Community Medicine

Epidemiology of Chronic Non-

Communicable Diseases and
Conditions
[Document subtitle]

Atul K Shankar
31
ESSAY
Discuss in brief the modifiable & non-modifiable risk factors in Coronary Heart
Disease. Explain some of the steps taken to prevent Coronary Heart Disease.
Modifiable Risk Factors for Coronary Heart Disease

The modifiable risk factors for CHD are:

- Cigarette smoking
- High Blood Pressure
- Elevated serum cholesterol
- Diabetes
- Obesity
- Sedentary habits
- Stress

Non-modifiable Risk Factors for Coronary Heart Disease

The non-modifiable risk factors for coronary heart disease are:

- Age
- Sex
- Family history
- Genetic factors
- Personality

Prevention of Coronary Heart Disease

Population Strategy:

- CHD is a mass disease and thus the strategy should be based on mass approach focusing
mainly on the control of underlying causes in the whole populations
- This approach is based on the principle that small changes in risk factor levels in total
populations can achieve the biggest reduction in mortality
- The aim should be to shift the whole risk-factor distribution in the direction of “biological
normality”
- The specific interventions are
o Dietary changes
 Reduction of fat intake to 20-30% of total energy intake
 Consumption of saturated fat is limited to 10% of total energy intake
 Reduction of dietary cholesterol
 Increase in complex carbohydrate consumption
 Avoidance of alcohol consumption
o Smoking
 To achieve the goal of smoke-free society, comprehensive health
programmes would be required
o Blood Pressure
 Small reduction of blood pressure by even 2-3mmHg would produce a large
reduction in the incidence of cardiovascular complications
 The goal would be to reduce the mean population blood pressure levels
 This involves a multifactorial approach based on a prudent diet
 o Physical Activity
 Regular physical activity should be a part of normal daily life
 It is important to encourage children to take up physical activities that they
can continue throughout their life

High-Risk Strategy:

- Identifying Risk
o High risk intervention can only start one those at high risk is identified
o By means of measuring blood pressure and serum cholesterol, it is possible to
identify individuals at special risk
o Individuals at special risk include
 Smokers
 Familial history of CHD
 Diabetes
 Obesity
 Young women using oral contraceptives
- Specific Advice
o Having identified the high-risk group, next step is to bring them under
preventative care and motivate them to take positive action against all the
identified risk factors
o High risk approach suffers from disadvantage that the intervention may be
effective in reducing the disease to the same extent in the general population

Secondary Prevention:

- Must be seen as a continuation of primary prevention

- It forms an important part of an overall strategy
- The aim is to prevent the recurrence and progression of CHD
- It is a rapidly expanding field with much research in progress
o Drug trials
o Coronary surgery
o Use of Pacemakers
- The principles are same as those set out for the population and high-risk strategy
- Most promising results have come from beta-blockers which appear to reduce the risk of
CHD mortality
- Despite advances in treatment, mortality of an acute heart attack is still high

Vision 2020
- Known as ‘VISION 2020 : The Right to Sight
- It is a global initiative to eliminate avoidable blindness
- It was launched by WHO on 18th February 1999
- One significant way in which this initiative differs from previous ones is that the concept
centres around Rights issues
- Recognition of sight as a fundamental human right by all countries can be an important
catalyst of initiatives for prevention and control of blindness
- The objective is to assist member countries in developing sustainable systems which will
enable them to eliminate avoidable blindness from major causes
o Cataract
o Xerophthalmia
SHORT NOTES
Diet in Coronary Heart Disease
The dietary changes required in Coronary Heart disease is a principal preventive strategy in the
prevention of CHD.

