Non-Communicable Diseases-Introduction

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Non-Communicable Diseases: NPCDCS & NPHCE:

Non-Communicable Diseases: NPCDCS & NPHCE State Institute of Health & Family Welfare, Jaipur 1 SIHFW: an ISO 9001:2008 certified Institution

Structure of Presentation:

Structure of Presentation NCD? Why NCDs – Epidemiological Transition Risk factors Burden of NCDs Impact Interventions NPCDCS & NPHCE 2 SIHFW: an ISO 9001:2008 certified Institution

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Risk factors and NCDs 4 largely preventable , and Manageable 3 SIHFW: an ISO 9001:2008 certified Institution

NCDs: some attributes:

NCDs: some attributes Cause –largely unknown, Risk factors Non infectious, Latent period, Indefinite onset Long Duration, slow progression Non reversible changes Leading causes of death-63% of all deaths, 36% in low & middle income countries No gender bias Preventable by modifying risk factors 4 SIHFW: an ISO 9001:2008 certified Institution

Drivers of NCDs:

Drivers of NCDs 5 SIHFW: an ISO 9001:2008 certified Institution

Major NCDs :

Major NCDs Cardiovascular ( HT, CAD, stroke ) Renal (Nephritis, Nephrotic syndrome) Nervous and mental ( mania, depression) Musculoskeletal ( arthritis) Respiratory (asthma, emphysema, bronchitis) Cancer Diabetes Obesity Blindness Degenerative disorders Accidents 6 SIHFW: an ISO 9001:2008 certified Institution

Why talk of NCDs :

Why talk of NCDs Epidemiological Transition 7 SIHFW: an ISO 9001:2008 certified Institution

Achievements in Health Sector:

Achievements in Health Sector Crude Death Rate has ↓ Crude birth rate is ↓ Life expectancy has ↑ Smallpox and guinea worm eradicated Leprosy has been eliminated Polio at the verge of eradication( No case since Feb. 2011) IMR ↓ Health care infrastructure – expanded 8 SIHFW: an ISO 9001:2008 certified Institution

Epidemiological Transition:

Epidemiological Transition Communicable diseases continue to be a public health problem Emerging & Re-emerging infections Non-communicable disease are on the rise co-existence of communicable diseases and increasing burden of non-communicable diseases 9 SIHFW: an ISO 9001:2008 certified Institution

Challenges:

Challenges ↑ Non-communicable diseases Cancers CVDs – CAD, hypertension Obesity Endocrine disorders Chronic bronchitis and Asthma Psychiatric illnesses Causes – ↑ longevity, ↑ proportion of geriatric population, (2000 to 2025 pop. >60 shall go from 4.4% to 7.7%) lifestyle changes, etc. 10 SIHFW: an ISO 9001:2008 certified Institution

Challenges:

Challenges Many communicable diseases continue to exist as a public health problem Malaria TB New emerging and re-emerging infections Plague Dengue fever / DHF / DSS Chikungunya HIV infection / AIDS 11 SIHFW: an ISO 9001:2008 certified Institution

Challenges in NCD control & Prevention:

Challenges in NCD control & Prevention Lack of partnerships between different sectors Weak surveillance Limited access to prevention & Treatment Limited Human resource Limited fund allocation Limited commitment of Industry & Pvt. Sector 12 SIHFW: an ISO 9001:2008 certified Institution

What is the Burden of NCDs:

What is the Burden of NCDs 13 SIHFW: an ISO 9001:2008 certified Institution

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Iceberg of NCDs What the physician does not see What the physician sees 14 SIHFW: an ISO 9001:2008 certified Institution

Magnitude:

Magnitude SEAR-2008: 14.5million total deaths 7.9 million (55%) due to NCDs (34% occurred before the age of 60 years v/s 23% in World). 25% for CVDs, 7-8% cancer, 2.1% Diabetes 22% of the global NCD deaths occur in the South-East Asia Region. Hypertension, raised blood glucose and tobacco use account for 3.5 million annual deaths in the region A 21% increase in NCD deaths is projected in the Region over the next 10 years. Source: NCD in SEA region: situation & response, 2011 , report by WHO 15 SIHFW: an ISO 9001:2008 certified Institution

Estimated % of deaths by cause, SEA Region, 2008:

Estimated % of deaths by cause, SEA Region, 2008 Source: Global Health Observatory. WHO 2011. 16 SIHFW: an ISO 9001:2008 certified Institution

Estimated %of premature deaths (<60 years), by cause, SEA Region v/s rest of the world, 2008:

Estimated %of premature deaths (<60 years), by cause, SEA Region v/s rest of the world, 2008 SEAR has a higher proportion of premature NCD deaths than the rest of the world Source: Global Health Observatory. World Health Organization 2011. 17 SIHFW: an ISO 9001:2008 certified Institution

Age-standardized mortality rates per 100 000 population by sex, South-East Asia Region, 2008:

Age-standardized mortality rates per 100 000 population by sex, South-East Asia Region, 2008 NCD mortality rates are higher in males than females Source: Global Health Observatory. World Health Organization 2011. 18 SIHFW: an ISO 9001:2008 certified Institution

Trends in estimated %of deaths by cause of death, SEA Region, 2004 and 2030 :

Trends in estimated %of deaths by cause of death, SEA Region, 2004 and 2030 Source: Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine 2006, 3(11):e442. 19 SIHFW: an ISO 9001:2008 certified Institution

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Estimated & Projected Burden of Diabetes & CAD, India 20 SIHFW: an ISO 9001:2008 certified Institution

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Estimated and Projected Deaths due to CAD, India 21 SIHFW: an ISO 9001:2008 certified Institution

Source: World Health Organization - NCD Country Profiles , 2011. :

Source: World Health Organization - NCD Country Profiles , 2011 . Total NCD deaths 2.96 M(Males) 2.273 M( Females) % of Deaths under 60 yrs. Males: 38.0 Females: 32.1 22 SIHFW: an ISO 9001:2008 certified Institution NCD deaths-India(2008)

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Pop.(2010): 1 224 614 327 Age standardized Death rates/ 100000 Total NCD deaths Males Females 781.7 571.0 Cancers 78.8 71.8 Chr. Resp. dis. 178.4 125.5 Cardiovascular diseases and diabetes 386.3 283.0 Source: World Health Organization - NCD Country Profiles , India ,2011 . 23 SIHFW: an ISO 9001:2008 certified Institution

Proportional mortality (% of total deaths, all ages):

Proportional mortality (% of total deaths, all ages) Source: World Health Organization - NCD Country Profiles , India, 2011 . 24 SIHFW: an ISO 9001:2008 certified Institution

Metabolic Risk factor Trends:

Metabolic Risk factor Trends 25 SIHFW: an ISO 9001:2008 certified Institution

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26 SIHFW: an ISO 9001:2008 certified Institution

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27 SIHFW: an ISO 9001:2008 certified Institution

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28 SIHFW: an ISO 9001:2008 certified Institution

Reported Cases & Deaths due to NCD-Rajasthan:

Reported Cases & Deaths due to NCD-Rajasthan Source-DM&HS 29 SIHFW: an ISO 9001:2008 certified Institution

Diseases wise Reported Cases:

Diseases wise Reported Cases Source-DM&HS 30 SIHFW: an ISO 9001:2008 certified Institution

Total Number of Diabetic Cases -Rajasthan:

Total Number of Diabetic Cases -Rajasthan Source: DM &HS-Rajasthan 31 SIHFW: an ISO 9001:2008 certified Institution

District wise Reported Cases of Type 1 DM-Rajasthan:

District wise Reported Cases of Type 1 DM-Rajasthan Source: DM &HS-Rajasthan Jan-Dec 2010 32 32 SIHFW: an ISO 9001:2008 certified Institution

Reported Deaths :Type 1 DM-Rajasthan:

Reported Deaths :Type 1 DM-Rajasthan District Deaths Male Female Ganganagar 2 0 Jhunjhunu 48 34 Nagaur 0 1 Jalore 2 0 Jhalawar 1 0 Total 53 35 Source: DM &HS-Rajasthan Jan-Dec 2010 33 33 SIHFW: an ISO 9001:2008 certified Institution

District wise Reported Cases of Type 2 DM:

District wise Reported Cases of Type 2 DM Source: DM &HS-Rajasthan Jan-Dec 2010 34 SIHFW: an ISO 9001:2008 certified Institution

Reported Deaths of Type 2 DM:

Reported Deaths of Type 2 DM District Deaths Male Female Ganganagar 3 3 Junjunu 9 1 Karauli 0 1 Jaipur 38 24 Pali 2 1 Total 52 30 Source: DM &HS-Rajasthan Jan-Dec 2010 35 35 SIHFW: an ISO 9001:2008 certified Institution

Reported Cases of Cancer-Rajasthan :

Reported Cases of Cancer-Rajasthan Source -DM&HS 36 SIHFW: an ISO 9001:2008 certified Institution

Reported Cases of Deaths Due to Cancer-Rajasthan :

Reported Cases of Deaths Due to Cancer-Rajasthan Source -DM&HS 37 SIHFW: an ISO 9001:2008 certified Institution

District –wise reported cancer cases-Rajasthan:

District –wise reported cancer cases-Rajasthan Source -DM&HS (Jan to July.2011) SIHFW: An ISO:9001:2008 certified Institution 38

District –wise reported Cancer Deaths:

District –wise reported Cancer Deaths District Male Female Ganganagar 1 1 Jaipur 46 23 Jalore 2 0 Pali 2 2 Jhalawar 2 0 Total 53 26 Source -DM&HS (Jan to July.2011) SIHFW: An ISO:9001:2008 certified Institution 39

Expenditure on Cancer Prevention:

Expenditure on Cancer Prevention 2007-08 (Rs in crores ) 2008-09 (Rs in crores ) 2009-10 (Rs in crores ) 2010-11 (Rs in crores ) Cancer Control 60.30 142.46 69.65 85.00 NCCP 46.30 33.60 28.25 55.00 Tobacco control 13.98 33.86 16.40 30.00 Source-NHP 2010 SIHFW: An ISO:9001:2008 certified Institution 40

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Impacts of NCD SIHFW: An ISO:9001:2008 certified Institution 41

Why NCDs considered a burden:

Why NCDs considered a burden Disease occurrence (Incidence+ Prevalence) is increasing Lifestyles are changing  ↑ risk ↑ life expectancy  ↑ in absolute numbers of elderly persons ↓ Crude Birth Rate compounded with ↑ life expectancy  ↑ in proportion of geriatric population (or geriatric dependents) Thus, occurrence of cases of NCDs is expected to increase further with time SIHFW: An ISO:9001:2008 certified Institution 42

Implications of ↑ burden of NCDs:

Implications of ↑ burden of NCDs ↑ Budgetary allocation to prevention and control of NCDs Impoverishment of already poor on account of continued treatment over long periods ↑ investment in human resources for health sector  more doctors, more nurses, more LTs, more dieticians, etc. ↑ investment of drugs  further ↑ in non-affordability of many for treatment Effect on society – nuclear families, etc. SIHFW: An ISO:9001:2008 certified Institution 43

NCD Impacts on MDG:

MDG-2 (universal primary education) Costs for NCD health care, medicines, tobacco and alcohol consumption eat on household resources that might be available for education. Problem acute in poor families MDGs 4 and 5 (Maternal and Child health) Rising prevalence of high BP & gestational diabetes increasing the adverse outcomes of pregnancy & maternal health Mothers who smoke & breastfeed for shorter period & have lower quantities of milk that is less nutritious Exposure to second-hand tobacco smoke increases the risks of childhood RI , Sudden infant death and Asthma NCD Impacts on MDG SIHFW: An ISO:9001:2008 certified Institution 44

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MDG-6 ( Combat HIV/AIDS, malaria and other diseases) NCD burden threatens the possibility to effectively control tuberculosis MDG-8 ( Provide access to affordable essential drugs in developing countries) access to essential drugs are limited largely to AIDS, TB & Malaria SIHFW: An ISO:9001:2008 certified Institution 45

Economic Impact:

Economic Impact loss of productivity -absenteeism and inability to work Each 10% rise in NCDs is associated with 0.5% lower rate of annual economic growth macroeconomic analysis From 2005 to 2015, India lost $ 237 billion (1.5% of the GDP). SIHFW: An ISO:9001:2008 certified Institution 46

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2% annual reduction in Chronic Disease Death Rates in India will result in economic gain of 15 billion dollars over the next 10 years WHO Per-capita income in India would increase by 87%. Source-Report of the Working Group on Disease Burden for 12th Five Year Plan SIHFW: An ISO:9001:2008 certified Institution 47

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SIHFW: An ISO:9001:2008 certified Institution 48

Answer to the problem: ACT NOW:

Answer to the problem: ACT NOW Preventive Strategies for NCDs SIHFW: An ISO:9001:2008 certified Institution 49

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Early Pathogenesis- Tissue changes Tissue changes Pre-Pathogenesis-A, H, E interaction Pathogenesis Levels of Prevention Primary Secondary Tertiary Health. Promotion Specific Protection Susceptibility Pre-symptomatic stage Clinical disease Early diagnosis Treatment Disability Limitation/ Rehabilitation Death Recovery Disability Chronic state Convalescence Preven-tion . Modes Immunity & Resistance 50 SIHFW: an ISO 9001:2008 certified Institution

Cost effective interventions:

Cost effective interventions Risk factor/disease Interventions Tobacco use: Protect people from tobacco smoke Warn about the dangers of tobacco Enforce bans on tobacco advertising Raise taxes on tobacco Use of alcohol : Enforce bans on alcohol advertising Restrict access to retailed alcohol Raise taxes on alcohol Unhealthy diet: Reduce salt intake in food Replace trans fat with polyunsaturated fat Cardiac diseases and diabetes: Provide counseling and multi-drug therapy (including glycaemic control for diabetes mellitus) for people with 10-year cardiovascular risk >30% Treat acute myocardial infarction (with aspirin) Cancers Hepatitis B vaccination to prevent liver cancer Detection and treatment of precancerous lesions 51

General Objectives:

General Objectives To strengthen prevention and control of chronic non-communicable diseases by tackling the major risk factors To reduce premature mortality and morbidity, and To improve quality of life SIHFW: An ISO:9001:2008 certified Institution 52

Action at National Level: NPCDCS:

Action at National Level: NPCDCS Two components Cancer Diabetes, Cardiovascular Diseases & Stroke SIHFW: An ISO:9001:2008 certified Institution 53

NPCDCS :Objectives:

NPCDCS :Objectives Prevent and control common NCDs through behavior and life style changes, Provide early diagnosis and management of common NCDs, Build capacity at various levels of health care for prevention, diagnosis and treatment of common NCDs, Train human resource within the public health setup and Establish and develop capacity for palliative & rehabilitative care. SIHFW: An ISO:9001:2008 certified Institution 54

Strategies:

Strategies Prevention through behavior change Early Diagnosis Treatment Capacity building of human resource Surveillance, Monitoring & Evaluation SIHFW: An ISO:9001:2008 certified Institution 55

States to Implement NPCDCS:

States to Implement NPCDCS SIHFW: An ISO:9001:2008 certified Institution 56

Services :

Services Preventive, promotive , curative and supportive services (core and integrated services) Health promotion, psycho-social counseling, management (out-and-in-patient), day care services, home based care, palliative care and referral Linkages of District Hospitals to private laboratories and NGOs for continuum of care and support for outreach services. SIHFW: An ISO:9001:2008 certified Institution 57

Services::

Services: Facility level Services PHC Health promotion for behavior change; ‘Opportunistic’ Screening using B.P measurement and blood glucose by strip method ; Referral of suspected cases to CHC CHC Prevention and health promotion including counseling ; Early diagnosis through clinical and laboratory investigations (Common lab investigations: Blood Sugar, lipid profile, ECG, Ultrasound, X ray etc.); Management of common CVD, diabetes and stroke cases (out patient and in patients.); Home based care for bed ridden chronic cases ; Referral of difficult cases, HMIS SIHFW: An ISO:9001:2008 certified Institution 58

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Facility Services DH Early diagnosis of diabetes, CVDs, Stroke and Cancer ; Investigations: Blood Sugar, lipid profile, Kidney Function Test (KFT),Liver Function Test ( LFT), ECG, Ultrasound, X ray, colposcopy , mammography etc. (if not available, will be outsourced); Medical management of cases ( out patient , inpatient and intensive Care ) ; Follow up and care of bed ridden cases; Day care facility; Referral; Health promotion for behavior change ; Trainings, HMIS SIHFW: An ISO:9001:2008 certified Institution 59

Services available under NPCDCS at different levels :

Services available under NPCDCS at different levels Tert . Level District hospital NCD Clinic Cardiac Care Unit Cancer Care Facility Sub Centre Screening facility (Health Promotion; Opportunistic Screening; Referral) CHC NCD Clinic (Early diagnosis & mgt. Laboratory Investigations, Home based care, Referral Institutional Framework Public Health Infrastructure Services Ref. Tertiary cancer care centers in Medical Colleges/RCC Health Promotion; Early diagnosis & management; Home Based Care; Day Care Facility State NCD District NCD Cell Block CHC (Rogi Kalyan Samiti) Village Health Committee National NCD SIHFW: An ISO:9001:2008 certified Institution 60

Institutional Framework:

Institutional Framework Integration with NRHM TRGs( One for Cancer, other for CAD, S, & D) State Health Society NPCD cells Retain funds for state level activity and release GIA to the District Health Societies. District Health Societies NPCD cells Utilization of funds and quarterly the financial management report SIHFW: An ISO:9001:2008 certified Institution 61

State NCD cell :

State NCD cell Composition State Program Officer 2. Program Assistant 3. Finance cum Logistics Officer 4. Data Entry Operators (2) ToR State action plan Develop district wise NCD mapping, Trainings Manpower Fund flow and SOE/ UCs epidemiological profiling Convergence with NRHM Availability of palliative and rehabilitative services Monitoring Public awareness SIHFW: An ISO:9001:2008 certified Institution 62

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What Medical Officer can do SIHFW: An ISO:9001:2008 certified Institution 63

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Surveillance Screening Services Statistics SIHFW: An ISO:9001:2008 certified Institution 64

MO to do: :

MO to do: Screening To conduct comprehensive examination to diagnose, investigate and manage the cases appropriately. To rule out complications or advanced stage. To refer complicated cases to higher care facility To provide follow up care to the patients Health promotion Data and record SIHFW: An ISO:9001:2008 certified Institution 65

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Health promotion activities – ( i )Educate regarding common risk factors, increased intake of healthy foods (ii) increased physical activity through sports, exercise, etc. (iii) avoidance of tobacco and alcohol and (iv) stress management. Risk assessment and management through opportunistic screening Motivate and create role models in the community SIHFW: An ISO:9001:2008 certified Institution 66

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Work closely with other sectors/ departments for NCD prevention Management of patients suffering from Cancer, Diabetes, CVDs and Stroke referred from different centers Establish an effective referral mechanism with the nearest medical colleges Supervision of the activities undertaken by paramedical workers Assist resource centers/ institution in organizing the training for different cadre of health workers SIHFW: An ISO:9001:2008 certified Institution 67

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Nursing staff: To assist in examination and investigation To teach the patient and family about risk factors of NCDs and promote patients wellbeing To assist in follow up and care Counselor: To provide counseling on diet and life style management To assist in follow up care and referral SIHFW: An ISO:9001:2008 certified Institution 68

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Surveillance? Surveillance is the ongoing collection, analysis, and use of health data for the planning, implementation, and assessment of disease control "information for action” SIHFW: An ISO:9001:2008 certified Institution 69

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Identify extent of the problem Map emerging patterns and trends Measure progress in primary prevention Contribute to policy making Surveillance helps SIHFW: An ISO:9001:2008 certified Institution 70

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… selected risk factors associated with major NCDs and amenable to interventions. … simple surveillance systems. … standard definition and methods. … surveillance for primary prevention of NCDs . Risk Factor Surveillance: Focus SIHFW: An ISO:9001:2008 certified Institution 71

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Selecting risk factors Greatest impact on NCD mortality and morbidity; Modifiable by intervention; Validated measurement; Meaningful comparisons possible; Measurement can be obtained following ethical standards. SIHFW: An ISO:9001:2008 certified Institution 72

Risk factors common to major non-communicable conditions :

Risk factors common to major non-communicable conditions Risk Factor Condition CAD Diabetes Cancer Respiratory Smoking     Alcohol   Nutrition   Physical Inactivity    Obesity     BP   Blood glucose    Blood Lipids    SIHFW: An ISO:9001:2008 certified Institution 73

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Step 3 Comprehensiveness Complexity Step 2 Step 1 Core Expanded Optional The WHO STEP approach to Surveillance of NCD Risk Factors At each step SIHFW: An ISO:9001:2008 certified Institution 74

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Levels of Risk Factor Surveillance SIHFW: An ISO:9001:2008 certified Institution 75 Measures Level Step 1 (Verbal) Step 2 (Physical) Step 3 (Biochemical) Core Demographics, Tobacco, Alcohol, Nutrition, Physical activity Measured weight + height, Waist girth, Blood pressure Cholesterol, Fasting blood sugar Expanded Education, Occupation Indicators, Hip girth, HDL-Chol, Triglycerides Optional Knowledge+ attitudes regarding health Health-related Quality of life and health-related behaviour Skinfolds , Pedometer Urine, etc.

