health observatory 2011 http://apps.who.int/ghodata/

Distribution of deaths by major cause-India 2001-2003

Deaths due to NCDs outnumber deaths due to communicable diseases, maternal and perinatal

causes and nutritional conditions combined

Others 9.9% (N=11,242)

Communicable disease, maternal

& perinatal conditions, nutritional

deficiencies38.2%

(N=43,390)

Noncommunicable disease42.4%

(N=48,170)

Injuries9.6%

(N=10,890)

Source: RGI-CGHR Million Death Study

Disease Burden due to NCDs

• More than 20% of the population have at least one chronic disease

• More than 10% have more than one chronic disease

Mortality estimates due to NCDs

• Globally all deaths (2005) 58 million*• Globally deaths due to NCD (2005) 35 million*

(60.3%)

• All deaths in India (2004) 10.3 million #

• Deaths due to NCDs in India (2004) 5.2 million # (50.5%)

* Source: WHO

# Source: ICMR

Cancer Scenario: India

• Incidence: 10 lakhs /yr• Prevalence: 28 lakhs• Deaths from cancer: 5 lakh / year • Age group affected: 60-70% in 35-64 years • Tobacco related cancers about 40 %• 2/3rd cases in advance stage at the time of

diagnosis

• Common Cancers Breast, uterine cervix & oral cavity in females Oral cavity, lung & oesophagus in males  

Gaps in the natural history of NCDWeb of causation

Changes in life style stress

Abundance of food lack of physical activity smoking emotional

disturbance

aging

Obesity hypertension

Hyperlipidemia thrombotic tendency

changes

artery walls

Coronary arthrosclerosis coronary occlusionMyocardialinfarction

Gaps in the natural history of NCD3. Long latent period: it is the period

between the first exposure to suspected cause and the eventual development of disease. This makes it difficult to link suspected causes with outcomes.

4. Indefinite onset : Most (NCD) are slow in onset and development. Distinction between diseased and non diseased may be difficult to establish.

Prevention of NCDLevels of prevention1. Primordial

2. Primary

3. Secondary

4. Tertiary

1. Primordial prevention- Prevention of the emergence or development of risk factors in countries or population groups in which they have not yet appeared. Efforts are directed towards discouraging children from adopting harmful life styles.

2. Primary prevention- Action taken prior to the onset of disease which removes the possibility that the disease will ever occur. Can be divided into population & high risk strategy.

For healthy people

For unhealthy people

Prevention of NCDInterventions:• Health promotion• Specific protection• Adequate nutrition• Safe water and sanitation

3. Secondary prevention-Action which halts the progress of the disease at its incipient stage and prevents complications. Mostly curative. Disadvantage - patient has already suffered mental & physical anguish & community to loss of production. Often more expensive &less effective. Intervention – EARLY DIAGNOSIS AND TREATMENT

4. Tertiary prevention- defined as all measures available to reduce impairments & disabilities, minimize suffering due to departure from good health & promote patient’s adjustment to irremediable conditions.Intervention – DISABILITY LIMITATION AND REHABILITATION

Primary prevention

DiseaseDiseaseOutcomesOutcomes• Heart disease• Stroke• Diabetes• Cancer• Chronic resp.

disease

Physiological RFPhysiological RF• BMI (obesity)• Blood pressure• Blood glucose• Cholesterol

Behavioral RFBehavioral RF• Tobacco• Alcohol• Physical

inactivity• Diet

The causal chain

Primary prevention

(Health Promotion)

Secondary prevention(Case management &

Health promotion

Tertiary prevention

(Tertiary care)

Risk factors and level of NCD prevention Risk factors and level of NCD prevention and managementand management

Objectives

1. To prevent and control common NCDs through behavior and lifestyle changes

2. To provide early diagnosis and management of common NCDs

3. To build capacity at various levels of health care facilities for prevention, diagnosis and treatment of common NCDs

4. To develop trained human resource within Public Health set up

5. To establish and develop capacity for palliative & rehabilitative care

14

Components

• Prevention through behaviour change

• Early Diagnosis

• Medical treatment

• Capacity building of human resource.

• Supervision, monitoring and evaluation

Strategies of Programme

• Promotion of healthy lifestyle through behaviour change

• Opportunistic screening of persons above 30 yrs • Comprehensive examination, diagnosis and

management of cancer, diabetes, cardiovascular diseases and stroke

• Development of trained manpower • Strengthening of tertiary level health facilities • Programme management at centre, state and district

Implementation

5000 Sub-Centres

164 Community Health Centres

1000 PHC’s

14 Districts

Key Interventions for implementation of NPCDCS

Key Area Activities

Health Promotion

Public awareness through multi-media Counseling for healthy lifestyle (Balanced diet,

regular exercise, avoid alcohol and tobacco)

Early Diagnosis Screening of persons above 30 years and all pregnant women for diabetes and hypertension at all levels; facilities up to Sub-centre level

Case Management

Facilities for diagnosis and treatment

Capacity Building

Infrastructure Development & Equipment Training of human resources at all levels

Management & Monitoring

Surveillance, monitoring & evaluation Regular review meetings

Community Awareness • Training of health workers namely ASHA, ANM, and

Male Health Workers

• Health promotion activities in community, school and workplace settings through IPC, education, mass media etc.

• Opportunistic screening using measurement BP for hypertension and blood glucose by strip method for diabetes at community level

• Patient referral cards to facilitate referral & follow-up

NCD Services at Sub- Centre

Infra structure available

ANM (1) , Male Health worker(1)

Services proposed

• ‘Opportunistic Screening’ of > 30 years:

• NCD risk factors (dietary habits ,physical inactivity, alcohol abuse and tobacco use)

• Diabetes by blood sugar strip method

• Blood Pressure

• Referral to CHC