WHO consider the following dietary changes to be appropriate for high incidence populations:

- Reduction of Fat Intake to 20-30% of total energy intake

- Consumption of Saturated fats must be limited to less than 10% of total energy intake
o Some of the reduction in saturated fat may be made up by mono- and poly-
unsaturated fats
- Reduction of dietary cholesterol to below 100 mg per 1000 kcal per day
- An increase in complex carbohydrate consumption (i.e. vegetables, fruits, whole grains,
legumes)
- Avoidance of alcohol consumptions; reduction of salt intake to 5 grams daily or less

Risk Factors of Diabetes Mellitus

- Agent Factors
o Pancreatic disorders
o Defects in the formation of insulin
o Destruction of beta cells
o Decreased insulin reactivity
o Genetic defects
- Host Factors
o Age – prevalent in middle years of life
o Sex – equal male to female ratio
o Genetic factors and markers
o Immune mechanisms
o Obesity
o Maternal diabetes
- Environmental Risk Factors
o Sedentary Lifestyle
o Diet
o Dietary Fibre
o Malnutrition
o Alcohol
o Viral infections
o Chemical Agents
o Stress
- Social Factors
o Occupation
o Marital status
o Religion
o Economic status
o Education
o Urbanization
o Lifestyle changes
 Avoidable Blindness
- The concept of avoidable blindness has gained increasing recognition during the years
- Many causes of blindness lend themselves to prevention or control by treating the cases of
infectious diseases, or by controlling the organisms which cause the infection, or by
improving safety conditions
- The components for action in national programmes include
o Initial Assessment
 First step is to assess the magnitude, geographic distribution and causes
of blindness within the country
 This is essential for setting the priorities and development of appropriate
intervention programmes
o Methods of Intervention
 Primary Eye Care
 Essential drugs such as topical tetracycline, vitamin A capsules,
eye bandages, shields, are provided to locally trained primary
health workers
 These aid in first line, grassroot health care of eye conditions
 Secondary Care
 Definitive management of common blinding conditions
 This is provided in PHCs and district hospitals
 May involve the use of mobile eye clinics
 Tertiary Care
 Services are established in the national or regional capitals
 Provides sophisticated eye care such as retinal detachment
surgery, corneal grafting and other complex forms of
management
 Other measures of rehabilitation include education of the blind in
special schools and utilization of there services
 Specific Programmes
 Trachoma control
 School eye health services
 Vitamin A prophylaxis
 Occupational eye health services
o Long Term Measures
 Aimed at improving the quality of life and modifying or attacking the
factors responsible for persistent eye health problems
 health education is an important long-term measure in order to
 create community awareness of the problem
 motivate community
 accept total eye health care programmes
 secure community participation
o Evaluation
 Integral part of intervention programmes
 Measures the extent to which ocular diseases and blindness have been
alleviated, assess the manner and degree to which programmes are
carried out, and determine the nature of changes produced
 Obesity
Obesity is defined as an abnormal growth of the adipose tissue due to an enlargement of fat cell
size or an increase in fat cell number or a combination or both.

It is expressed in terms of BMI (body mass index), with overweight is usually due to obesity but
can arise from other causes such as abnormal muscle development or fluid retention.

- Prevalence
o Obesity is the most prevalent form of malnutrition
o As a chronic disease, it is prevalent in both developed and underdeveloped
countries, and increasingly affecting children
o One of the most significant contributors to ill health
- Epidemiology
o Age
 Obesity can occur at any age, and increases with age
 Most adipose cells are formed early in life and obese infant lays down more
of these cells than the normal infant
o Sex
 Women generally have a higher rate of obesity than men
o Genetic Factors
 There is a genetic component to the etiology of obesity
o Physical Inactivity
 Regular physical exercise is protective against unhealthy weight gain
 Major reduction in activity without the relative reduction in energy intake
is a major cause of increased obesity
o Socio-economic Status
 Relationship of obesity to social class is well established
 Obesity has been found to be more prevalent in the lower socio-economic
groups
o Eating habits
 Eating habits are established very early in life
 Diet containing more energy than needed leads to prolonged post-
prandial hyperlipidaemia and to the deposition of triglycerides in the
adipose tissue
o Psychological Factors
 Overeating can be a symptom of depression, anxiety, frustration and
lonliness in childhood as it is in adult life
- Assessment of Obesity
o Body Weight
 Body Mass Index = Weight/Height
 Ponderal Index = Height / Cube root of body weight
 Brocca Index = height - 100
𝐻𝑒𝑖𝑔ℎ𝑡−150
 Lorentz’s Formula = Height – 100 - 2 (𝑤𝑜𝑚𝑒𝑛) 𝑜𝑟 4 (𝑚𝑒𝑛)
 Corpulence Index = Actual weight / desirable weight
 Should not exceed 1.2
o Skinfold Thickness
o Waist Circumference and Waist Hip Ratio
 Danger Signals of Cancer
The early warning signs, or ‘danger signals’ of cancer are:

- Lump or hard area in the breast

- Change in a wart or mole
- Persistent change in digestive and bowel habits
- Persistent cough or hoarseness
- Excessive loss of blood at a monthly period or a loss of blood outside of the usual cycle
- Blood loss from any natural orifice
- Swelling or sore that does not get better
- Unexplained loss of weight

Screening Methods for Cancer

Screening for Cancer Cervix:
- Prolonged early phase of cancer in situ is detected by the Pap smear
- This requires excessive resources in terms of labs, equipment and personnel
- This has led to an alternative screening methods
o Visual Inspection with Acetic Acid (VIA)
o VIA with Magnification (VIAM)
o Visual Inspection Post-application of Lugol’s Iodine (VILI)

Screening for Breast Cancer:

- The basic techniques for early detection of breast cancer are:

o Breast Self-examination by the patient
 Probably the only feasible approach to wide population coverage
o Palpation by a physician
 Unreliable for large fatty breasts
o Thermography
 Has the advantage that patient is not exposed to radiation
o Mammography
- The use of mammography has 3 potential drawbacks;
o Exposure to radiation
o Mammography requires technical equipment of a high standard and radiologists
with very considerable experience
o Biopsy from a suspicious lesion may end up as a false-positive in as many as 5-10
cases

Screening for Lung Cancer:

- At present there is only 2 techniques for screening for lung cancer

o Chest Radiograph
o Sputum Cytology
- Mass radiography has been suggested for early diagnosis at six monthly intervals
- It is doubtful whether the disease satisfies the criteria of suitability for screening
 Importance of Tracking of Blood Pressure
- If blood pressure levels of individuals were followed up over a period of years from early
childhood into the adult life, then those individuals whose pressure were high in the
distribution, would continue in the same track as adults
- Low blood pressure levels tend to remain low, and high levels tend to become higher as
individuals grow older
- this phenomenon of persistence of rank order is described as tracking
- this knowledge can be applied in identifying children and adolescents at risk of
developing hypertension at a future date.

Assessment of Obesity
Body Weight

- Body Mass Index = Weight/Height

- Ponderal Index = Height / Cube root of body weight
- Brocca Index = height – 100
𝐻𝑒𝑖𝑔ℎ𝑡−150
- Lorentz’s Formula = Height – 100 –
2 (𝑤𝑜𝑚𝑒𝑛) 𝑜𝑟 4 (𝑚𝑒𝑛)
- Corpulence Index = Actual weight / desirable weight
o Should not exceed 1.2

Skinfold Thickness

- Large proportion of total body fat is located just under the skin
- The method most used is measurement of skinfold thickness
- It is a rapid and non-invasive method for assessing body fat
- The measurement may be taken at all the 4 sites – mid-triceps, biceps, subscapular,
suprailiac regions
- The sum of measurements should be less than 40 mm in boys and 50 mm in girls
- In extreme obesity, measurements may not be impossible
- The main drawback is poor repeatability

Waist Circumference and Waist Hip Ratio

- Waist Circumference
o Measured at the mid-point between the lower border of the rib cage and the iliac
crest
o It is a convenient and simple measurement that is unrelated to height, correlates
closely with BMI and WHR
o It is an appropriate index of intra-abdominal fat mass and total body fat
- There is an increased risk of metabolic complications for men with a waist circumference
or more than 102 cm and women with a circumference of more than 88 cm

Other Measures:

- Total body water

- Total body potassium
- Total body density