Actions at Hospitals:

Actions at Hospitals Counseling of identified patients of NCDs: What is the illness What is the prognosis What complications can arise What drugs to take – proper dosage, importance of regularity of drug intake, possible side effects What other interventions can reduce the severity of illness Habitual physical exercise Balanced diet Meditation SIHFW: An ISO:9001:2008 certified Institution 76

Actions at Hospitals:

Actions at Hospitals Proper depiction / display of health education messages / posters Educate women on self-examination of breast Educate persons coming to the hospital on risk factors for different NCDs (health education corners, documentaries may be shown on TV screens, etc. ) SIHFW: An ISO:9001:2008 certified Institution 77

Actions at Hospitals:

Actions at Hospitals Screening for early diagnosis of NCDs Routine measurement of BP of all patients Screening tests In high-risk cases Pap smear examination Routine examination of oral cavity for early signs of cancer Training of different categories of health staff SIHFW: An ISO:9001:2008 certified Institution 78

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Thanks SIHFW: An ISO:9001:2008 certified Institution 79

Risk Factors in NCDs:

Risk Factors in NCDs State Institute of Health & Family Welfare, Jaipur SIHFW: An ISO:9001:2008 certified Institution 80

Structure of presentation:

Structure of presentation Risk factor ? Types of Risk Factors Risk Factor Assessment and management Primary Prevention through Health Promotion Role of Medical Officer of DH,CHC,PHC under NPCDCS and NPHCE SIHFW: An ISO:9001:2008 certified Institution 81

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Risk factors and NCDs 4 largely preventable , and Manageable SIHFW: An ISO:9001:2008 certified Institution 82

Risk factor in NCD:

Risk factor in NCD Any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury. A determinant that can be modified by intervention Cumulative effect- Dose and Time response Co-existence SIHFW: An ISO:9001:2008 certified Institution 83

Risk factors:

Risk factors only suggestive Presence does not imply that the disease will occur neither absence is guarantee of disease Observable /identifiable prior to event Smoking, obesity Combination is purely additive or synergistic Smoking and occupational exposure :bladder cancer Smoking ,high blood cholesterol and HT SIHFW: An ISO:9001:2008 certified Institution 84

Risk factors:

Risk factors May be truly causative smoking and lung cancer May be merely contributory to undesired outcome lack of physical exercise and CAD Predictive only in statistical sense illiteracy for IMR SIHFW: An ISO:9001:2008 certified Institution 85

Risk factors:

Risk factors Modifiable Behavioral Tobacco Alcohol Physical inactivity Nutrition Physiological BMI Blood pressure Blood glucose Cholesterol Non-Modifiable Age Heredity, Genetic Gender Ethnicity SIHFW: An ISO:9001:2008 certified Institution 86

NHD of NCD:

Changes in life style Excess intake Smoking stress Lack of Physical activity Emotional disturbance Aging Obesity Hypertension Hyperlipidemia Thrombotic tendency Atherosclerosis NHD of NCD Coronary Occlusion Arterial changes Myocardial infarction SIHFW: An ISO:9001:2008 certified Institution 87

Risk factors common to major non-communicable conditions :

Risk factors common to major non-communicable conditions Risk Factor Condition CAD Diabetes Cancer Respiratory Smoking     Alcohol   Nutrition   Physical Inactivity    Obesity     BP   Blood glucose    Blood Lipids    SIHFW: An ISO:9001:2008 certified Institution 88

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Step 3 Comprehensiveness Complexity Step 2 Step 1 Core Expanded Optional The WHO STEP approach to Surveillance of NCD Risk Factors At each step SIHFW: An ISO:9001:2008 certified Institution 89

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Levels of Risk Factor Surveillance SIHFW: An ISO:9001:2008 certified Institution 90 Measures Level Step 1 (Verbal) Step 2 (Physical) Step 3 (Biochemical) Core Demographics, Tobacco, Alcohol, Nutrition, Physical activity Measured weight + height, Waist girth, Blood pressure Cholesterol, Fasting blood sugar Expanded Education, Occupation Indicators, Hip girth, HDL- Chol , Triglycerides Optional Knowledge+ attitudes regarding health Health-related Quality of life and health-related behaviour Skinfolds , Pedometer Urine, etc.

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STEPS emphasizes that small amounts of good quality data are more valuable than large amounts of poor data. It is based on the following two key premises: • Collection of standardized data, and • Flexibility for use in a variety of country situations and settings. 91 SIHFW: an ISO 9001: 2008 certified institution

Population Focus:

Population Focus STEPS uses a representative sample of the study population. 92 SIHFW: an ISO 9001: 2008 certified institution

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93 SIHFW: an ISO 9001: 2008 certified institution

STEPS Instrument:

STEPS Instrument STEPS Instrument covers three different levels "steps" for risk factor assessment. These steps are: Questionnaire - self reported behaviors and life style risk factors Physical measurements - blood pressure and anthropometric status Biochemical measurements - collection of blood samples 94 SIHFW: an ISO 9001: 2008 certified institution

Step1:Questionnaire Based Assessment :

Step1:Questionnaire Based Assessment Description: Gathering demographic and behavioural information by questionnaire in a household setting. Purpose: To obtain core data on: Socio-demographic information Tobacco and alcohol use Nutritional status Physical activity Recommendation: All countries/sites should undertake the core items of Step 1. 95 SIHFW: an ISO 9001: 2008 certified institution

Step 2: Simple Physical Measurements :

Step 2: Simple Physical Measurements Description: Collecting physical measurements with simple tests in a household setting. Purpose: To build on the core data in Step 1 and determine the proportion of adults that: are overweight and obese, and have raised blood pressure Recommendation: Most countries/sites should undertake Step 2. 96 SIHFW: an ISO 9001: 2008 certified institution

Step 3: Biochemical Measurements :

Step 3: Biochemical Measurements Description: Taking blood samples for biochemical measurement in a clinic. Purpose: To measure prevalence of diabetes or raised blood glucose and abnormal blood lipids. Recommendation: Only recommended for well resourced settings Note: Within each Step, there are three levels of data collection, core, expanded and optional levels 97 SIHFW: an ISO 9001: 2008 certified institution

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Core Items Expanded Items Optional Modules Step 1: Behavioural Basic demographic information, including age, sex, literacy, and highest level of Education Tobacco use Alcohol consumption Fruit and vegetable Consumption Physical activity Expanded demographic information including years at school, ethnicity, marital status, employment status, household income Smokeless tobacco use Past 7 days drinking Oil and fat consumption History of blood pressure, treatment for raised blood Pressure History of diabetes, treatment for diabetes Mental health, intentional and unintentional injury and violence and oral health. Objective measure of physical activity behavior 98 SIHFW: an ISO 9001: 2008 certified institution

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Core Items Expanded Items Optional Modules Step 2: Physical measurements Weight and height Waist circumference Blood pressure Hip circumference, Heart rate Skin fold thickness, assessment of physical fitness 99 SIHFW: an ISO 9001: 2008 certified institution

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Core Items Expanded Items Optional Modules Step 3: Biochemical measurements Fasting blood sugar Total cholesterol Fasting HDL-cholesterol and triglycerides Oral glucose tolerance test, urine examination, 100 SIHFW: an ISO 9001: 2008 certified institution

Behavioral Risk Factors:

Behavioral Risk Factors “Actions/Behavior that people engage in that put their health at risk” NCDs Diseases of affluence Diseases due to urbanization Diseases of developed world Chronic diseases Bio-behavioral disorders 101 SIHFW: an ISO 9001: 2008 certified institution

Behavioral Risk Factors:

Behavioral Risk Factors 2008 estimated prevalence (%) males females total Current daily tobacco 25.1 2.0 13.9 Smoking Physical inactivity 10.8 17.3 14.0 Source: World Health Organization - NCD Country Profiles , 2011. 102 SIHFW: an ISO 9001: 2008 certified institution

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Modifiable Risk Factor: 2008 estimated prevalence (%) Males Females Total Raised BP 33.2 31.7 32.5 Raised blood glucose 10.0 10.0 10.0 Overweight 9.9 12.2 11.0 Obesity 1.3 2.4 1.9 Raised cholesterol 25.8 28.3 27.1 Source: World Health Organization - NCD Country Profiles , 2011. 103 SIHFW: an ISO 9001: 2008 certified institution

A. Cardio vascular diseases:

Atherosclerosis Increased level of C reactive protein (CRP). Low physical inactivity Smoking Unhealthy diet A. Cardio vascular diseases SIHFW: An ISO:9001:2008 certified Institution 104

B. Diabetes:

Obesity Sedentary Life style Unhealthy eating habits Lack of regular exercise Genetics & family history High blood pressure & high cholesterol Increased age B. Diabetes SIHFW: An ISO:9001:2008 certified Institution 105

C. Stroke:

1. Controllable Risk Factors: High Blood Pressure Atrial Fibrillation High Cholesterol Diabetes Atherosclerosis Circulation Problems Tobacco Use and Smoking Alcohol Use Physical Inactivity Obesity . C. Stroke SIHFW: An ISO:9001:2008 certified Institution 106

D. Cancer:

Environment Life style Tobacco addicted Over weight Low fruit or vegetable intake Low physical inactivity Alcohol addiction Air pollution Sexually transmitted infections D. Cancer SIHFW: An ISO:9001:2008 certified Institution 107

Risk Factors:

Risk Factors % of cancer deaths (35–64 yrs ) Factors Best estimate Tobacco 30-40 Alcohol 3-10 Rep. & Sexual behavior 10 Occupation 6–8 Pollution 2 Industrial Products 1 Medicines &Medical procedures 1 Geophysical factors 3 SIHFW: An ISO:9001:2008 certified Institution 108

Risk factors and level of NCD prevention and management :

Risk factors and level of NCD prevention and management Behavioral RF Physiological RF Disease Outcome • Unhealthy Diet • BMI (Obesity) • Diabetes • Physical inactivity • Hypertension • Heart disease • Hyper- cholesterolemia • Stroke • Tobacco • Cancer • Alcohol • High Blood sugar level • Chronic respiratory disease • Stress LEVELS OF PREVENTION Primary Prevention Secondary Prevention Tertiary Prevention Health promotion Case management & HP Case management SIHFW: An ISO:9001:2008 certified Institution 109

Risk Assessment And Management :

Risk Assessment And Management There should be evidence-based approach on how to reduce the occurrence of first clinical events of coronary heart disease (CHD), cerebrovascular disease ( CeVD ) and peripheral vascular disease (PVD) in the population. The evidence-based guidelines provide guidance on which specific preventive actions to initiate, and with what degree of intensity. The accompanying World Health Organization/ International Society of Hypertension (WHO/ISH) risk prediction charts enable the estimation of total cardiovascular risk of people in the first category. SIHFW: An ISO:9001:2008 certified Institution 110

Goals of implementing these guidelines:

Goals of implementing these guidelines The goals are to prevent CHD, CeVD and PVD events and Cancer by lowering risk. The recommendations assist people to: Quit tobacco use, or reduce the amount smoked, or not just start the habit Make healthy food choices Be physically active Reduce body mass index, waist hip ratio/waist circumference Lower blood pressure Lower blood cholesterol and low density lipoprotein cholesterol (LDL-cholesterol) Control hyperglycemia Take anti platelet therapy when necessary. SIHFW: An ISO:9001:2008 certified Institution 111

Referral to a specialist facility:

Referral to a specialist facility Referral is required if there are clinical features suggestive of: Acute cardiovascular events such as: heart attack, angina, heart failure, arrhythmias, stroke, and transient ischemic attack. Secondary hypertension, malignant hypertension. Diabetes mellitus (newly diagnosed or uncontrolled). Established cardiovascular disease (newly diagnosed or if not assessed in a specialist facility). Suspected lesions for Cancer People needing medical therapy to quit smoking. SIHFW: An ISO:9001:2008 certified Institution 112

Follow up:

Follow up Once the condition of the above categories of people (except with suspected lesion) is assessed and stabilized, they can be followed up in a primary care facility based on the recommendations provided in Manual of MO. They will need periodic reassessment in specialty SIHFW: An ISO:9001:2008 certified Institution 113

Grading cardiovascular risk using charts for making treatment decisions:

Grading cardiovascular risk using charts for making treatment decisions Some individuals are at high cardiovascular risk because they have established cardiovascular disease or very high levels of individual risk factors. Risk stratification is not necessary for making treatment decisions for these individuals as they belong to the high risk category; all of them need intensive lifestyle interventions and appropriate drug therapy . SIHFW: An ISO:9001:2008 certified Institution 114

High risk :

High risk With established cardiovascular disease Without established CVD who have a total cholesterol ≥ 320 mg/dl or low density lipoprotein (LDL) cholesterol ≥ 240 mg/dl or TC/HDL-C (total cholesterol/high density lipoprotein cholesterol) ratio >8 Without established CVD who have persistent raised blood pressure of ≥160/ ≥100 mmHg With renal failure or renal impairment. SIHFW: An ISO:9001:2008 certified Institution 115

WHO risk prediction chart:

WHO risk prediction chart SIHFW: An ISO:9001:2008 certified Institution 116

If cholestrol can not be measured:

If cholestrol can not be measured SIHFW: An ISO:9001:2008 certified Institution 117

Use of chart:

Use of chart Step 1 Select the appropriate chart depending on the presence or absence of diabetes Step 2 Select male or female tables Step 3 Select smoker or non smoker boxes Step 4 Select age group box (if age is 50-59 years select 50,if 60-69 years select 60 etc) Step 5 Within this box find the nearest cell where the individual’s systolic blood pressure (mm Hg) and total blood cholesterol level (mg/dl) cross. The color of this cell determines the 10 year cardiovascular risk. SIHFW: An ISO:9001:2008 certified Institution 118

Prevention of CVD (according to individual total risk) :

Prevention of CVD (according to individual total risk) 10 year risk Risk classification Intervention Risk <10% Low Risk Low risk does not mean “no” risk. Conservative management focusing on lifestyle an intervention is suggested. Risk assessed after 5 years unless significant change in health status. Risk 10% to <20% Moderate Risk Monitor risk profile every 2 years. Risk 20% to <30% High Risk Monitor risk profile yearly. Risk ≥30% Very High Risk Individuals in this category are at very high risk of fatal or non-fatal vascular events. Monitor risk profile every 3–6 months. SIHFW: An ISO:9001:2008 certified Institution 119

CVD risk may be higher if following are already present:

CVD risk may be higher if following are already present Already on antihypertensive therapy Premature menopause Approaching the next age category or systolic blood pressure category Obesity (including central obesity) Sedentary lifestyle Family history of premature CHD or stroke in first degree relative (male <55 years, female < 65 years) Raised triglyceride level (≥150 mg/dl) Low HDL cholesterol level (≤40mg/dl in males, ≤ 50 mg/dl in females) Fasting glycaemia , or impaired glucose tolerance Microalbuminuria Socioeconomic deprivation. SIHFW: An ISO:9001:2008 certified Institution 120

NPCDCS Components :

NPCDCS Components Prevention through behaviour change Early Diagnosis Medical treatment Capacity building of human resource. Supervision, monitoring and evaluation SIHFW: An ISO:9001:2008 certified Institution 121

Key Interventions for NPCDCS:

Key Interventions for 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 ( NCD Clinic) at CHC level & above CCU at District Hospital and above Treatment of cancer at District Hospital & above Capacity Building Infrastructure Development & E quipment Training of human resources at all levels Management & Monitoring NCD Cell at National, State & District level Surveillance, monitoring & evaluation Regular review meetings SIHFW: An ISO:9001:2008 certified Institution 122

PowerPoint Presentation:

Thank you SIHFW: An ISO:9001:2008 certified Institution 123

Diet, Life Style Modification & NCDs :

Diet, Life Style Modification & NCDs SIHFW: An ISO:9001:2008 certified Institution 124

PowerPoint Presentation:

Stroke COPD CVD MI Diabetes HT Overweight Smoking Alcohol Unhealthy diet Physical inactivity Env. Pollution Hit the trunk, branches will fall automatically Problem on the rise : NCDs Cancer SIHFW: an ISO 9001: 2008 certified Institution 125

Modifiable risk factors for NCDs:

Modifiable risk factors for NCDs SIHFW: an ISO 9001: 2008 certified Institution 126

Major diet related NCDs:

Major diet related NCDs SIHFW: an ISO 9001: 2008 certified Institution 127

Diet and NCDs :

Diet and NCDs Dietary factors Mechanisms Health risks Excess energy intake ↑ Adipose tissue development ↑ , metabolic changes NIDDM, CHD, Hormone dependent ( breast )or GI cancer , osteoarthritis , gallbladder diseases Total Fat ↑ Passive overconsumption NIDDM, CHD, P:ratate cancer , breast cancer , colorectal cancer Animal fat ↑ Unclear fat metabolism by products Colon cancer Saturated fat ↑ TC ↑, LDL ↑, TG ↑, HDL ↓ Arthrosclerosis, CHD, Hypertension, NIDDM SIHFW: an ISO 9001: 2008 certified Institution 128

Diet Related-Cancers:

Diet Related-Cancers Type of cancers Risk factors Prevention Cancer s of oral cavity , pharynx and esophagus Alcohol Tobacco Obesity / Overweight Micronutrient deficiencies related to  Intake of fruits , vegetables and animal products Consumption of foods at very high ( thermal) temperatures Management of obesity  intake of fruits and vegetables ad animal products Stomach cancer Infection with helicobacter pylori Increased intakes of traditionally preserved salted foods , ( meats and pickles)  intakes of fruits and vegetables ( vitamin C) Colorectal cancer Obesity / Overweight  Physical activity  intake of meats and fats  intake of preserved and red meat  intake of fruits , vegetables, dietary fibers and calcium  Folate consumption SIHFW: an ISO 9001: 2008 certified Institution 129

PowerPoint Presentation:

Type of cancers Risk factors Prevention Liver cancer Chronic infection with Hepatitis B Aflatoxins contaminated foods Excessive alcohol consumption  alcohol consumption Pancreatic cancer Obesity / Overweight  intake of red meats  Intake vegetables and fruits Lung cancer  Smoking (  risk 30 times )  intake of fruits , veg. and related nutrients ( - carotene )  Intake of fruits and veg . Breast cancer Age at Menarche Obesity , Alcohol Endometrial cancer Obesity ( 3 times  risk in obese women )  Saturated and total fats  total fats / saturate fats Prostate cancer Intakes of red meat , dairy products Vit . E, selenium , lycopene has protective effects Kidney cancer Overweight / obesity Weight management SIHFW: an ISO 9001: 2008 certified Institution 130

Prominent risk factor:

Prominent risk factor Disease Modifiable- Risk factors Obesity Heart disease Smoking, HTN, Dyslipidemia, Diabetes, Obesity , Sedentary habits, Stress Some types of Cancers Smoking, alcohol, solar radiation, ionizing radiation, work-site hazards, environmental pollution, medications, infectious agents, dietary factors , Obesity Stroke High BP, Elevated cholesterol, smoking, obesity / overweight Diabetes Obesity , diet SIHFW: an ISO 9001: 2008 certified Institution 131

Dietary risk factors :

Dietary risk factors Total fats Saturated fats Sugars Salt Alcohol Refined grains Foods of animal origin SIHFW: an ISO 9001: 2008 certified Institution 132

Life Style Modification:

Life Style Modification Primary Prevention through health promotion Diet Physical Activity Weight Control Tobacco Cessation Alcohol (moderation) SIHFW: An ISO:9001:2008 certified Institution 133

Obesity: The other side of poor nutrition:

Obesity: The other side of poor nutrition Killer lifestyle disease Pandora box of health issues + emotional troubles Public health challenge Overweight is defined as a body mass index (BMI) of 25 to 29.9 kg/m 2 . Obesity is defined as an excess of total body fat more than a BMI of ≥30 kg/m 2 . SIHFW: an ISO 9001: 2008 certified Institution 134

Burden of the Bulge    :

Burden of the Bulge In India 1 in 6 women and 1 in 5 men are overweight (WHO) 1.2 billion people worldwide are officially classified as overweight. (WHO) > 25 % of Indians are overweight & > 3% are Obese (3 crore Indians). Death rates increases by 200 % for men and women who are significantly overweight WHO predicts that by 2015, about 2.3 billion adults will be overweight and over 700 million people will be classified as obese. SIHFW: an ISO 9001: 2008 certified Institution 135 Source: Obesity foundation of India

Types of obesity Gynecoid & Android :

Types of obesity Gynecoid & Android Gynecoid : Lower-body obesity--Pear shape Encouraged by estrogen and progesterone Less health risk than upper-body obesity SIHFW: an ISO 9001: 2008 certified Institution 136

PowerPoint Presentation:

Android : Upper-body obesity--apple shape Associated with more heart disease, HTN, Type II Diabetes Encouraged by testosterone and excessive alcohol intake Defined as waist measurement of > 40” for men and >35” for women (WHO) Asian women more than 31 inches. Asian men more than 35 inches. Risk factor for NCDs SIHFW: an ISO 9001: 2008 certified Institution 137

Central obesity:

Central obesity The waist circumference and waist to hip ratio are useful for estimation of central obesity Central obesity  Chronic Degenerative Diseases Central obesity is a risk factor for diabetes and Indians are genetically susceptible to weight accumulation around waist SIHFW: an ISO 9001: 2008 certified Institution 138

Assessment of central obesity :

Assessment of central obesity Waist to Hip Ratio of more than 0.9 in men and more than 0.8 in women is associated with increased risk of several chronic diseases. The waist circumference cut off levels for Asian Indians are 80 Cm for women and 90 cm for men SIHFW: an ISO 9001: 2008 certified Institution 139

Measuring waist circumference :

Measuring waist circumference Locate the top of the hip bone Place the tape measure evenly around the bare abdomen at the level of this bone Read the tape measure and record the same Ensure the tape is sung but does not push tightly into the skin. Measure waist circumference after breathing out normally; do not “suck in” the stomach. SIHFW: an ISO 9001: 2008 certified Institution 140

Why is this happening?:

Why is this happening? Drivers of the obesity epidemic Societal changes + Worldwide nutrition transition. Economic growth Modernization Urbanization Globalization of food markets SIHFW: an ISO 9001: 2008 certified Institution 141

Transitional Facets:

Transitional Facets SIHFW: an ISO 9001: 2008 certified Institution 142

Nutrition transitions: Absolute cause :

Nutrition transitions: Absolute cause Changes in food handling processes Marketing Media Exposure Women in labor market Life style changes with easy money Sedentary nature of work, low physical activity Ready to eat junk food Affluence, Availability, Accessibility SIHFW: an ISO 9001: 2008 certified Institution 143

Causes of Obesity:

Causes of Obesity Heredity Unhealthy eating habits Low physical activity level Metabolic errors in energy utilization Insulin Imbalance :favoring fat deposition. Low /high birth weight ( < 2500 ; > 3500 ) Obesogens : School environment, family customs and practices, Food advertising and labeling policies, Obesity during pregnancy and after menopause. SIHFW: an ISO 9001: 2008 certified Institution 144

Body Mass Index (BMI ) :

Body Mass Index (BMI ) Quetlet’s Index Tool to calculate adiposity Developed by Adolphe Quetelet Risk indicator: increased BMI, increased risk SIHFW: an ISO 9001: 2008 certified Institution 145

BMI Calculation:

BMI Calculation BMI greater than or equal to 25 is overweight BMI greater than or equal to 30 is obesity BMI = Weight (Kg) / height (m 2 ) SIHFW: an ISO 9001: 2008 certified Institution 146

BMI Classification:

BMI Classification Classification WHO BMI cut offs Asians BMI cut offs Underweight <18.5 <18.5 Normal Range 18.5 – 24.9 18.5- 22.9 Overweight >= 25.0 >= 23 Pre-obese 25.0 – 29.9 22.9-24.9 Obese >= 30.0 >= 25.0 Obese Class I 30.0 – 34.9 25- 29.9 Obese Class II >= 35.0 >= 30.0 Source: WHO 1998 , Western pacific region of WHO, 2000 SIHFW: an ISO 9001: 2008 certified Institution 147

Health consequences of Obesity:

Health consequences of Obesity High blood pressure High cholesterol Diabetes Heart disease Stroke Gallbladder disease Osteoarthritis Obesity is not a simple problem for it can trigger at least 53 diseases SIHFW: an ISO 9001: 2008 certified Institution 148

PowerPoint Presentation:

Sleep apnea and respiratory problems Some cancers (endometrial, breast and colon) Liver disease Venous disease Acid reflux Menstrual irregularities and infertility Health repercussions of obesity , published in the Lancet, has revealed that “by 2030, non communicable disease will account for nearly 70% of all global deaths and 80% of these deaths will occur in developing countries like India” SIHFW: an ISO 9001: 2008 certified Institution 149

Bell the Fat” Anti obesity day: Nov 26”:

Bell the Fat” Anti obesity day: Nov 26” Multi-pronged strategy for Effective weight management Prevention of chronic diseases Secret to maintaining optimum weight. Healthy lifestyle Proper diet and exercise SIHFW: an ISO 9001: 2008 certified Institution 150

Weight management :

Weight management Balancing energy intake and energy expenditure is the basis of weight management throughout life Weight gain Calories consumed > calorie used Weight loss Calories consumed < calorie used No Weight change Calories consumed = calorie used INPUT Calories from food OUTPUT Calories used during PA SIHFW: an ISO 9001: 2008 certified Institution 151

Long-term strategies : Weight management :

Long-term strategies : Weight management Prevention Weight loss Weight maintenance Management of co-morbidities SIHFW: an ISO 9001: 2008 certified Institution 152

Weight loss goals :

Weight loss goals Realistic Achievable Sustainable Strong Imperative SIHFW: an ISO 9001: 2008 certified Institution 153

How much weight loss????:

How much weight loss???? NIH guidelines recommend a weight loss of 500 grams – 1 kg /week Allow 6 months to achieve 10% weight loss After 6 months, focus should shift to weight maintenance for 6 months SIHFW: an ISO 9001: 2008 certified Institution 154

Lifestyle medicine: Need for change :

Lifestyle medicine: Need for change Use of lifestyle interventions in the treatment and management of lifestyle diseases. Diet rectifications (Eat Low Fat, Low Salt, High Fiber Diet ) Exercise ( Physical activity ) Stress management Smoking cessation Avoid alcohol SIHFW: an ISO 9001: 2008 certified Institution 155

Emphasis of lifestyle medicine :

Emphasis of lifestyle medicine Assessing lifestyle Evaluating the risk factors Evaluating laboratory reports Discussing the opportunities for interventions Prescribing an optimal lifestyle Tracking and follow-ups SIHFW: an ISO 9001: 2008 certified Institution 156

Dietary interventions Managing / preventing NCDs :

Dietary interventions Managing / preventing NCDs SIHFW: an ISO 9001: 2008 certified Institution 157

PowerPoint Presentation:

DIET is what We eat NUTRITION is what we Get from Diet What is diet ??? SIHFW: an ISO 9001: 2008 certified Institution 158

Life style modification & Diet:

Life style modification & Diet Balanced Diet Different foods Adequate quantity and proportions Carbohydrates, Fat, Proteins, Vitamins, Minerals, Fiber Energy source: 50% of from complex carbohydrates 15-20% from proteins. 25-30% from total fat. (Of this, saturated fat should be < 1/3 SIHFW: an ISO 9001: 2008 certified Institution 159

Balanced Diet:

Balanced Diet foods in quantities and proportions so that the need of calories, proteins, vitamins, minerals and other nutrients is adequately met. Includes a variety of foods from all the food groups. Differ according to age, sex, physical activity and physiological status The healthy combination is low fat, low refined carbohydrates, optimal amount of Vitamins, Minerals and fiber SIHFW: an ISO 9001: 2008 certified Institution 160

PowerPoint Presentation:

SIHFW: an ISO 9001: 2008 certified Institution 161

PowerPoint Presentation:

SIHFW: an ISO 9001: 2008 certified Institution 162

Total energy requirement:

Total energy requirement Total energy requirement is a sum of : 1. Basal metabolism 2. Daily activities 3. Occupation; expressed as RDA depends on Age, gender and physical work SIHFW: an ISO 9001: 2008 certified Institution 163

RDA for an Adult Sedentary Worker:

RDA for an Adult Sedentary Worker Gender Energy (Kcal/d) Protein (g/d) Fat (g/d) Calcium (mg/d) Iron (mg/d) Male 2320 60 25 600 17 Female* 1900 55 20 600 21 *Pregnancy +300 and lactation+550 and 400 ICMR, 2010 SIHFW: an ISO 9001: 2008 certified Institution 164

Diet for NCD: Main focus :

Diet for NCD: Main focus Gradual weight loss. Achieve & maintain the desirable body weight. Correct eating habits. Reduce the increased lipid levels. (CHD) Meet the nutritional requirements Reduce sodium intake (Hypertension) Maintain blood sugar levels. (Diabetes) SIHFW: an ISO 9001: 2008 certified Institution 165

Foods promoting health :

Foods promoting health Minimally processed grains Legumes Fiber rich foods Vegetables Fruits Foods of plant origin SIHFW: an ISO 9001: 2008 certified Institution 166

Promoting Healthy lifestyle:

Promoting Healthy lifestyle Traditional healthy diets Avoid tobacco, Alcohol Maintain weight Daily physical activities Restrict foods high in sugar , refined starch and saturated and trans fats to children SIHFW: an ISO 9001: 2008 certified Institution 167

Dietary Guidelines for Indians ICMR :

Dietary Guidelines for Indians ICMR Consume nutritionally adequate diet through a wise choice from a variety of foods. Additional food and extra care during pregnancy and lactation. Exclusive breast-feeding. Breast – feeding can be continued up to two years with appropriate and adequate frequent supplements Oils and animal foods in moderation, and restrict vanaspati /ghee/butter SIHFW: an ISO 9001: 2008 certified Institution 168

Strategies for Obesity Prevention:

Strategies for Obesity Prevention For infants and young children: Promotion of exclusive breastfeeding Avoid use of added sugars and starches when feeding formula Instruct mothers to accept their child’s ability to regulate energy intake rather than feeding until the plate is empty Assure the appropriate micronutrient intake needed to promote optimal linear growth SIHFW: an ISO 9001: 2008 certified Institution 169

PowerPoint Presentation:

For children and adolescents Promote and active lifestyle Limit television viewing Promote the intake of fruits and vegetables Restrict the intake of energy dense , micronutrient poor foods (e.g. packaged foods) Restrict the intake of sugar sweetened soft drinks SIHFW: an ISO 9001: 2008 certified Institution 170

Tips for weight reduction:

Tips for weight reduction Slow and steady Avoid severe fasting Achieve energy balance and appropriate weight for height Encourage physical activity Eat small frequent meals Cut down on sugar, salt, fatty foods and alcohol. SIHFW: an ISO 9001: 2008 certified Institution 171

PowerPoint Presentation:

Promote complex carbohydrates and fiber rich diets Increase consumption of fruits and vegetables, legumes, whole grains and nuts. Limit energy intake from total fat and shift from saturated to unsaturated Eliminate the use of trans fatty acids rich food products and sweets. Use low fat milk. Avoid fasting & feasting. Read the labels carefully. SIHFW: an ISO 9001: 2008 certified Institution 172

PowerPoint Presentation:

Avoid fried foods and bakery products Avoid organ meats like liver and brain, poultry with skin, higher fat meat cuts like hamburgers, bacon and sausages. Avoid excessive alcohol, stop smoking SIHFW: an ISO 9001: 2008 certified Institution 173

PowerPoint Presentation:

The 5 “W” Plan 1. What to eat ? 2. When to eat ? 3. Where to eat ? 4. Why to eat ? 5. Way to eat ? What you eat ? Have a balanced diet. Include micro and macro nutrients and fiber in adequate amounts Be careful about your fat intake. Avoid saturated fat. Restrict salt and sugar intake. SIHFW: an ISO 9001: 2008 certified Institution 174

PowerPoint Presentation:

When to eat ? Set aside a time for breakfast ,lunch and dinner too. Have smaller meals at regular intervals. Never sleep immediately after your meals. Where to eat ? Decide one place in your house or office to eat food. While eating your meals, concentrate only on eating SIHFW: an ISO 9001: 2008 certified Institution 175

PowerPoint Presentation:

Why to eat ? Eat when you feel hungry Don not eat because you have nothing else to do Do not eat because you cannot say “NO” to anyone SIHFW: an ISO 9001: 2008 certified Institution 176

PowerPoint Presentation:

Way to eat ? Eat slowly. Chew properly. Spend at least 15- 20 mins to complete your meals. Never drink water during your meals. Drink water 20 mts . after meals. stroll for about 15 mts . after meals SIHFW: an ISO 9001: 2008 certified Institution 177

Recommendations for cancer preventions :

Recommendations for cancer preventions Maintain weight / avoid weight gain Maintain Regular Physical activity Avoid alcohol Preserved foods and salt : Moderate consumption Minimal exposure to Alflatoxins in foods Diet with 400 gms of total fruits and vegetables Moderate consumption of preserved meats Do not consume food and drink at very hot temperature SIHFW: an ISO 9001: 2008 certified Institution 178

Recommendations in preventing diabetes:

Recommendations in preventing diabetes Prevention / treatment of obesity Maintain optimum BMI weight reduction in overweight or obese individuals with impaired glucose tolerance Increase Physical activity Limit total fat intake : >10 % of the total energy intake NSP / dietary fibers : adequate amounts SIHFW: an ISO 9001: 2008 certified Institution 179

Recommendations in preventing CVDs:

Fats: restrict SFA (less than 10% of daily energy intake )Trans fatty acid( less than 1% of daily energy intake) Fruits and Veg. : 400-500 gms / day Sodium restriction <5gms / day Potassium: Na: ratio = 1 NSP : adequate intake Alcohol: Regular small intake is protective Physical Activity: at least 30 min. moderate workout Recommendations in preventing CVDs SIHFW: an ISO 9001: 2008 certified Institution 180

Calculating balanced diet?:

Calculating balanced diet? Know Recommended Dietary Allowance (RDA) Menu Analysis Food Exchange List SIHFW: an ISO 9001: 2008 certified Institution 181

RDAs for an Adult Sedentary Worker:

RDAs for an Adult Sedentary Worker Gender Energy (Kcal/d) Protein (g/d) Fat (g/d) Calcium (mg/d) Iron (mg/d) Male 2320 60 25 600 17 Female* 1900 55 20 600 21 * Pregnancy +300 ; lactation+550 ICMR, 2010 SIHFW: an ISO 9001: 2008 certified Institution 182

How to calculate balance diet? :

How to calculate balance diet? Step I : Recommended Dietary Allowance (RDA) (specific for age, gender and activity). Step II : Menu Analysis SIHFW: an ISO 9001: 2008 certified Institution 183

Common Home Measures- Weight & Volume Equivalents:

Common Home Measures- Weight & Volume Equivalents 1 Medium size bowl: 150-160 ml 1 Table spoon (level): 15g or ml (approx) 1 Table spoon (heaped): 20 g 1 Tea spoon (level): 5g or ml 1 Tea spoon (heaped): 7 g 1 Medium size tea cup: 180-200 ml Big size glass/Cup: 250 ml SIHFW: an ISO 9001: 2008 certified Institution 184

Key recommendations - Diet:

Key recommendations - Diet  Fruit and vegetable intake  Unhealthy fats (Saturated fats e.g. Animal fats, milk products; transfats – hydrogenated oil) Substitute with healthy fats PUFA(poly) e.g. Fish oil; MUFA(Mono) e.g. pea nut oil  Salt intake  Consumption of simple sugars SIHFW: an ISO 9001: 2008 certified Institution 185

Health Promotion through exercises :

Health Promotion through exercises Calorie consumption in different activities Activity Kcal/hr. Activity Kcal/hr. Cleaning 210 Gardening 300 Watching TV 86 Cycling,15/h 360 Running,12/hr 750 Walking4/hr 160 Shuttle 348 Tennis 392 TT 245 Dancing 372 Typing 108 Sleeping 57 Standing 132 Sitting 86 SIHFW: an ISO 9001: 2008 certified Institution 186

PowerPoint Presentation:

Thank you SIHFW: an ISO 9001: 2008 certified Institution 187

NPCDCS & NPHCE:

NPCDCS & NPHCE State Institute of Health & Family Welfare, Jaipur Cancer SIHFW: an ISO 9001: 2008 certified Institution 188

Structure of presentation:

Structure of presentation Basic Understanding Common cancers Early Diagnosis Breast Cancer Screening of common cancer Case based discussions Prevention of cancer Palliative care SIHFW: an ISO 9001: 2008 certified Institution 189

Cancer – How old disease is ?:

Cancer – How old disease is ? Even in Bones of Dinosaurs Even in calcified mummies SIHFW: an ISO 9001: 2008 certified Institution 190

What is Cancer? :

What is Cancer? SIHFW: an ISO 9001: 2008 certified Institution 191

Cancer?:

Cancer? A group of diseases Uncontrolled cell multiplication Benign Malignant SIHFW: An ISO:9001:2008 certified Institution 192

PowerPoint Presentation:

Growth of Cells Undesirable Uncontrolled Unregulated Useless Harmful Can invade Surrounding tissue Cancer - What Is It? SIHFW: An ISO:9001:2008 certified Institution 193

Determinants:

Determinants Tobacco- (Primary prevention possible) Occupational exposures Diet- high protein, low fiber, alcohol, Junk, Reproductive pattern influences Late marriage/ single pregnancy/Lactation Sexual practices and hygiene Life style, customs Viruses- Hepatitis-B virus/Human papilloma virus/CMV SIHFW: An ISO:9001:2008 certified Institution 194

Common Cancer sites:

Common Cancer sites Male- Mouth Oro-pharynx Stomach Esophagus Lungs Female- Cervix Breast Mouth/Oro-pharynx Esophagus SIHFW: An ISO:9001:2008 certified Institution 195

Common cancers :

Lung Breast (women) Colon Bladder Prostate (men) sarcomas: Fat Bone Muscle Lymphomas: Lymph nodes Leukemias Blood stream Common cancers SIHFW: An ISO:9001:2008 certified Institution 196

Naming Cancer:

Prefix Meaning adeno - gland chondro - cartilage erythro - red blood cell hemangio - blood vessels hepato - liver lipo - fat lympho - lymphocyte melano - pigment cell myelo - bone marrow myo - muscle osteo - bone Cancer Prefixes Location Naming Cancer SIHFW: An ISO:9001:2008 certified Institution 197

Global :

Global 7.6 million deaths (13% of all deaths) in 2008 Tobacco is the most important risk factor for cancer Viral infections (HBV/HCV &HPV) responsible for 20% of cancer deaths Approx 70 % of cancer deaths occur in low- and middle-income countries. Projected-13.1 million deaths in 2030 Source-WHO SIHFW: An ISO:9001:2008 certified Institution 198

India:

India 0.8 million new cases/year 2.4 million prevalent cases Tobacco Related Cancers (TRC) are amenable for primary prevention. 48% cancers in men and 20% in women are due to tobacco. 13% cancers of uterine cervix can be potentially screened and prevented 9% of breast cancers can be detected early and treated effectively SIHFW: An ISO:9001:2008 certified Institution 199 Source-WHO

PowerPoint Presentation:

SIHFW: An ISO:9001:2008 certified Institution 200

Five Common Cancers :

Five Common Cancers Rank World India Male 1 Lung Lung 2 Stomach Lip 3 Prostate Oral Cavity 4 Colon/Rectum Other pharynx 5 Liver Esophagus Female 1 Breast Uterine Cervix 2 Uterine Cervix Breast 3 Colon/Rectum Ovary 4 Lung Lip, Oral cavity 5 Stomach Esophagus SIHFW: An ISO:9001:2008 certified Institution 201

Dynamics of Cancer:

Dynamics of Cancer Increased Life expectancy Accuracy of Diagnosis Improved ? Life style Tobacco Alcohol Newer infections Environment-physical & social Diet SIHFW: An ISO:9001:2008 certified Institution 202

Issues in Cancer control :

Issues in Cancer control Burden of disease Poor/ unavailable diagnostic facility Awareness Trained manpower Competing priorities National guidelines- detection/therapy/ palliative SIHFW: An ISO:9001:2008 certified Institution 203

Issues in Cancer control:

Issues in Cancer control Early diagnosis-Individual /Clinic/ Community Therapy Palliative care-availability & level Nursing Service Delivery-DCCS/NGO/Private SIHFW: An ISO:9001:2008 certified Institution 204

Cancer patterns:

Cancer patterns Predominance of Tobacco related cancers Lung, oral , cervix and breast Increasing with decrease in communicable diseases Majority detected late SIHFW: An ISO:9001:2008 certified Institution 205

Prevention and screening programs:

Prevention and screening programs Primary- Health promotion Specific protection implementation of tobacco control strategies, promotion of adequate and balanced dietary practices and reduction of alcohol intake. a wareness risk factor modification. and Legislation SIHFW: An ISO:9001:2008 certified Institution 206

Prevention and screening:

Prevention and screening Secondary- Early Diagnosis & Treatment pap smear/ mammography Tertiary- Infrastructure for Chemotherapy/ Radiotherapy/Palliative SIHFW: An ISO:9001:2008 certified Institution 207

Cancer control- strategies for primary prevention :

Cancer control- strategies for primary prevention Awareness & education programs Role and use of media Community participation Combining with other programs SIHFW: An ISO:9001:2008 certified Institution 208

PowerPoint Presentation:

Early diagnosis Individual’s role Reporting early Self examination- Breast/Oral cavity promoting genital hygiene and sexual behavior. lifestyle modification. System’s role Screening SIHFW: An ISO:9001:2008 certified Institution 209

Common Risk factors and Screening for Cancers:

Common Risk factors and Screening for Cancers Cancer Risk factor Screening procedures Breast Age, parity, heredity Self examination Cervix Parity, age, multiple partners PAP smear Oral cancer Self examination, examination for leokoplakia SIHFW: An ISO:9001:2008 certified Institution 210

Diagnosis :

Diagnosis Radiological Biochemical Endoscopy Pathological Immunological SIHFW: An ISO:9001:2008 certified Institution 211

Treatment:

Treatment Surgery Radiotherapy Chemotherapy Palliative care SIHFW: An ISO:9001:2008 certified Institution 212

Interventions in different cancers:

Interventions in different cancers Cancer Early Detection Surgery Radiation Chemotherapy/ Hormonal adjuvant therapy Palliative Care Mouth/Pharynx + ++ +++ + +++ Esophagus - + ++ - +++ Stomach + + - - +++ Colon/Rectum ++ +++ ++ +++ +++ Liver - + - - +++ Lung - + ++ - +++ Breast +++ +++ ++ +++ +++ Cervix +++ ++ +++ - +++ Source-NCCP-Policies & Managerial Guidelines, WHO 2 nd Edition 2002 SIHFW: An ISO:9001:2008 certified Institution 213

Burden of Disease:

Burden of Disease SIHFW: An ISO:9001:2008 certified Institution 214

Age wise distribution of deaths due to Cancer per 100000 pop. :

Age wise distribution of deaths due to Cancer per 100000 pop. Source-WHO Organisation Mondiale de la Santé Department of Measurement and Health Information April 2011 SIHFW: An ISO:9001:2008 certified Institution 215

Common Cancer (Female):

Common Cancer (Female) ( Source: - National Health Profile, 2010 Based on cancer registries across the country, cervix and breast cancers accounted for more than 36% of cancer incidence in the country. SIHFW: An ISO:9001:2008 certified Institution 216

Common Cancer in Male:

Common Cancer in Male Source: - National Health Profile, 2010 SIHFW: An ISO:9001:2008 certified Institution 217

New Cancer Cases-India:

New Cancer Cases-India Thousands Source- WHO (GLOBOCON 2008) SIHFW: An ISO:9001:2008 certified Institution 218

No of Cancer Deaths -India:

No of Cancer Deaths -India Source- WHO (GLOBOCON 2008) Thousands SIHFW: An ISO:9001:2008 certified Institution 219

Cancer-Rajasthan :

Cancer-Rajasthan Source -DM&HS SIHFW: An ISO:9001:2008 certified Institution 220

Cancer Deaths -Rajasthan :

Cancer Deaths -Rajasthan Source -DM&HS SIHFW: An ISO:9001:2008 certified Institution 221

District –wise Reported Cases of Cancer-Rajasthan:

District –wise Reported Cases of Cancer-Rajasthan Source -DM&HS (Jan to July.2011) SIHFW: An ISO:9001:2008 certified Institution 222

District wise Reported Cancer Deaths -Rajasthan:

District wise Reported Cancer Deaths -Rajasthan District Male Female Ganganagar 1 1 Jaipur 46 23 Jalor 2 0 Pali 2 2 Jhalawar 2 0 Total 53 26 Source -DM&HS (Jan to July.2011) SIHFW: An ISO:9001:2008 certified Institution 223

Age – wise distribution of Deaths due to Oral Cancer :

Age – wise distribution of Deaths due to Oral Cancer Source-WHO Organisation Mondiale de la Santé Department of Measurement and Health Information April 2011 SIHFW: An ISO:9001:2008 certified Institution 224

PowerPoint Presentation:

Years Males Females Oral cancer Oral cancer Tongue Mouth Tongue Mouth 2008 23932 28066 7687 14402 2009 24330 29474 7829 14669 2010 24735 30921 7974 14940 2015 26590 38380 8689 16280 Projected Cases of Oral Cancer in India Source: National Health Profile, 2009 SIHFW: An ISO:9001:2008 certified Institution 225

Patient with suspicious oral lesion (Self-respected or on examination):

Patient with suspicious oral lesion (Self-respected or on examination ) Clinical examination by Health professional Suspicious lesion Pre-malignant lesion Investigate for possibility of malignancy Malignant Not-Malignant Refer for appropriate treatment Treat lesion Management SIHFW: An ISO:9001:2008 certified Institution 226

Age – wise distribution of Deaths due to Cervical Cancer :

Age – wise distribution of Deaths due to Cervical Cancer Source-WHO Organisation Mondiale de la Santé Department of Measurement and Health Information April 2011 SIHFW: An ISO:9001:2008 certified Institution 227

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Stages of Cervical Cancer SIHFW: An ISO:9001:2008 certified Institution 228

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Post-menopausal bleeding Post-coital bleeding Inter menstrual bleeding Blood stained discharge per vaginum Excessive seropurulent discharge Backache Symptoms of Cervical Cancer SIHFW: An ISO:9001:2008 certified Institution 229

PowerPoint Presentation:

Cusco's Speculum and Ayre's Spatula SIHFW: An ISO:9001:2008 certified Institution 230

Evaluation and Management after Pap smear cytology:

E valuation and Management after Pap smear cytology LEEP LEEP Biospy Cryotherapy at the same sitting Normal CIN Repeat PAP after 1 YR Cryo therapy LEEP ASCUS/AGUS Inflammation Normal CIN/DYSPLASIA PAP Re-screen after 5 yrs Repeat after 6 mths Colposcopy Normal Abnormal Normal & Satisfactory Abnormal Unsatisfactory SIHFW: An ISO:9001:2008 certified Institution 231

Visual Inspection using 4% Acetic acid (VIA): :

Visual Inspection using 4% Acetic acid (VIA): Acetic acid causes dehydration of the cells Surface coagulation of proteins reducing the transparency of the epithelium. SIHFW: An ISO:9001:2008 certified Institution 232

Criteria for Categorizing VIA Test Results   :

Criteria for Categorizing VIA Test Results VIA Category Description Negative • No aceto -white lesions • Transparent lesions or faint patchy lesions without definite margins • Nabothian cysts becoming aceto -white • Faint line like aceto -whitening at the junction of columnar and squamous epithelium • Aceto -white lesions far away from the transformation zone. Positive • Distinct, opaque aceto -white area • Margin should be well defined, may or may not be raised • Abnormality close to the squamocolumnar junction in the transformation zone and not far away from the os . INvasive Obvious growth or ulcer in the cervix. Acetowhite area may not be visible because of bledding . SIHFW: An ISO:9001:2008 certified Institution 233

Evaluation and management after screening by VIA :

E valuation and management after screening by VIA LEEP Normal CIN Cryotherapy at the same sitting Repeat via after 1 yr Cryotherapy LEEP Management LEEP Biospy PAP if available Re-screen after 5 YRS Negative Positive VIA Colposcopy Normal & Satisfactory Unsatisfactory Abnormal SIHFW: An ISO:9001:2008 certified Institution 234

PowerPoint Presentation:

Cryotherapy (ablation) Loop Electrosurgical Excisional procedure (LEEP) Cervical cancer can be treated Surgery Radiotherapy Chemotherapy Combination of the three Management SIHFW: An ISO:9001:2008 certified Institution 235

Breast Cancer:

Breast Cancer Second most common cancer among women Data from Hospital Based Cancer Registry (HBCR) show that only about 15% of patients present in localized stage. SIHFW: An ISO:9001:2008 certified Institution 236

Age – wise distribution of Deaths due to Breast Cancer :

Age – wise distribution of Deaths due to Breast Cancer Source-WHO Organisation Mondiale de la Santé Department of Measurement and Health Information April 2011 SIHFW: An ISO:9001:2008 certified Institution 237

PowerPoint Presentation:

Breast Cancer Risk Not modifiable: Genetic family history Age Age at menarche Modifiable: Diet BMI Exercise Exogenous estrogen use Alcohol consumption Reproductive history Potentially modifiable Age at first birth Age at menopause Breast feeding SIHFW: An ISO:9001:2008 certified Institution 238

PowerPoint Presentation:

A lump or thickening in or near the breast or in the underarm area C hange in the size or shape of the breast Nipple turned inward Discharge (fluid) from the nipple, especially if it's bloody Dimpling or puckering in the skin of the breast Scaly, red, or swollen skin on the breast, nipple, or areola Sign and Symptoms SIHFW: An ISO:9001:2008 certified Institution 239

TNM Staging of Breast Cancer :

TNM Staging of Breast Cancer Primary Tumor Regional lymph nodes Distant metastases T x : Tumor cannot be assessed T 0 : No evidence of primary tumor T is : Carcinoma in situ T 1 : Tumor 2cm or less in its greatest dimension T 2 : Tumor 2-5cm. in greatest dimension T 3 : Tumor>5cm. in greatest dimension T 4 : Tumor of any size, with direct extension to N x : Cannot be assessed N 0 : No palpable regional lymph nodes N 1 : Palpable, mobile, lpsilateral axillary lymph node N 2 : Fixed ipsilateral axillary lymph node N 3 : lpsilateral internal mammary/ supraclavicular lymph nodes. M 0 : No distant metastases M 1 : Presence of distant metastases SIHFW: An ISO:9001:2008 certified Institution 240 240

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SIHFW: An ISO:9001:2008 certified Institution 241

Breast Examination by a Health Professional:

Breast Examination by a Health Professional Patient lying down- look for any asymmetry in the breast With the flat of the hand, both the breasts are palpated in a circular manner starting from the nipple and areola in a clockwise manner towards the periphery and the axillary tail of the breast in sitting and lying down position. The axilla, supraclavicular region and liver are also examined SIHFW: An ISO:9001:2008 certified Institution 242

Diagnosis:

Diagnosis Breast awareness & breast self examination Clinical Breast Examination (CBE) Mammography SIHFW: An ISO:9001:2008 certified Institution 243

PowerPoint Presentation:

Prompt referral and appropriate management Malignant lump Convey result to patient and support her to accept diagnosis Patient with lump in breast (Detected by BSE) Benigm lump Reassure patient Refer to higher centre for Investigation Reassure patient – all lumps need not be cancer Clinical examination by a health professional Management of Breast Cancer SIHFW: An ISO:9001:2008 certified Institution 244

Key Messages :

Key Messages Health professionals can – Create ‘Breast Awareness, Offer Clinical Breast Examinations To Women Aged 40-69 Years Reassure – All Lumps Are Not Cancer Ensure Prompt Referral And Appropriate Management Provide pain relief and palliative care SIHFW: An ISO:9001:2008 certified Institution 245

Lung Cancer:

Lung Cancer Defined as a malignant tumour of the lung arising within the wall or epithelium of the bronchus. OR It is a disease which consists of uncontrolled cell growth in tissues of the lung . This growth may lead to metastasis SIHFW: An ISO:9001:2008 certified Institution 246

Projected Cases of Lung Cancer in India :

Projected Cases of Lung Cancer in India Source: National Health Profile, 2009 SIHFW: An ISO:9001:2008 certified Institution 247

Causes:

Causes Smoking Passive smoking Asbestos fibers Radon gas Familial predisposition Lung diseases Prior history of lung cancer Air pollution SIHFW: An ISO:9001:2008 certified Institution 248

Symptoms  :

Symptoms Persistent cough or worsening of an existing chronic cough blood in the sputum Persistent bronchitis or Repeated Respiratory infections Chest pain Unexplained weight loss Fatigue Breathing difficulties such as shortness of breath or wheezing SIHFW: An ISO:9001:2008 certified Institution 249

Treatment and Staging NSCLC:

Treatment and Staging NSCLC Stage Description Treatment Options Stage I a/b Tumor of any size is found only in the lung Surgery Stage II a/b Tumor has spread to lymph nodes associated with the lung Surgery Stage III a Tumor has spread to the lymph nodes in the tracheal area, including chest wall and diaphragm Chemotherapy followed by radiation or surgery Stage III b Tumor has spread to the lymph nodes on the opposite lung or in the neck Combination of chemotherapy and radiation Stage IV Tumor has spread beyond the chest Chemotherapy and/or palliative (maintenance) care SIHFW: An ISO:9001:2008 certified Institution 250

PowerPoint Presentation:

National Programme SIHFW: An ISO:9001:2008 certified Institution 251

National Cancer Control Programme:

National Cancer Control Programme Established in 1975–76. Objectives Primary prevention of tobacco related cancer Secondary prevention i.e. early detection and diagnosis of cancers Strengthening of existing cancer treatment facilities Palliative care in terminal stage of the cancer At least 30% of the future cancer burden is potentially preventable by tobacco control SIHFW: An ISO:9001:2008 certified Institution 252

National Cancer Registry Programme:

National Cancer Registry Programme Initiated in 1982 by ICMR for data base of cancer cases Two types of registries: Population Based Cancer Registry (21 ) Hospital Based Cancer Registries (6) Data was collected from all cancer registries and all medical colleges for the “Development of an Atlas of Cancer in India” Cancer Awareness Day -7th November SIHFW: An ISO:9001:2008 certified Institution 253

PowerPoint Presentation:

Y ear 1975-76 National Cancer Control Program was launched with priorities for equipping the premier cancer hospital/institutions 1984-85 The strategy was revised and stress was laid on primary prevention and early detection 1990-91 District Cancer Control Program was started in selected districts (near the medical college hospitals) 2000-2001 Modified District Cancer Control program initiated 2004 Evaluation of NCCP was done by National Institute of Health & Family Welfare, New Delhi. 2005 The program was further revised after evaluation 2012 National Programme for prevention and control of Cancer, Diabetes and Cardio Vascular Diseases (NPCDCS) SIHFW: An ISO:9001:2008 certified Institution 254

Schemes under NCCP:

Schemes under NCCP Recognition of New Regional Cancer Centers (RCCs) Strengthening of existing Regional Cancer Centers Development of Oncology Wing District Cancer Control Program Decentralized NGO Scheme Regional Cancer Centers Oncology wing District Cancer Control Program IEC Activities SIHFW: An ISO:9001:2008 certified Institution 255

IEC Strategies:

IEC Strategies Under NCCP IEC material used in the form of Audio video spots Posters Leaflets Flipcharts SIHFW: An ISO:9001:2008 certified Institution 256

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SIHFW: An ISO:9001:2008 certified Institution 257

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SIHFW: An ISO:9001:2008 certified Institution 258

Services under NCCP at provider level:

Services under NCCP at provider level District Health Promotion Home Care/ Early Detection Pain Relief/Palliative Care Treatment of common cancers Histopathology Endoscopy SIHFW: An ISO:9001:2008 certified Institution 259

PowerPoint Presentation:

PHC Health education Health promotion Home care Early detection Palliative care and pain relief SIHFW: An ISO:9001:2008 certified Institution 260

PowerPoint Presentation:

Medical college Health Promotion & Home Care Early Detection & Treatment Pain Relief/Palliative Care Training of Health personals Early detection/ Registration/ mobile units Radiotherapy with cobalt-60 units Diagnosis and staging by clinical/ histopathological/ biochemical/ radiological/ endoscopic/ immunological/ isotope SIHFW: An ISO:9001:2008 certified Institution 261

PowerPoint Presentation:

Regional cancer centre Health Promotion Home Care Early Detection Pain Relief/Palliative Care/Comprehensive Cancer treatment Organize screening programme/Cytology training/ Basic and applied research/Training of all categories of personnel Cancer Registries Epidemiology SIHFW: An ISO:9001:2008 certified Institution 262

Why include Cancer In NPCDCS ?:

Why include Cancer In NPCDCS ? No uniform cancer prevention strategy No education on risk factors, early warning signals and their management Cancer screening is not practiced in an organized fashion Diagnostic infrastructure is limited SIHFW: An ISO:9001:2008 certified Institution 263

NPCDCS:

NPCDCS formed after merging the NCCP &NPDCS Provide technical & financial support to 65 Health care centers. These centers are known as “Tertiary Cancer Center” (TCC) NPCDCS has two component: Cancer Diabetes,CVD & Stroke NPCDCS Total 22 cancer drugs are prescribed under NPCDCS guidelines SIHFW: An ISO:9001:2008 certified Institution 264

Objective of TCC Scheme:

Objective of TCC Scheme Develop regional referral cancer centers to provide specialized and comprehensive cancer care, Provide training and research facilities in an all types of cancer with focus on Oral, Cervix & Breast Cancer SIHFW: An ISO:9001:2008 certified Institution 265

Financial Assistance For Cancer Component Under NPCDCS :

Yearly (Rs lakhs) District cancer care facility 166.42 District NCD Cell 21.44 State NCD cell 23.48 Financial Assistance For Cancer Component Under NPCDCS Financial assistance of Rs 6 crores for procurement of equipment, Construction of building & HR recruitment is provided Central & State share will be 80 :20 SIHFW: An ISO:9001:2008 certified Institution 266

Thank You :

Thank You For more details log on to www. Sihfwrajasthan.com or contact : Director-SIHFW on sihfwraj@yahoo.co.in SIHFW: An ISO:9001:2008 certified Institution 267

NPCDCS & NPHCE:

NPCDCS & NPHCE State Institute of Health & Family Welfare, Jaipur Cerebro -vascular accidents: Stroke SIHFW: An ISO:9001:2008 certified Institution 268

Definition:

Definition Group of brain dysfunctions related to disease of the blood vessels supplying the brain. Include diseases of the vascular system that causes Ischemia Infarction of the brain Spontaneous hemorrhage into the brain Subarachnoid space. SIHFW: An ISO:9001:2008 certified Institution 269

Cerebrovascular Accident:

Cerebrovascular Accident 25% with initial stroke die within 1 year 50-75% will be functionally independent 25% will live with permanent disability Physical, cognitive, emotional, & financial impact SIHFW: An ISO:9001:2008 certified Institution 270

Burden of Disease:

Burden of Disease SIHFW: An ISO:9001:2008 certified Institution 271

Epidemiological Determinants:

Epidemiological Determinants Hematologic disorders Athero Thromboembolism Trauma Fibro muscular dysplasia Congenital arterial anomalies Embolism from arterial aneurysm Inflammatory vascular disease Excessive irradiation of the head and neck Dementia Cerebral infarction and ischemia Occlusion or stenosis SIHFW: An ISO:9001:2008 certified Institution 272

Risk Factors :

Risk Factors Age and Sex Hypertension and Cardiac diseases Atrial fibrillation (AF) Coronary artery disease Lipids and Obesity Oral contraceptive use Transient ischemic attacks Blood viscosity Smoking/ Alcohol Diabetes Mellitus SIHFW: An ISO:9001:2008 certified Institution 273

CV Accident: Risk Factors:

CV Accident: Risk Factors Non-modifiable: Age – Occurrence doubles each decade >55 years Gender – Equal for men & women; women die more frequently than men Race – African Americans, Hispanics, Native Americans, Asian Americans -- higher incidence Heredity – family history, prior transient ischemic attack, or prior stroke increases risk SIHFW: An ISO:9001:2008 certified Institution 274

Cerebrovascular Accident Risk Factors:

Cerebrovascular Accident Risk Factors Controllable Risks : High blood pressure Diabetes Cigarette smoking TIA (Aspirin) High blood cholesterol Obesity Heart Disease Atrial fibrillation Oral contraceptive use Physical inactivity Sickle cell disease Asymptomatic carotid stenosis Hypercoagulability SIHFW: An ISO:9001:2008 certified Institution 275

CVA – Risk Factors:

CVA – Risk Factors SIHFW: An ISO:9001:2008 certified Institution 276

Cerebrovascular Accident Anatomy of Cerebral Circulation:

Cerebrovascular Accident Anatomy of Cerebral Circulation Blood Supply 20% of cardiac output—750-1000ml/min >30 second interruption– neurologic metabolism is altered; metabolism stops in 2 minutes; brain cell death < 5 mins . SIHFW: An ISO:9001:2008 certified Institution 277

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SIHFW: An ISO:9001:2008 certified Institution 278

Cerebrovascular Accident Pathophysiology :

Cerebrovascular Accident Pathophysiology Ischemic Cascade Series of metabolic events Inadequate ATP adenosine triphosphate production Loss of ion homeostasis Release of excitatory amino acids – glutamate Free radical formation Cell death Border Zone (ischemic penumbra) : reversible area that surrounds the core ischemic area in which there is reduced blood flow but which can be restored (3 hours +/-) SIHFW: An ISO:9001:2008 certified Institution 279

PowerPoint Presentation:

Atherosclerosis: Thrombus formation & emboli development Abnormal filtration of lipids in the intimal layer of the arterial wall Plaque develops & locations of increased turbulence of blood - bifurcations Increased turbulence of blood or a tortuous area Calcified plaques rupture or fissure Platelets & fibrin adhere to the plaque Narrowing or blockage of an artery by thrombus or emboli Cerebral Infarction: blocked artery with blood supply cut off beyond the blockage SIHFW: An ISO:9001:2008 certified Institution 280

Symptoms:

Symptoms Trouble in walking Altered movement coordination and disequilibrium Sudden confusion or trouble in speaking or understanding. Weakness of facial muscles causing drooling. Dysarthria Apraxia SIHFW: An ISO:9001:2008 certified Institution 281

PowerPoint Presentation:

Sudden trouble in seeing with one or both eye, troubled walking, dizziness, loss of balance or coordination Aphasia Visual field defect Memory deficits Disorganized thinking, confusion, hypersexual gestures Anosognosia Altered smell, taste, hearing, or vision SIHFW: An ISO:9001:2008 certified Institution 282

Identification of an acute event:

Identification of an acute event Sudden numbness or weakness of face, arm, or leg, especially on one side of the body. Sudden onset of inability or difficulty in speech Sudden loss of consciousness. Sudden onset of blindness in or both eyes. Sudden onset of imbalance. Sudden severe headache with no known cause. Seizure SIHFW: An ISO:9001:2008 certified Institution 283

Cerebrovascular Accident Transient Ischemic Attack:

Cerebrovascular Accident Transient Ischemic Attack Temporary focal loss of neurologic function Caused by ischemia to one of the vascular territories of the brain Microemboli with temporary blockage of blood flow Lasts less than 24 hrs – often less than 15 mins Most resolve within 3 hours Warning sign of progressive cerebrovascular disease SIHFW: An ISO:9001:2008 certified Institution 284

Cerebrovascular Accident Transient Ischemic Attack:

Cerebrovascular Accident Transient Ischemic Attack Diagnosis: CT without contrast Confirm that TIA is not related to brain lesions Cardiac Evaluation Rule out cardiac mural thrombi Treatment: Medications that prevent platelet aggregation ASA-300mg st followed by 150mg/day, Clopidogrel-300mg loading, then 75mg daily. Oral anticoagulants SIHFW: An ISO:9001:2008 certified Institution 285

Cerebrovascular Accident Classifications :

Cerebrovascular Accident Classifications Based on underlying pathophysiologic findings SIHFW: An ISO:9001:2008 certified Institution 286

Cerebrovascular Accident Classifications:

Cerebrovascular Accident Classifications Ischemic Stroke Thrombotic Embolic Hemorrhagic Stroke Intracerebral Hemorrhage Subarachnoid Hemorrhage Aneurysm Berry or Saccular SIHFW: An ISO:9001:2008 certified Institution 287

Cerebrovascular Accident Classifications:

Cerebrovascular Accident Classifications Ischemic Stroke —inadequate blood flow to the brain from partial or complete occlusions of an artery--85% of all strokes Extent of a stroke depends on: Rapidity of onset Size of the lesion Presence of collateral circulation Symptoms may progress in the first 72 hours as infarction & cerebral edema increase Types of Ischemic Stroke : Thrombotic Stroke Embolic Stroke SIHFW: An ISO:9001:2008 certified Institution 288

CVA Recognition:

CVA Recognition SIHFW: An ISO:9001:2008 certified Institution 289

Cerebrovascular Accident Ischemic – Thrombotic Stroke:

Cerebrovascular Accident Ischemic – Thrombotic Stroke Lumen of the blood vessels narrow – then becomes occluded – infarction Associated with HTN and Diabetes Mellitus >60% of strokes 50% are preceded by TIA Lacunar Stroke: development of cavity in place of infarcted brain tissue – results in considerable deficits – motor hemiplegia , contralateral loss of sensation or motor ability SIHFW: An ISO:9001:2008 certified Institution 290

Cerebrovascular Accident Thrombotic Stroke:

Cerebrovascular Accident Thrombotic Stroke SIHFW: An ISO:9001:2008 certified Institution 291

PowerPoint Presentation:

SIHFW: An ISO:9001:2008 certified Institution 292

Cerebrovascular Accident Common Sites of Atherosclerosis:

Cerebrovascular Accident Common Sites of Atherosclerosis SIHFW: An ISO:9001:2008 certified Institution 293

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SIHFW: An ISO:9001:2008 certified Institution 295

Cerebrovascular Accident Ischemic – Embolic Stroke:

Cerebrovascular Accident Ischemic – Embolic Stroke Embolus lodges in and occludes a cerebral artery Results in infarction & cerebral edema of the area supplied by the vessel Second most common cause of stroke – 24% Emboli originate in endocardial layer of the heart – atrial fibrillation, MI, infective endocarditis , rheumatic heart disease, valvular prostheses Rapid occurrence with severe symptoms – body does not have time to develop collateral circulation Any age group Recurrence common if underlying cause not treated SIHFW: An ISO:9001:2008 certified Institution 296

Cerebrovascular Accident Embolic Stroke:

Cerebrovascular Accident Embolic Stroke SIHFW: An ISO:9001:2008 certified Institution 297

Cerebrovascular Accident Goals for Management:

Cerebrovascular Accident Goals for Management Immediate – assess & stabilize ABCs, Oxygen if hypoxic IV access Check glucose 12-lead EKG SIHFW: An ISO:9001:2008 certified Institution 298

Cerebrovascular Accident Goals for Management:

Cerebrovascular Accident Goals for Management CT Scan – No hemorrhage: Consider Fibrinolytic therapy Check for exclusions tPA No anticoagulants or antiplatelet therapy for 24 hours If not a candidate: Antiplatelet Therapy CT Scan – Hemorrhage: Neurosurgery? If no surgery: Stroke Unit Monitor BP and treat Hypertension Monitor Neuro status Monitor blood glucose and treat as needed Supportive therapy SIHFW: An ISO:9001:2008 certified Institution 299

Cerebrovascular Accident Hemorrhagic Stroke:

Cerebrovascular Accident Hemorrhagic Stroke Hemorrhagic Stroke 15% of all strokes Result from bleeding into the brain tissue itself Intracerebral Subarachnoid SIHFW: An ISO:9001:2008 certified Institution 300

Cerebrovascular Accident Hemorrhage Stroke Intracerebral Hemorrhage :

Cerebrovascular Accident Hemorrhage Stroke Intracerebral Hemorrhage Rupture of a vessel Hypertension – most important cause Others: vascular malformations, coagulation disorders, anticoagulation, trauma, brain tumor, ruptured aneurysms Sudden onset of symptoms with progression Neurological deficits, headache, nausea, vomiting, decreased LOC, and hypertension Prognosis: poor – 50% die within weeks 20% functionally independent at 6 months SIHFW: An ISO:9001:2008 certified Institution 301

Cerebrovascular Accident Hemorrhage Stroke Intracerebral Hemorrhage:

Cerebrovascular Accident Hemorrhage Stroke Intracerebral Hemorrhage SIHFW: An ISO:9001:2008 certified Institution 302

PowerPoint Presentation:

SIHFW: An ISO:9001:2008 certified Institution 303

Cerebrovascular Accident Hemorrhagic-Subarachnoid:

Cerebrovascular Accident Hemorrhagic-Subarachnoid Hemorrhagic Stroke–Subarachnoid Hemorrhage Intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain SIHFW: An ISO:9001:2008 certified Institution 304

Cerebrovascular Accident Hemorrhagic-Subarachnoid:

Cerebrovascular Accident Hemorrhagic-Subarachnoid Commonly caused by rupture of cerebral aneurysm (congenital or acquired) Saccular or berry – few to 20-30 mm in size Majority occur in the Circle of Willis Other causes: Arteriovenous malformation (AVM), trauma, illicit drug abuse Incidence: 6-16/100,000 Increases with age and more common in women SIHFW: An ISO:9001:2008 certified Institution 305

Cerebrovascular Accident Hemorrhagic-Subarachnoid Cerebral Aneurysm:

Cerebrovascular Accident Hemorrhagic-Subarachnoid Cerebral Aneurysm Warning Symptoms: sudden onset of a severe headache – “worst headache of one’s life” Change of LOC, Neurological deficits, nausea, vomiting, seizures, stiff neck Despite improvements in surgical techniques, many patients die or left with significant cognitive difficulties SIHFW: An ISO:9001:2008 certified Institution 306

Delayed Neurological deficit in SAH:

Delayed Neurological deficit in SAH Rerupture Vasospasm Hydrocephalus Hyponatremia SIHFW: An ISO:9001:2008 certified Institution 307

Hemorrhagic-Subarachnoid Cerebral Aneurysm:

Hemorrhagic-Subarachnoid Cerebral Aneurysm Surgical Treatment: Clipping the aneurysm – prevents rebleed Coiling – platinum coil inserted into the lumen of the aneurysm to occlude the sac Postop : Vasospasm prevention – Calcium Channel Blockers SIHFW: An ISO:9001:2008 certified Institution 308

PowerPoint Presentation:

SIHFW: An ISO:9001:2008 certified Institution 309

Hemorrhagic-Subarachnoid Cerebral Aneurysm – Surgical Tx:

Hemorrhagic-Subarachnoid Cerebral Aneurysm – Surgical Tx SIHFW: An ISO:9001:2008 certified Institution 310

Hemorrhagic-Subarachnoid Cerebral Aneurysm – Coiling:

Hemorrhagic-Subarachnoid Cerebral Aneurysm – Coiling SIHFW: An ISO:9001:2008 certified Institution 311

Cerebrovascular Accident Classification:

Cerebrovascular Accident Classification SIHFW: An ISO:9001:2008 certified Institution 312 Type Gender/Age Warning Time of Onset Course /Prognosis Ischemic Thrombotic Men more than women, oldest median age TIA (30%-50% of cases) During or after sleep Stepwise progression, signs and symptoms develop slowly, usually some improvement, recurrence in 20%-25% of survivors Embolic Men more than women TIA (uncommon) Lack of relationship to activity, sudden onset Single event, signs and symptoms develop quickly, usually some improvement, recurrence common without aggressive treatment of underlying disease Hemorrhagic Intracerebral Slightly higher in women Headache (25% of cases) Activity (often) Progression over 24 hr; poor prognosis, fatality more likely with presence of coma Subarachnoid Slightly higher in women, youngest median age Headache (common) Activity (often), sudden onset Most commonly related to head trauma Single sudden event usually, fatality more likely with presence of coma TIA, Transient ischemic attack SIHFW: An ISO:9001:2008 certified Institution 312

Cerebrovascular Accident Clinical Manifestations Middle Cerebral Artery Involvement :

Cerebrovascular Accident Clinical Manifestations Middle Cerebral Artery Involvement Contralateral weakness Hemiparesis ; hemiplegia Contralateral hemianesthesia Loss of proprioception , fine touch and localization Dominant hemisphere: aphasia Nondominant hemisphere – neglect of opposite side; anosognosia – unaware or denial of neuro deficit Homonymous hemianopsia – defective vision or blindness right or left halves of visual fields of both eyes SIHFW: An ISO:9001:2008 certified Institution 313

Cerebrovascular Accident Clinical Manifestations Anterior Cerebral Artery Involvement :

Cerebrovascular Accident Clinical Manifestations Anterior Cerebral Artery Involvement Brain stem occlusion Contralateral weakness of proximal upper extremity sensory & motor deficits of lower extremities Urinary incontinence Sensory loss (discrimination, proprioception ) Contralateral grasp & sucking reflexes may be present Apraxia – loss of ability to carry out familiar purposeful movements in the absence of sensory or motor impairment Personality change: flat affect, loss of spontaneity, loss of interest in surroundings Cognitive impairment SIHFW: An ISO:9001:2008 certified Institution 314

Cerebrovascular Accident Clinical Manifestations Posterior Cerebral Artery & Vertebrobasilar Involvement :

Cerebrovascular Accident Clinical Manifestations Posterior Cerebral Artery & Vertebrobasilar Involvement Alert to comatose Unilateral or bilateral sensory loss Contralateral or bilateral weakness Dysarthria – impaired speech articulation Dysphagia – difficulty in swallowing Hoarseness Ataxia, Vertigo Unilateral hearing loss Visual disturbances (blindness, homonymous hemianopsia , nystagmus , diplopia ) SIHFW: An ISO:9001:2008 certified Institution 315

Cerebrovascular Accident Clinical Manifestations Right Brain – Left Brain Damage:

Cerebrovascular Accident Clinical Manifestations Right Brain – Left Brain Damage SIHFW: An ISO:9001:2008 certified Institution 316

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Cerebrovascular Accident Treatment Goals:

Cerebrovascular Accident Treatment Goals Prevention – Health Maintenance Focus: Healthy diet Weight control Regular exercise No smoking Limit alcohol consumption Routine health assessment Control of risk factors-BP, Hyperglycemia, hyperlipidemia SIHFW: An ISO:9001:2008 certified Institution 319

Cerebrovascular Accident Treatment Goals:

Cerebrovascular Accident Treatment Goals Prevention Drug Therapy Surgical Therapy Rehabilitation SIHFW: An ISO:9001:2008 certified Institution 320

Cerebrovascular Accident Diagnostic Studies:

Cerebrovascular Accident Diagnostic Studies Done to confirm CVA and identify cause PE: Neuro Assessment; Carotid bruit Carotid doppler studies (ultrasound study) CT – primary – identifies size, location, differentiates between ischemic and hemorrhagic CTA – CT Angiography – visualizes vasculature MRI – greater specificity than CT May not be able to be used on all patients (metal, claustrophobia) Angiography: gold standard for imaging carotid arteries SIHFW: An ISO:9001:2008 certified Institution 321

Cerebrovascular Accident Treatment Goals:

Cerebrovascular Accident Treatment Goals Drug Therapy – Thrombotic CVA – to reestablish blood flow through a blocked artery Thrombolytic Drugs : tPA (tissue plasminogen activator) produce localized fibrinolysis by binding to the fibrin in the thrombi Plasminogen is converted to plasmin ( fibrinolysin ) Enzymatic action digests fibrin & fibrinogen Results is clot lysis Administered within 3 hours of symptoms of ischemic CVA Confirmed DX with CT Patient anticoagulated ASA SIHFW: An ISO:9001:2008 certified Institution 322

CVA - Treatment Goals:

CVA - Treatment Goals Surgical Treatment Carotid endarterectomy – preventive – > 100,000/year Removal of atheromatous lesion Clipping, wrapping, coiling Aneurysm Evacuation of aneurysm-induced hematomas larger than 3 cm. Treatment of AV Malformations SIHFW: An ISO:9001:2008 certified Institution 323

Carotid Endarterectomy:

Carotid Endarterectomy SIHFW: An ISO:9001:2008 certified Institution 324

Cerebrovascular Accident Treatment Goals:

Cerebrovascular Accident Treatment Goals Drug Therapy Measures to prevent the development of a thrombus or embolus for “At Risk” patients: Antiplatelet Agents Aspirin Clopidogrel Combinatio Oral anticoagulation – Coumadin Treatment of choice for individuals with atrial fibrillation who have had a TIA SIHFW: An ISO:9001:2008 certified Institution 325

Cerebrovascular Accident Acute Phase:

Cerebrovascular Accident Acute Phase Patient Education: Clear explanations for all care/treatments Focus on improvements—regained abilities Include family SIHFW: An ISO:9001:2008 certified Institution 326

Cerebrovascular Accident Rehabilitation:

Cerebrovascular Accident Rehabilitation Comprehensive plan – Physical Medicine & Rehabilitation Learn techniques to self-monitor & maintain physical wellness Avoid complications of stroke Communication Maintain nutrition & hydration Use community resources Family cohesiveness SIHFW: An ISO:9001:2008 certified Institution 327

PowerPoint Presentation:

SIHFW: An ISO:9001:2008 certified Institution 328

Cardio-Vascular Diseases :

Cardio-Vascular Diseases SIHFW: An ISO:9001:2008 certified Institution 329

Introduction:

Introduction Cardiovascular disease (CVD) includes dysfunctional conditions of- Heart, Arteries and Veins SIHFW: An ISO:9001:2008 certified Institution 330

Burden of Disease:

Burden of Disease Number one cause of death globally: more people die annually from CVDs than from any other cause 17.3 million people died from CVDs in 2008 30%of all global deaths 7.3 million - coronary heart disease 6.2 million – stroke By 2030, almost 23.6 million people will die from CVDs, mainly from heart disease and stroke. Source: WHO SIHFW: An ISO:9001:2008 certified Institution 331

Estimated cases of CHD in India :

Estimated cases of CHD in India Source: - NCMH Burden of Diseases in India, 2005 SIHFW: An ISO:9001:2008 certified Institution 332

Cardiovascular Diseases?:

Cardiovascular Diseases? group of disorders of the heart and blood vessels, and include: Coronary heart disease Cerebrovascular disease Peripheral arterial disease Rheumatic heart disease Congenital heart disease Deep vein thrombosis and pulmonary embolism Heart attacks and strokes SIHFW: An ISO:9001:2008 certified Institution 333

PowerPoint Presentation:

Risk Factors High cholesterol High BP Diabetes Obesity Smoking Ageing Consequence Stiff Arteries Results Heart Attack Stroke Heart Failur e SIHFW: An ISO:9001:2008 certified Institution 334

Newly emerging CVD risk factors:

Newly emerging CVD risk factors Low birth weight Folate deficiency Infections SIHFW: An ISO:9001:2008 certified Institution 335

WHO CVD-Risk Management Package :

WHO CVD-Risk Management Package Designed primarily for the management of cardiovascular risk in individuals detected to have hypertension through opportunistic screening includes Conditions that characterize the three scenarios Skill-level of the health worker Diagnostic and therapeutic facilities Available health services SIHFW: An ISO:9001:2008 certified Institution 336

PowerPoint Presentation:

Resource required Scenario-1 Scenario-2 Scenario-3 Human resource Health worker Medical Doctor or Nurse Medical doctor with specialist care Equipments Stethoscope BP instrument Measuring tape Weighing scale Test tubes Burner Strips for urine sugar Stethoscope BP instrument Measuring tape Weighing scale Test tubes Burner Strips for urine sugar and albumin Stethoscope BP instrument Measuring tape Weighing scale ECG machine Ophthalmoscope Blood chemistry analysis support Test tubes Burner Strips for urine sugar SIHFW: An ISO:9001:2008 certified Institution 337

PowerPoint Presentation:

Generic drugs Thiazide diuretics Metformin (optional) Thiazides Angiotensin converting enzyme inhibitors Calcium channel blockers Betablokers Aspirin Metformin Thiazides Angiotensin converting enzyme inhibitors Calciumchannel blockers Betablokers Aspirin Insulin Metformin Glibenclamide Statins (cost?) Angiotensin blockers (cost?) Other facilities Referral Maintenance& Calibration of BP instrument Referral Maintenance& Calibration of BP instrument Specialist care Maintenance &Calibration of BP instrument SIHFW: An ISO:9001:2008 certified Institution 338

Prevention of CVD:

Prevention of CVD Heart disease and stroke can be prevented through- Healthy diet Regular physical activity Avoiding tobacco smoke A diet rich in Nuts, fruit and vegetables Maintaining a healthy body weight SIHFW: An ISO:9001:2008 certified Institution 339

Hypertension:

Hypertension SIHFW: An ISO:9001:2008 certified Institution 340

Hypertension “ high blood pressure“ :

Hypertension “ high blood pressure “ A chronic medical condition in which the systemic arterial blood pressure is elevated. SIHFW: An ISO:9001:2008 certified Institution 341

Introduction :

Introduction Abnormally elevated blood pressure is a pathological condition which increases the work load on the heart. This condition is termed as high blood pressure or hypertension. Hypertension doubles the risk of CAD, CHF, ischemic and hemorrhagic stroke, renal failure and PAD Based on the etiology, high blood pressure is of two types: Primary/essential Secondary SIHFW: An ISO:9001:2008 certified Institution 342

Classification:

Classification Primary / Essential hypertension No medical cause found. 90–95% of cases relate to it. Secondary hypertension Caused by identified conditions affecting kidneys, arteries, heart, or endocrine system.

Primary V/s secondary:

Primary More Common Gradual :in onset Age: Affects after 40 Strong Family History Cause Premature Artherosclerosis Is life long Secondary Less common Dramatic in onset Age:1 st 2 nd Decade/5 th 6 th decade F.H: May/may not be present Causes: Endocrine tumor Chronic steroids May/or may not resolve Primary V/s secondary SIHFW: An ISO:9001:2008 certified Institution 344

Epidemiological Determinants:

Epidemiological Determinants Risk/ trigger factors Stress Potassium deficiency & sodium sensitivity Alcohol intake Vitamin D deficiency Obesity/metabolic disorder Sedentary lifestyle and Smoking Pre- eclampsia during pregnancy SIHFW: An ISO:9001:2008 certified Institution 345

Secondary Causes of Hypertension:

Secondary Causes of Hypertension Chronic kidney disease – CRF, PCKD, obstructive uropathy Drug-induced or related causes Primary aldosteronism Renovascular disease – atherosclerotic, fibromuscular dysplasia Chronic steroid therapy and Cushing’s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease Sleep apnea SIHFW: An ISO:9001:2008 certified Institution 346

Symptoms:

Symptoms Headache Drowsiness Confusion Vision disorders Nausea and Vomiting SIHFW: An ISO:9001:2008 certified Institution 347

Drug-Induced Hypertension: Prescription Medications:

Drug-Induced Hypertension: Prescription Medications Steroids Estrogens NSAIDS Phenylpropanolamines Cyclosporine/tacrolimus Erythropoietin Sibutramine Methylphenidate Ergotamine Ketamine Desflurane Carbamazepine Bromocryptine Metoclopramide Antidepressants Venlafaxine Buspirone SIHFW: An ISO:9001:2008 certified Institution 348

PowerPoint Presentation:

Criteria for diagnosing high blood pressure Category Systolic Diastolic Normal Less than 120 Less than 80 Pre-hypertension 120-139 80-89 High Blood Pressure Stage 1 140-159 90-99 Stage 2 160 or higher 100 or higher Source: JNC VII classification SIHFW: An ISO:9001:2008 certified Institution 349

Management of Hypertension:

Management of Hypertension Assessment of medical history Physical Examination Laboratory Investigation SIHFW: An ISO:9001:2008 certified Institution 350

Assessment of medical history:

Assessment of medical history Headache (severe hypertension) < morning in occipital region Dizziness, palpitations, easy fatigability Ask for: 1.Risk factors Lack of physical activity (or sedentary lifestyle). Obesity or being overweight Abdominal obesity High sodium intake/high salt intake Excess alcohol consumption SIHFW: An ISO:9001:2008 certified Institution 351

PowerPoint Presentation:

2.Family history 3.Symptoms of consequences of hypertension 4.Frequent intake of pain relieving drugs (NSAIDS) 5.Steroid intake for asthma 6.Breathing difficulty particularly on exertion 7.Swelling of feet 8.Urinary difficulties, history of passing stones in the past SIHFW: An ISO:9001:2008 certified Institution 352

Physical Examination:

Physical Examination Physical examination should include Pulse rate Palpating all peripheral pulses BP measurement at least in one upper and one lower limb Assessment of BMI (Body weight and height to obtain BMI Measurement of Waist circumference Palpation of neck for enlarged thyroid Auscultation for bruit (renal, carotid, abdominal and others) Eye evaluation if ophthalmology facility is available SIHFW: An ISO:9001:2008 certified Institution 353

Laboratory Tests:

Laboratory Tests Essential: Blood Sugar Urine analysis for proteinuria SIHFW: An ISO:9001:2008 certified Institution 354

PowerPoint Presentation:

Desirable: (at CHC/sub-district/district level hospitals depending upon the available facilities for laboratory investigations) Haemogram , Serum creatinine Serum sodium, potassium and calcium levels Lipid profile Complete Urine analysis Electrocardiogram(ECG) X-Ray chest Thyroid function test SIHFW: An ISO:9001:2008 certified Institution 355

Management:

Management Therapeutic life-style management Drug Therapy SIHFW: An ISO:9001:2008 certified Institution 356

PowerPoint Presentation:

Life style advice is advocated for the first six month after the diagnosis of high BP in the following situations : If the BP is less than 160/100 mm of Hg There is no diabetes, co-existing heart disease stroke or peripheral vascular disease No evidence of LVH on ECG Absence of urinary proteinuria and Serum creatinine <1.6mg/dl SIHFW: An ISO:9001:2008 certified Institution 357

Lifestyle modifications to manage hypertension :

Lifestyle modifications to manage hypertension Weight reduction Dietary salt reduction Adapt DASH – type dietary plan Moderation of alcohol consumption Physical activity Attain and maintain BMI <25 kg/m2 < 6g NaCl /d Diet rich in fruits, vegetables, and low – fat dairy products with reduced content of saturated and total fat For those who drink alcohol , Consume ≤2 drinks /day in men and ≤1drink/day in women Regular aerobic activity, e.g., brisk walking for 30 min/d SIHFW: An ISO:9001:2008 certified Institution 358

Treatment Goals:

Treatment Goals The aim should be to get to blood pressure levels of less than 120/80 mms of Hg without bothersome side-effects. Don't accept blood pressure levels of 140/90 mms of Hg or more Maintain healthy blood pressure throughout the person’s lives Prevent and control risk factors which could give rise to high blood pressure. Always make sure that risk factors are controlled. Prevent and control risk factors which could increase risk of complications due to high blood pressure. SIHFW: An ISO:9001:2008 certified Institution 359

Pharmacologic therapy:

Pharmacologic therapy Diuretics Ace inhibitors/ARB’s Aldosterone antagonists Beta blockers Calcium channel blockers α -adrenergic blockers Sympatholytic agents Direct vasodilators SIHFW: An ISO:9001:2008 certified Institution 360

Diuretics:

Diuretics Thiazide Inhibit Na + / Cl - pump in DCT Hydrochlorthizide 6.25-50mg/day (1-2) Chlorthalidone 25-50mg/day (1) C/I Diabetes, dyslipidemia , hyperuricemia , Gout, hypokalemia Loop diuretics Furosemide 40-80mg/day (2-3) C/I Diabetes, dyslipidemia,hyperuricemia , gout, hypokalemia Aldosterone antagonists Spironolactone 25-100mg/day (1-2) Eplerenone 50-100mg/day (1-2) C/I Renal failure, hyperkalemia K + retaining Amiloride 5-10mg/day(1-2) Triamterene 50 –100mg/day(1-2) C/I Renal failure, hyperkalemia SIHFW: An ISO:9001:2008 certified Institution 361

ACE inhibitors:

ACE inhibitors Decrease production of angiotensin II, thus causing efferent arteriolar vasodilatation Enalapril 5-40mg/day(1-2) Captopril 25-200mg/day(2) Lisinopril10-40mg/day (1) Ramipril 2.5-20mg/day(1-2) Can be combined with diuretics and CCB Side effects-Dry cough, Angioedema , Hyperkalemia ARB’s Losartan 25-100mg/day (1-2) Valsartan 80-320mg/day(1) Candesartan 2-32mg/day (1) Telmisartan 20-80mg/day(1) Olmisartan 20-40mg/day(1) C/I of ACEI’s and ARB’s are renal failure, bilateral renal artery stenosis , pregnancy SIHFW: An ISO:9001:2008 certified Institution 362

Beta blockers:

Beta blockers Act by decreasing cardiac output, due to reduction of heart rate and contractility Selective (ß1) Acebutolol-200-600mg/day(2) Atenolol-50-100mg/day(1) Metoprolol-12.5-100mg/day(2) Bisoprolol-10mg/day(1) Esmolol-50-300µg/kg/min IV Nonselective Propranolol-40-160mg/day(2) Combined alpha/beta Labetalol-200-800mg/day(2) Carvedilol-12.5-50mg/day(2) Contraindications are asthma, COPD, PR-<60/min, 2 nd or 3 rd degree heart block, sick-sinus syndrome. SIHFW: An ISO:9001:2008 certified Institution 363

Calcium channel blockers:

Calcium channel blockers Reduce vascular resistance through L channel blockade, which reduces intracellular Ca and causes vasodilatation Dihydropyridines Amlodipine-5-10mg/day Felodipine-5-10mg/day Nicardipine-20-40mg tid Nifedipine (LA)-30-60mg/day(1) Nondihydropyridines Diltiazem-30-80mg qid Diltiazem (LA)-180-420mg/day(1) Verapamil-40-160mg tid Side effects are flushing, headache, pedal edema SIHFW: An ISO:9001:2008 certified Institution 364

α adrenergic blockers:

α adrenergic blockers Lower BP by decreasing peripheral vascular resistance Selective Prazosin 2-20mg/day (2-3) Doxazosin 1-16mg/day(1) Terazosin 1-10mg/day(1-2) Nonselective Phenoxybenzamine 20-120mg/day(2-3) SIHFW: An ISO:9001:2008 certified Institution 365

Sympatholytic agents :

Sympatholytic agents Decrease peripheral resistance by inhibiting sympathetic outflow Clonidine 0.1-0.6mg/day(2) Methyldopa 250-1000mg/day(2) Reserpine 0.05-0.25mg/day(1) Usefulness is limited by dryness of mouth, orthostatic hypotension, sexual dysfunction, sedation and numerous drug-drug interaction Direct vasodilators Reduce peripheral resistance Hydralazine 25-100mg/day(2) Minoxidil 25-80mg/day(1-2) Hydralazine - may cause lupus –like syndrome and minoxidil may cause hirsutism and pericardial effusion SIHFW: An ISO:9001:2008 certified Institution 366

PowerPoint Presentation:

Medicines are tailored depending on the following factors 1. Blood pressure level Patient characteristics (like age, body weight, occupation ) 3. Co-existing risk factors 4. Type and extent of target organ damage 5. Other associated diseases 6. Affordability SIHFW: An ISO:9001:2008 certified Institution 367

PowerPoint Presentation:

diuretics ( hydrochchlorthiozide ), calcium channel blockers ( amlodipine ) and ACE inhibitors ( Enalapril ) are relatively cheap. Drug therapy should be started in individuals at the time of diagnosis if they have blood pressure more than 160/100mmHg (despite non-pharmacological interventions) or if BP>140/90 in diabetic subjects or end organ damage such as proteinurea , high blood urea, ECG evidence of left ventricular hypertrophy, presence of heart diseases and evidence of retinopathy. In all other individuals life style modification should be tried for at least six months before initiating drug therapy. SIHFW: An ISO:9001:2008 certified Institution 368

PowerPoint Presentation:

Start with calcium channel blockers (specifically if the person is older than 55 years) and ACE inhibitors if less than 55 years. Recheck the BP in 2 weeks. If BP is not under control adding diuretics (Hydrochlorothiazide 12.5 mg a day) may be helpful. Normally this should bring the BP under control. If the BP is not controlled by the combination of Amlodipine 10mg + Hydrochlorothiazide 25mg a day or Enalapril 10mg and Hydrochlorothiazide 25mg a day, a referral to a higher center may be necessary. SIHFW: An ISO:9001:2008 certified Institution 369

Treatment of Hypertension:

Treatment of Hypertension Lifestyle Modifications Goal Blood Pressure (<140/90 mmHg) (< 130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Stage 2 HTN (SBP > 160 or DBP > 100 mmHg) 2-drug combination for most (usually thiazide -type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 HTN (SBP 140–159 or DBP 90–99 mmHg) Thiazide -type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. SIHFW: An ISO:9001:2008 certified Institution 370

Compelling Indications for Individual Drug Classes:

Compelling Indications for Individual Drug Classes Compelling Indication Initial Therapy Options Diabetes ACEI, ARB, CCB, THIAZ, BB, Chronic kidney disease ACEI, ARB Recurrent stroke prevention THIAZ, ACEI SIHFW: An ISO:9001:2008 certified Institution 371

Compelling Indications for Individual Drug Classes:

Compelling Indications for Individual Drug Classes Compelling Indication Initial Therapy Options Heart failure THIAZ, BB, ACEI, ARB, ARA Postmyocardial infarction BB, ACEI High CAD risk THIAZ, BB, ACEI, CCB SIHFW: An ISO:9001:2008 certified Institution 372

PowerPoint Presentation:

Management of Hypertension at different levels of care Services Levels of Care Sec. care CHC PHC Screening for Hypertension √ √ √ Initial Risk Assessment Assessment of Medical History √ √ √ Physical Examination √ √ √ Laboratory Investigation Essential √ √ √ Desirable √ √ Therapeutic Lifestyle Management √ √ √ Pharmacotherapy Initiation (Uncomplicated cases) √ √ √ Initiation (Complicated cases) √ √ √ Follow-up √ √ √ Annual Assessment √ √ √ 373 SIHFW: An ISO:9001:2008 certified Institution

Causes of Resistant Hypertension:

Causes of Resistant Hypertension Resistant hypertension -BP persistently >140/90mmHg despite taking 3 or more agents including a diuretic, in reasonable combination and at full dose Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication Inadequate doses Drug actions and interactions: Non-steroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics , oral contraceptives Over-the-counter (OTC) drugs and herbal supplements Excess alcohol intake Identifiable causes of HTN SIHFW: An ISO:9001:2008 certified Institution 374

Follow-up and Monitoring:

Follow-up and Monitoring Patients should return for follow-up and adjustment of medications every 1-2 months until the BP goal is reached After BP at goal and stable, follow-up visits at 3- to 6-month intervals More frequent visits for stage 2 HTN or with complicating comorbid conditions Continue to encourage self BP monitoring Serum potassium and creatinine monitored 1–2 times per year SIHFW: An ISO:9001:2008 certified Institution 375

Ischemic heart disease :

Ischemic heart disease SIHFW: An ISO:9001:2008 certified Institution 376

Ischemic Heart Disease :

Ischemic Heart Disease Myocardial impairment due to imbalance between coronary blood flow and myocardial requirement. SIHFW: An ISO:9001:2008 certified Institution 377

Cause:

Cause Atherosclerotic coronary artery disease Imbalance between supply and demand in left ventricular hypertrophy SIHFW: An ISO:9001:2008 certified Institution 378

Burden of IH Disease:

Burden of IH Disease SIHFW: An ISO:9001:2008 certified Institution 379

Epidemiological Determinants:

Epidemiological Determinants Heredity High cholesterol Tobacco Obesity and High-fat diet Hypertension Diabetes Physical inactivity Emotional stress and Type A personality (impatient, aggressive, competitive) SIHFW: An ISO:9001:2008 certified Institution 380

Symptoms:

Symptoms Abrupt, unexpected cardiac arrest. Chest pain on exertion (angina pectoris), which may be relieved by rest. Shortness of breath on exertion & Irregular heartbeat. Jaw/back/arm pain, especially on left side, either during exertion or at rest. Palpitations Dizziness, light-headedness, or fainting Weakness on exertion or at rest SIHFW: An ISO:9001:2008 certified Institution 381

Diagnosis:

Diagnosis Physical findings related to elevated BP, corneal arcus , Retinal arteriolar changes and aortic stenosis ECG monitoring Left ventricular Function assessment Coronary anatomy assessment Stress testing Echocardiography SIHFW: An ISO:9001:2008 certified Institution 382

Treatment of IHD:

Treatment of IHD Medical treatment Platelet inhibitors Lipid lowering agents Beta blockers( Metoprolol,Atenolol ) Calcium channel blockers( Nifedipine,diltiazem ) Potassium channel openers( Nicorandil ) Estrogen replacement Antioxidants Gene therapy Metabolic modulation Interventional Percutaneous coronary intervention Surgical revascularization Trans-myocardial laser revascularization Spinal cord stimulation Transcutaneous electric nerve stimulation SIHFW: An ISO:9001:2008 certified Institution 383

Lifestyle modification for treatment of IHD:

Lifestyle modification for treatment of IHD Cessation of smoking Exercise Diet Alcohol SIHFW: An ISO:9001:2008 certified Institution 384

Management & Prevention: Modifying the risk factors:

Management & Prevention: Modifying the risk factors High blood fats LDL Triglycerides Smoking Diabetes Hypertension Obesity Inactivity Emotional stress Regular follow-up visits with your health care provider / taker are essential. SIHFW: An ISO:9001:2008 certified Institution 385

PowerPoint Presentation:

Drooping of eyelid ( ptosis ) and weakness of ocular muscles Decreased reflexes: gag, swallow, pupil reactivity to light Decreased sensation and muscle weakness of the face Balance problems and nystagmus Altered breathing and heart rate SIHFW: An ISO:9001:2008 certified Institution 386

PowerPoint Presentation:

Weakness in sternocleidomastoid muscle with inability to turn head to one side Weakness in tongue (inability to protrude and/or move from side to side) Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. SIHFW: An ISO:9001:2008 certified Institution 387

Diagnosis:

Diagnosis CT scan for brain hemorrhage Conventional angiogram for view the blood vessels Carotid Doppler ultrasound for detect decreasing blood flow in the carotid arteries ECG for abnormal heart rhythms SIHFW: An ISO:9001:2008 certified Institution 388

Prevention:

Prevention Strokes are preventable Check blood pressure Health diet and exercise Control diabetes. Stop smoking SIHFW: An ISO:9001:2008 certified Institution 389

Rehabilitation:

Rehabilitation Speech therapy Occupational therapy to regain as much function dexterity in the arms and hands as possible SIHFW: An ISO:9001:2008 certified Institution 390

PowerPoint Presentation:

Physical therapy to improve strength and walking Family education to orient them in caring for their loved one at home and the challenges they will face. SIHFW: An ISO:9001:2008 certified Institution 391

Rheumatic heart diseases:

Rheumatic heart diseases SIHFW: An ISO:9001:2008 certified Institution 392

Rheumatic heart diseases:

Rheumatic heart diseases Complication of rheumatic fever Usually occurs after attacks of rheumatic fever. SIHFW: An ISO:9001:2008 certified Institution 393

Epidemiological Determinants :

Epidemiological Determinants Untreated strep throat. Damage the heart valves SIHFW: An ISO:9001:2008 certified Institution 394

Symptoms:

Symptoms Breathlessness Fatigue Palpitations Chest pain, and Fainting attacks SIHFW: An ISO:9001:2008 certified Institution 395

Treatment :

Treatment Include medication and surgery. Medication aim to avoid overexertion. Surgery to replace the damaged valve(s). SIHFW: An ISO:9001:2008 certified Institution 396

Prevention :

Prevention Seek immediate medical attention for sore throat Do not let it progress to rheumatic fever. SIHFW: An ISO:9001:2008 certified Institution 397

Comprehensive and integrated action to prevent and control CVDs:

Comprehensive and integrated action to prevent and control CVDs Focus on main risk factors for a range of chronic diseases such as CVD, diabetes and cancer Comprehensive Tobacco Control Policies Healthy diet Physical activity, Healthy meals SIHFW: An ISO:9001:2008 certified Institution 398

PowerPoint Presentation:

Thank you SIHFW: An ISO:9001:2008 certified Institution 399

National Program for Health and Care of Elderly :

National Program for Health and Care of Elderly SIHFW: An ISO:9001:2008 certified Institution 400

Conceptualization of NPHCE :

Conceptualization of NPHCE UN Convention on the Rights of Persons with Disabilities (UNCRPD), National Policy on Older Persons (NPOP) adopted by the Government of India in 1999 & Section 20 of “The Maintenance and Welfare of Parents and Senior Citizens Act, 2007” dealing with provisions for medical care of Senior Citizen. SIHFW: An ISO:9001:2008 certified Institution 401

NPHCE:

NPHCE 10 th June, 2010 ; Rs.288.00 crore for the remaining period of the 11 th five year plan(20% by states ) Implemented in 30 districts of 21 states during the year 2010-11 and 70 added during 2011-12. Expected to be expanded to the entire country during the 12 th Plan. SIHFW: An ISO:9001:2008 certified Institution 402

Objectives:

Objectives Provide Preventive, curative and rehabilitative services to the elderly persons; To strengthen referral system; To develop specialized man power and to promote research in the field of diseases related to old age. SIHFW: An ISO:9001:2008 certified Institution 403

Ageing:

Ageing Age-related changes in molecules and cells (theories of ageing) Normal ageing and associated disorders of key physiological systems Influence of environment and lifestyle. SIHFW: An ISO:9001:2008 certified Institution 404

Ageing?:

Ageing? Ageing is not a disease. Ageing is a progressive biological process SIHFW: An ISO:9001:2008 certified Institution 405

Common terms:

Common terms Elderly Senior Citizen Aged Old Person Older Person SIHFW: An ISO:9001:2008 certified Institution 406

Ageing means…..:

Ageing means….. Demographers: A Number Economists: A Burden Politicians: A Vote Medical Doctors: A Case Nurses: A Patient You: ????????????????????????? SIHFW: An ISO:9001:2008 certified Institution 407

Global Population 60 + Years : 1980-2020 :

Global Population 60 + Years : 1980-2020 Source : United Nations , World Demographic Estimate and Projections 1980 1990 2000 2010 2020 World 8.6 9.2 9.9 10.8 12.9 Developed 15.2 16.8 18.4 19.7 22.4 Developing 6.3 7 7.7 8.7 10.9 Africa 4.9 4.8 4.8 4.9 5.6 Latin America 6.5 7 7.7 8.8 11 Asia (excl. Japan) 6.5 7.4 8.5 9.8 12.8 China 7.4 9 10.5 12.4 16.6 India 6.5 7.3 8.4 9.9 12.6 SIHFW: An ISO:9001:2008 certified Institution 408

Ageing:

Ageing Progressive and generalized impairment of functions loss of adaptive response to stress and increasing risk of age-related diseases. UN -‘ageing population’ proportion of people over 60 reaches 7 per cent As per 2001 census people aged 60 and above constituted about 7.7% of the total population (up from 6.7 % in 1991). It is projected to rise to about 172 million by the year 2026 (about 12 % of the total population) SIHFW: An ISO:9001:2008 certified Institution 409

Some Facts!:

Some Facts! Aging is an end product of demographic transition. The number of elderly people in developing countries is almost 3-4 times of that of developed countries. The developed countries have already experienced the consequences of this transition. SIHFW: An ISO:9001:2008 certified Institution 410

Some Facts!:

Some Facts! World population of 6.9 billion in 2011 is likely to become 7.5 billion in 2020 Global aged population is 86.5 million (2011) Global aged population constitutes 0.8% of world population.(2011) SIHFW: An ISO:9001:2008 certified Institution 411 Source:HDR-2011,UNDP and UN, Population Division, Department of Economic and Social Affairs ( World Population Prospects: The 2010 Revision)

Some Facts!:

Some Facts! 73 % of deaths in the elderly are related to heart diseases, smoking and cancers. 20% of doctor’s visits, 30 % of hospital days and 50% of bedridden days are ascribed to elderly patients. ‘Ageing adds to BOD due to chronic non-communicable diseases. SIHFW: An ISO:9001:2008 certified Institution 412

Projections:

Projections 60+ 24 million in 1961 increased to 86.5 million in 2011. Projected to rise to 179 million in 2031 and 301 million in 2050. 70 and above projected to increase from 45 million in 2011 to 146 million in 2050. 80+ would be fastest to grow – 21 million in 2011 to 40 million in 2050. SIHFW: An ISO:9001:2008 certified Institution 413 Source:HDR-2011,UNDP and UN, Population Division, Department of Economic and Social Affairs ( World Population Prospects: The 2010 Revision)

India: Some Facts!:

India: Some Facts! 2 nd largest elderly (60+) population in the world (2010) Elderly(60+) :-100.819 million Source : United Nations , Population Division, Department of Economic and Social Affairs (World Population Prospects: The 2010 Revision) 80% are in rural areas 40% are below poverty line Over 73 per cent are Illiterate. about 90 % of the old people have no official social security (i.e., without PF, Gratuity and Pension etc). SIHFW: An ISO:9001:2008 certified Institution 414

India: Some Facts!:

India: Some Facts! Life expectancy 31.7 years in 1941 increased to 66.9 years (Census 2011) and 65.4 years(HDR-2011,UNDP) in 2011. 55% of the women of 60 years and above are widows. Older women most vulnerable. Elderly poverty is a major risk of ageing in developing countries. SIHFW: An ISO:9001:2008 certified Institution 415

Household population + 60 Age:

Household population + 60 Age Source : NFHS-III SIHFW: An ISO:9001:2008 certified Institution 416

Household population + 60 Age By Sex:

Household population + 60 Age By Sex Source : NFHS-III SIHFW: An ISO:9001:2008 certified Institution 417

Not just the numbers…:

Not just the numbers… Family structure is changing to nuclear/small unit families. Without the safe, secure and dignified status in the family, the elderly are finding themselves vulnerable. Welfare of the elderly has been a low priority with the state… SIHFW: An ISO:9001:2008 certified Institution 418

Ageing: Common Myths :

Ageing: Common Myths Most elderly need long-term care Anyone over a certain set age (such as 65) is old Elderly people are incompetent All elderly people live in poverty Older people are unhappy and lonely Elderly individuals do not want to work, and prior to retirement, they lose interest in work Retired people feel dejected SIHFW: An ISO:9001:2008 certified Institution 419

Ageing process:

Ageing process Physical changes are a normal part of the aging process Rate and degree of change varies Usually related to a decreased function of body systems Recognizing normal changes allows the individual to adapt and cope SIHFW: An ISO:9001:2008 certified Institution 420

Integumentary System:

Integumentary System Production of new skin cells decreases Sebaceous (oil) and sudoriferous (sweat) glands become less active Circulation to skin decreases Hair loses color; hair loss may occur SIHFW: An ISO:9001:2008 certified Institution 421

Musculoskeletal System:

Musculoskeletal System Muscles lose tone, volume, and strength Osteoporosis Arthritis SIHFW: An ISO:9001:2008 certified Institution 422

Circulatory System:

Circulatory System Heart muscle becomes less efficient at pushing blood into the arteries Blood vessels narrow and become less elastic Blood flow may decrease to brain and other vital organs SIHFW: An ISO:9001:2008 certified Institution 423

Respiratory System:

Respiratory System Respiratory muscles become weaker Rib cage becomes more rigid Bronchioles lose elasticity Changes in larynx affect voice SIHFW: An ISO:9001:2008 certified Institution 424

Nervous System:

Nervous System Progressive loss of brain cells Decreasing Senses Poor adaptation to changes SIHFW: An ISO:9001:2008 certified Institution 425

Digestive System:

Digestive System Reduced secretions and enzymes Slower smooth Muscle action peristalsis decreases Teeth are lost Liver function is reduced SIHFW: An ISO:9001:2008 certified Institution 426

Urinary System:

Urinary System Decreased circulation to kidneys Decreased number of nephrons Kidneys decrease in size; are less efficient Bladder function weakens SIHFW: An ISO:9001:2008 certified Institution 427

Endocrine System:

Endocrine System Increased/ decreased production of some hormones SIHFW: An ISO:9001:2008 certified Institution 428

Reproductive System:

Reproductive System Female: vaginal walls thin and secretions decrease; decreased support of uterus; breasts sag when fat is redistributed Male: production of sperm decreases; response to sexual stimuli is slower; ejaculation takes longer; testes become smaller and less firm; seminal fluid becomes thinner and less is produced SIHFW: An ISO:9001:2008 certified Institution 429

PowerPoint Presentation:

Aging causes many physical changes in all body systems; rate and degree vary All experience some degree of change Adapting and coping means fuller enjoyment of life within physical limitations Tolerance, patience, and empathy are essential SIHFW: An ISO:9001:2008 certified Institution 430

Psychosocial Changes of Aging:

Psychosocial Changes of Aging Loneliness Dependency Failure to adjust Feeling of vegetative life Irritability Dejection Depression SIHFW: An ISO:9001:2008 certified Institution 431

Disease and Disability:

Disease and Disability Elderly people are more prone to disease and disability Diseases sometimes cause permanent disabilities When functioning is affected, psychological stress is experienced Sick people often have fear of death, chronic illness, loss of function, and pain SIHFW: An ISO:9001:2008 certified Institution 432

PowerPoint Presentation:

Psychosocial changes can be a major source of stress As changes occur, individuals must learn to accommodate the changes and function in new situations With support, understanding, and patience, health care workers can assist individuals as they learn to adapt SIHFW: An ISO:9001:2008 certified Institution 433

Confusion and Disorientation in the Elderly:

Confusion and Disorientation in the Elderly Most remain mentally alert until death Signs of confusion or disorientation It is sometimes a temporary condition Disease and/or damage to the brain can result in chronic confusion or disorientation SIHFW: An ISO:9001:2008 certified Institution 434

Dementia :

Dementia Term used to describe a loss of mental ability Characteristics include decrease in intellectual ability, loss of memory, and personality change Acute dementia Chronic dementia SIHFW: An ISO:9001:2008 certified Institution 435

Alzheimer’s Disease:

Alzheimer’s Disease One form of dementia Causes progressive changes in brain cells Lack of neurotransmitter Frequently occurs in 60s, but can occur as young as 40 years of age Cause is unknown SIHFW: An ISO:9001:2008 certified Institution 436

Alzheimer’s Disease (continued):

Alzheimer’s Disease (continued) Terminal incurable brain disease; usually lasting 3-10 years Early stage Middle stage Terminal stage SIHFW: An ISO:9001:2008 certified Institution 437

Caring for the Confused or Disoriented Patient:

Caring for the Confused or Disoriented Patient Provide safe and secure environment Follow the same routine Follow “reality orientation” guidelines Caring for a confused or disoriented individual can be frustrating and even frightening Perform continual assessments Design program to maximize function Practice patience, consistency, and sincere caring SIHFW: An ISO:9001:2008 certified Institution 438

Meeting the Needs of the Elderly:

Meeting the Needs of the Elderly Geriatric care can be challenging but rewarding Elderly people have the same needs as others Cultural needs Religious needs Freedom from abuse Respect patient’s rights SIHFW: An ISO:9001:2008 certified Institution 439

Common problems with Ageing:

Common problems with Ageing Nutrition- Digestion, Denture, Taste Arthritis-Exercise, movement restriction Smoking-Whiling time, addiction Alcohol – slowed metabolism Accidents-Fall, decreased vision Adverse dug reactions: Overdose-forgetfulness CVDs, Hypotension, Syncope Incontinence SIHFW: An ISO:9001:2008 certified Institution 440

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Social status of older Indians:

Social status of older Indians General lowering of social status Dependency-Burden. Authority weakened Elderly abuse (30%) SIHFW: An ISO:9001:2008 certified Institution 442

Gender and Ageing in India:

Gender and Ageing in India Discrimination on account of gender, widowhood and age‘, ( and poverty ). Widowhood, -lowers the socio-economic level of women. Most older women are either illiterate or poorly educated. Low social status, discriminatory practices, food taboos, and poor attention to health are responsible for the poor health of older women ( more prone to chronic disabilities ). SIHFW: An ISO:9001:2008 certified Institution 443

Services for Elderly in India:

Services for Elderly in India Constitutional and legal provisions. Maintenance and welfare of parents and senior citizens Bill 2007 Ministry of Social Justice & Empowerment National policy on older persons January , 1999. areas of intervention -- financial security, healthcare and nutrition, shelter, education, welfare, protection of life and property etc. for the wellbeing of older persons in the country. National Council for Older Persons Constituted by the Ministry of Social Justice and Empowerment to operationalise the National Policy on Older Persons. SIHFW: An ISO:9001:2008 certified Institution 444

Care – Services for Elderly in India:

Care – Services for Elderly in India "Old Age Social and Income Security (OASIS )“ The Scheme of assistance to Panchayati Raj Institutions/Voluntary Organizations/Self Help Groups for construction of old age homes/multi service centers for older persons Old age pension for the general public National Old Age Pension (NOAP) Scheme. Annapurna (schemes & programs to provide food & security ). Pension, family pension, widow’s pension and Gratuity. Relief in taxation Insurance schemes for elderly Travel Miscellaneous Telephone, Helpline, Expeditious disposal of Court cases, Banking , Magazines for the elderly SIHFW: An ISO:9001:2008 certified Institution 445

Role of NGO’s & Private Sectors:

Role of NGO’s & Private Sectors Help Age India Age-well foundation in Delhi Dignity foundation The center for old in Need (COIN), Age care India The Self Employed Women’s Association (SFWA ) Centre for Health Education, Training and Nutrition Awareness (CHETNA ) SIHFW: An ISO:9001:2008 certified Institution 446

Primary Health Center:

Primary Health Center Training of medical and Para medical staff Provide basic medical care for common illnesses and follow-up ,coordinate rehabilitative services . Identify patients who would need the specialist care . Provide preventive services like immunization, health education and screening. These centers will be equipped with the basic investigative facilities also . The MMU could visit these centers also for organizing medical camps and care.

Secondary Care Hospital:

Secondary Care Hospital Comprehensive health care service with multidisciplinary approach A special Geriatric unit The hospital -elderly friendly particularly with the architect and behavior and communication skills of the staff . Separate investigations lab & imaging facilities for elderly. Mobile medical unit will also located here. The Geriatric unit will maintain close liaison with Primary care center and community. SIHFW: An ISO:9001:2008 certified Institution 448

How to achieve it?:

How to achieve it? Active advocacy at various levels of planning Most of the infrastructure and health care services already exist in the country Need for reorganization of the facilities and approach Efforts to be made to revive cultural values and reinforce the traditional practice of interdependence among generations Reinforcing the existing familism SIHFW: An ISO:9001:2008 certified Institution 449

Thank You:

Thank You SIHFW: An ISO:9001:2008 certified Institution 450

Mental Health : Problem, Strategies and Program Non-Communicable Diseases: NPCDCS & NPHCE:

Mental Health : Problem, Strategies and Program Non-Communicable Diseases: NPCDCS & NPHCE State Institute of Health & Family Welfare, Jaipur 451 SIHFW: an ISO 9001:2008 certified Institution

Key Facts:

More than 450 million people suffer from mental disorders. Many more have mental problems. Mental health is an integral part of health; indeed, there is no health without mental health. Mental health is more than the absence of mental disorders. Mental health is determined by socio-economic, biological and environmental factors. Cost-effective intersectoral strategies and interventions exist to promote mental health. Key Facts SIHFW: An ISO:9001:2008 certified Institution 452

Health ?:

"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.“ Mental health is an integral and essential component of health. Health ? SIHFW: An ISO:9001:2008 certified Institution 453

Mental Health:

Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. In this positive sense, mental health is the foundation for individual well-being and the effective functioning of a community. Mental Health SIHFW: An ISO:9001:2008 certified Institution 454

Mental Health Problems in India:

1%----Severe Mental Disorder (Schizophrenia, Other psychoses)-10-12 millions 10% ---Minor mental disorders(Anxiety, neurotic disorders)-100 millions 20-30% attending General clinical settings suffers from underlying psychiatric disorders Suicide rate- 10 per lac population 1-2% of all children have underlying M H Problem. 0.5-1% of all children have Mental Retardation. Mental Health Problems in India SIHFW: An ISO:9001:2008 certified Institution 455

Major Drug Abuse: India:

Drug Type NHS(Current prevalence,%) DAMS (% among treatment seekers) Alcohol 21.4% 43.9 Cannabis 3.0% 11.6 Heroin 0.2% 11.1 Opium 0.4% 8.6 Major Drug Abuse: India Source : National Survey, 2004 As per Global Adult tobacco Survey (GATS), India (2010), more than one-third (35%) of adults in India use tobacco in some form. SIHFW: An ISO:9001:2008 certified Institution 456

Extent of the problem…:

Extent of the problem… Mental Health Problem In Future Projections for 2020 Mental illnesses are expected to increase their proportion of total global burden of disease 15 percent The top three causes of disease burden projected to be IHD, depression and RTAs While psychiatric conditions are responsible for little more than 1 % of deaths, account for almost 11 % of disease burden worldwide Source: White Paper, April 2000: Responding to The Global Burden of Disease(WHO) SIHFW: An ISO:9001:2008 certified Institution 457

Mental Health Resources In India:

Psychiatric practice in India Psychiatrist Allopathic practitioner Traditional practitioner Faith healer Temple healing Yoga and meditation method Mental Health Resources In India SIHFW: An ISO:9001:2008 certified Institution 458

Mental Health Resources In India:

Manpower Estimated Requirement Current estimate Psychiatrists 11500 4000 Clinical Psychologists 17250 500-800 Psychiatric Social Workers 23000 400-600 Psychiatric Nurses 3000 900-1200 Mental Health Resources In India Source : Health Ministry Annual Report 2008-2009 SIHFW: An ISO:9001:2008 certified Institution 459

Mental Health Resources In India…:

Psychiatric Beds per 10,000 population World India Total psychiatric beds 1.69 0.25 Psychiatric beds in mental hospitals 1.16 0.2 Psychiatric beds in general hospitals 0.33 0.05 Psychiatric beds in other settings 0.20 0.01 Professionals per 100,000 population Number of psychiatrists 1.20 0.2 Number of psychiatric nurses 2.0 0.05 Number of psychologists 0.60 0.03 Number of social workers 0.40 0.03 (WHO country profile 2001) Mental Health Resources In India… SIHFW: An ISO:9001:2008 certified Institution 460

Mental Health Resources In India…:

The Indian Psychiatric Society (2011), 4000 registered psychiatrists in this country. If equitably distributed, this translates to just one psychiatrist for every three lakh population Currently the total numbers of seats recognized and permitted by the MCI are 266 for MD in Psychiatry and 124 for DPM, 49 students qualify for DNB Psychiatry . (http://mciindia.org/tools/medical_colleges/courses.htm accessed on 17th August 2010). Mental Health Resources In India… SIHFW: An ISO:9001:2008 certified Institution 461

Health Budget – Allocation to Mental Health in India:

Year Total Health Budget Crore rupees) Mental Health Budget ( Crore rupees) % Spend on Mental Health 2006-2007 8207 50(NMHP) 0.60 2007-2008 15291(10890 NRHM) 70(NMHP) 0.45 2008-2009 16534(12050 NRHM ) 70(NMHP) 0.42 11 Plan period (2007-2012) 152910 1000(NMHP) 0.66 Health Budget – Allocation to Mental Health in India Budget for mental health increasing but still it is less then 1% and most of other developed country. SIHFW: An ISO:9001:2008 certified Institution 462

Mental Health Resources in India:

25000 beds in 37 mental hospitals 3000-4000 beds in general & teaching hospital One psychiatric bed per 30000 population 5000-6000 qualified psychiatrists, 1500 clinical psychologist and 800-1000 psychiatric social workers One psychiatrist per 3 lacs population Mental Health Resources in India SIHFW: An ISO:9001:2008 certified Institution 463

National Mental Health Program 1982:

Aims : Prevention and treatment of mental and neurological disorders and their associated disabilities. to improve general health services. Application of mental health in total national development to improve quality of life National Mental Health Program 1982 SIHFW: An ISO:9001:2008 certified Institution 464

National Mental Health Program:

Objectives 1. Ensure availability and accessibility of minimum mental health care for all 2. Encourage application of mental health knowledge in general health care and in social development. 3. Promote community participation in the mental health services development and to stimulate efforts towards self-help in the community. National Mental Health Program SIHFW: An ISO:9001:2008 certified Institution 465

District Mental Health Programme:

Developed by NIMHANS in Bellary Start under the National Mental Health Programme 1996–97 Currently forms the central mental health intervention as part of the NMHP The objective of DMHP : Integration of mental health care with general health care and overall socio economic development through development of community mental health services and community involvement District Mental Health Programme SIHFW: An ISO:9001:2008 certified Institution 466

Essentials of DMHP:

1. A decentralized training programme 2. Provision of mental health in all health facilities 3. Involvement of all categories of health workers 4. Provision of essential psychiatric drugs 5. A simple record keeping 6. monitor PHC personnel in mental health care 7. Mental health team at district level, 8. Referral support 9. Supervision 10. Administrative support of local government Essentials of DMHP SIHFW: An ISO:9001:2008 certified Institution 467

Service in DMHP:

Team consisting of psychiatrist, clinical psychologist, psychiatric social worker, psychiatric nurse, statistician, programme manager, programme assistant Medical consultation on difficult cases Hospitalization & treatment for psychiatric patients including ECT treatment Training of medical officers and health personnel Support to NGOs Linkage with state mental hospital and medical college for further referral facilities Service in DMHP SIHFW: An ISO:9001:2008 certified Institution 468

Restrategised NMHP 2003:

Components Expansion of DMHP to 100 districts Strengthening and Modernization of State run Mental Hospitals Upgradation of Psychiatry Wings of Govt. Medical colleges/General Hospitals IEC activities Research and Training in Mental Health for improving the service delivery Restrategised NMHP 2003 SIHFW: An ISO:9001:2008 certified Institution 469

Revised NMHP [11th Five-Year Plan (‘07–’12)]:

Establish Centres of Excellence in Mental Health by upgrading and strengthening of identified existing mental hospitals Modernization of state run mental hospitals and up gradation of psychiatric wings of medical colleges/general hospitals DMHP with added components of Life Skills training Research & Training IEC NGOs and Public Private Partnership for implementation Effective Monitoring ,Implementation ,Evaluation at Central/State/District level Support for Central and State Mental Health Authorities Revised NMHP [11th Five-Year Plan (‘07–’12)] SIHFW: An ISO:9001:2008 certified Institution 470

Integration of NMHP in NRHM :

National Rural Health Mission A major initiative of the Government to revamp and strengthen the health care delivery system Integration initiated during the 11th five Year plan Basic objective of improving mental health services and effective outreach of initiatives under NMHP with integrate mental health into general health system Integration of NMHP in NRHM SIHFW: An ISO:9001:2008 certified Institution 471

Need for Integration of NMHP into NRHM :

Optimal use of existing infrastructure at various levels of health care delivery system Use of NRHM platform for transfer/flow of funds to the states/U.T.s for better accountability and flexibility Involvement of state/district level health authorities in the programme monitoring & implementation Integrated IEC activity under NRHM Involvement of NRHM infrastructure for training related to mental health in District Involving AYUSH practitioners in delivering mental health services at grass root level. Involvement of community based organisation Building of credible referral chains Need for Integration of NMHP into NRHM SIHFW: An ISO:9001:2008 certified Institution 472

DMHP Evaluation :

Independent evaluation carried out during 2008-2009,the(Indian Council of Marketing Research) covering 20 of the 123 districts. The main objective was to assess the functioning of DMHP objectively and critically and to suggest future expansion of the scheme along with improvement in implementation based upon the evaluation To strengthen the services at sub center, PHC, CHC level so that the services become more accessible A need for strong IEC for awareness creation/stigma reduction was noted DMHP Evaluation SIHFW: An ISO:9001:2008 certified Institution 473

DMHP Evaluation :

Lessons learnt Limited development of the DMHP in its operational aspects by the Central agency Limited state level capacity to implement the DMHP Lack of emphasis on creating awareness in the community Lack of mental health indicators Lack of monitoring DMHP Evaluation SIHFW: An ISO:9001:2008 certified Institution 474

NMHP Achievement :

NMHP Achievement Scheme Financial Support Provided District under DMHP 123 Up gradation of Psychiatry wings of Medical colleges/GHs 85 Psychiatry Wing Modernization of State run Mental hospitals 29 institutions Centers of Excellence 9 Institutions Support for new departments of Mental Health disciplines 19 SIHFW: An ISO:9001:2008 certified Institution 475

NMHP Achievement :

43 State-run Mental hospitals/mental health institutions. 292 Departments of Psychiatry in Medical Colleges. Approx. 30,000 psychiatric beds, PG Training Infrastructure: NMHP Achievement SIHFW: An ISO:9001:2008 certified Institution 476

Failures:

It is top down approach It is not based on the cultural aspects of the country It is driven by WHO policies The community voices have not been included The programme is a singular approach of DMHP Failures SIHFW: An ISO:9001:2008 certified Institution 477

NMHP Implementation Barriers :

Poor funding in the initial period Non availability of Psychiatrists and other mental health professionals like psychiatric social workers & clinical psychologists in many states. Limited undergraduate training in psychiatry Limited number of models and their evaluation Uneven distribution of resources across states There is lack of co-ordination at state level Little scope for community participation, NGO‘s, Civil Society were not involved to take up the activities to grass root level. Lack of regular & dedicated monitoring and facilitating mechanism. No operational guidelines for implementation NMHP Implementation Barriers SIHFW: An ISO:9001:2008 certified Institution 478

Urban Mental Health:

Meta analysis by Reddy and Chandrasekhar(1998) Higher prevalence of mental disorders in urban area i.e., 80.6%, whereas it was 48.9% in rural area Mental disorders primarily composed of depression and neurotic disorders Women often disproportionately bear burden of changes associated with urbanization Huge mental health service gap(82-96%) Lack of sub specialty health service and human resource deficit in non medical health professional Urban Mental Health SIHFW: An ISO:9001:2008 certified Institution 479

Improvement In Urban Mental Health:

Reorientation of DMHP Involvement of private sector and NGO Recognition there is huge mental health service gap in urban area Encouraging specific clinical and social service research Carrying out more health services research Improvement In Urban Mental Health SIHFW: An ISO:9001:2008 certified Institution 480

NGO Work In INDIA :

SCARF (Schizophrenia Research Foundation): SCARF, is a Chennai-based organisation that Specialises in patient of schizophrenia and research. Chaitanya : Pune -based organisation Runs a half-way home for schizophrenics patient. Snehi: Snehi is an organisation committed to community mental health care for young people for their psychological well being through its community mental health programmes. Paripurnata : Paripurnata is a Kolkata-based organisation It provides shelter, treatment and rehabilitation to women with mental illness who have been imprisoned or hospitalised. NGO Work In INDIA SIHFW: An ISO:9001:2008 certified Institution 481

NGO Work In India :

Ashra: Ashra is an Orissa-based organisation for the rescue, treatment, rehabilitation and resettlement of homeless women with mental illness. The Richmond Fellowship Society (India ): The world's largest network of mental health service providers It provides care and psychosocial rehabilitation for persons with mental health needs in India and neighboring countries. SANJIVINI Addressed the mental health needs of our community since 1976. It provides free and confidential counselling to anyone faced with situation that causes emotional and mental distress. SUMAITRI Delhi based voluntary organization It running a crisis intervention centre for people who are depressed, distressed or may be feeling suicidal. NGO Work In India SIHFW: An ISO:9001:2008 certified Institution 482

Mental Health NGO Activities :

Treatment: care and rehabilitation Community-based activities and prevention Research and training Advocacy and empowerment Mental Health NGO Activities SIHFW: An ISO:9001:2008 certified Institution 483

NGO Strength And Limitation:

STRENGTHS Working in partnership Innovation in practice Transparency in administration LIMITATION Sustainability Accountability Scope NGO Strength And Limitation SIHFW: An ISO:9001:2008 certified Institution 484

Community Awareness Activities:

Role of media Agony aunts columns Phone help lines Phone in programmes on Radio/TV Mental Illness Awareness Week (MIAW) First week of October Mental Health Camps Community Awareness Activities SIHFW: An ISO:9001:2008 certified Institution 485

School Mental Health Program:

Early detection and treatment Training of Teacher Impact of Life Skill to Children Enhance Psychosocial Competency Holistic approach School Mental Health Program SIHFW: An ISO:9001:2008 certified Institution 486

Tobacco:

As per Global Adult tobacco Survey (GATS), India (2010), more than one-third (35%) of adults in India use tobacco in some form. The prevalence of smokeless tobacco use (26%) is almost twice of the prevalence of smoking (14%). The prevalence of tobacco use among men (48%) is more than twice than women (20%). Smoking causes a 10-year decrease in life expectancy in smokers in India It is estimated that smoking will contribute to almost a million deaths per year from 2010 . Tobacco SIHFW: An ISO:9001:2008 certified Institution 487

Changing Trends Of Drug Use :

Changing trends of drug use A review of several of the rapid situation assessments of drug abuse commissioned by the UNODC 31 suggests the following trends: More younger users More female users High rates of alcohol and tobacco consumption Increasing rates of opiate use, particularly pharmaceutical opiates Increasing use of solvents, particularly among impoverished populations Changing Trends Of Drug Use SIHFW: An ISO:9001:2008 certified Institution 488

Stepped Care Approach in Substance Use :

A stepped care approach Step 1: Recognition of substance use and related problems in the primary health care/general hospital setting Step 2: Management of hazardous/harmful use at the primary care level Step 3: Management of moderate to severe dependence in primary care and referral to specialized units for relapse prevention Step 4: Management by mental health or addiction specialists Step 5: In-patient treatment Stepped Care Approach in Substance Use SIHFW: An ISO:9001:2008 certified Institution 489

Looking Ahead- Challenges :

Challenges Very uneven distribution of resources Low allocation of budget Low human resources for mental health Poor training in psychiatry at UG level Lack of welfare programmes. Public ignorance Stigma with psychiatry Hope Increasing interest from the State Increasing allocation of budget Centre of excellence Increasing facilities for training of mental health manpower Upgrading of departments of psychiatry and mental health institutions Looking Ahead- Challenges SIHFW: An ISO:9001:2008 certified Institution 490

Future Direction:

Vision 2020: Road Map for the Future The Need for a Balanced Approach Mainstreaming Mental Health Psychiatric services should be available to all sections. Psychiatry should not be seen as a peripheral discipline but must become a part of mainstream medicine Mental health services must become more relevant for Indian cultural needs Develop public-private partnership and support for NGO initiatives Increasing public awareness about mental disorders Future Direction SIHFW: An ISO:9001:2008 certified Institution 491

Conclusion :

India has been in the forefront of addressing mental health problems of its people. Programmes and initiative not spread widely. Large treatment gap. Larger problem of the chronically mental ill. The stigma of mental illness await major initiative to fight. Comprehensive service of promotion, prevention and treatment have just been started. Conclusion SIHFW: An ISO:9001:2008 certified Institution 492

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