ESCALATING BURDEN OF CHD (1) key note address

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This presentation is a keynote address delivered by me in regional level conference of indian association of preventive and social medicine(IAPSM) in oct.2013 at goverment medical college haldwani,uttrakhand

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1 ESCALATING BURDEN OF CHD- an overview DR HARIVANSH CHOPRA D.C.H.,M.D PROFESSOR COMMUNITY MEDICINE LLRM MEDICAL COLLEGE MEERUT

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THREE REAL STORIES Eighteen year old smart boy son of a doctor suffered from myocardial infarction and could not be saved despite getting best available treatment 2

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Thirty eight year old a famous specialist doctor, son of professor of Medicine Died at home on the first floor. Unfortunately no medical assistance was possible due to acuteness of episode 3 THREE REAL STORIES

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THREE REAL STORIES Fourty two year old faculty member of a medical college had an episode of impending infarction and fortunately was given treatment in private sector in first thirty minutes and survived. 4

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5 Facts 50% of Mortality in MI / CHD occurs in first thirty minutes CHD is occurring a decade earlier in india as compared to developed countries. Risk factor assessment is not prevalent in public health system

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6 TOP FIVE CAUSES OF MORTALITY 6 WHO INFOBASE

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Deaths below 70 Years Gupta R. Burden of coronary heart disease in India. Indian Heart J 2005; 57 : 632-8 . Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ 2004; 328 : 807-10 . 7

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Source: Global Health Observatory. World Heath organization 2011 8

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Trends in estimated percentage of deaths by cause of death, South-East Asia region, 2004 and 2030 9

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10 Estimated burden of CHD in India Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ 2004; 328 : 807-10 .

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AGE HYPERTENSION SMOKING DIABETES D YSLIPIDEMIA OBESITY/ LACK OF EXERCISE PREMATURE FAMILY HISTORY OF CAD TRADITIONAL RISK FACTORS 12

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NON TRADITIONAL RISK FACTORS ABNORMAL ABI HOMOCYSTEINUREA METABOLIC SYNDROME LVH RENAL DISEASE CALCIUM SCORE CHRONIC INFLAMATION CHRONIC INFLAMATORY DISEASE LIPOPROTIEN a HIV BNP FIBRINOGEN 13 CRP

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Schematic representation of an iceberg for NCDs 14

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TRADITIONAL RISK FACTORS DIABETES DIABETES DIABETES 19

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20 Diabetes mellitus: In India King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025 : prevalence, numerical estimates, and projections . Diabetes Care 1998; 21 : 1414-31. 20

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21 ICMR estimates Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005; 366 : 1746-51. 21

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* Fasting glucose> 7.0 mmol /L or on medication for diabetes Source: World Health Organization. Global status report on non communicable diseases, 2010. Geneva, 2011 22

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23 Diabetes: Top 10 Countries (absolute numbers)

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24 PECULARITY OF CHD IN DIABETES 24 DIABETIC SUBJECTS HAVE 2-4 TIMES MORE RISK OF CHD CHD MAY BE SILENT OCCURS AT YOUNGER AGE RESULT IN MICROVASCULAR ANGINA WORSE OUTCOME FOLLOWING REVASCULARISATION

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TRADITIONAL RISK FACTORS HYPERTENSION HYPERTENSION HYPERTENSION 25

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27 Hypertension: Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004; 18 : 73-8 .

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28 2000 2025 No. of Persons with HYPERTENSION 118 Million 214 Million No. of Persons Dying from TOBACCO 900,000 2 Million + Rising Chronic Disease Burdens Source: Jha et al, NEJM, Feb 2008 . WHO infobase

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TRADITIONAL RISK FACTORS SMOKING SMOKING SMOKING 29

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30 Cigarette smoking An alarming rate of current tobacco use of 56 % among Indian men aged 12-60 yr.

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Survey of sixth and eighth graders attending school in an urban setting revealed that the prevalence of tobacco use (any history of use or current use) was 2-3 times higher among sixth graders compared with eighth graders. Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005; 366 : 1746-51. 31

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TRADITIONAL RISK FACTORS NUTRITIONAL DYSLIPIDEMIA FAMILIAL DYSLIPIDEMIA METABOLIC DYSLIPIDEMIA 33

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TRADITIONAL RISK FACTORS OBESITY FAMILIAL METABOLIC ENDOCRINAL 35

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36 OBESITY RUNS IN THE FAMILY NO BODY RUNS IN THE FAMILY

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Childhood obesity is an emerging issue. In a Mysore (India) study on 43 152 school children , obesity and overweight prevalence was 3.4 % and 8.5%, respectively. 38

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39 NUTRITIONAL STATUS OF CHILDREN (5-15 YRS) IN URBAN MEERUT

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40 Physical activity Daily moderate intensity physical activity ( e.g. , the equivalent of briskly walking 35-40 min per day) is associated with a 55 percent lower risk for CHD . Rastogi T, Vaz M, Spiegelman D, Reddy KS, Bharathi AV, Stampfer MJ, et al . Physical activity and risk of coronary heart disease in India. Int J Epidemiol 2004; 33 : 759-67.

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Source : Abegunde DO, et al. The burden and cost of chronic diseases in low-income and middle-income countries. Lancet 2007;370:1929-38. *GDP: Gross Domestic product 44

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The total income loss due to chronic diseases in India was between Indian Rupee (INR) 1094–1113 billion . Income loss due to hypertension : INR 199 billion Due to diabetes: INR 163 billion Due to CVDs : INR 144–158 billion 46

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Physicians 2000-2010 Nursing and midwifery personnel 2000-2010 Public health workers 2000-2010 Community health workers 2000-2010 Number Density* Number Density* Number Density* Number Density* 660801 6.0 1430555 13 --- --- 507150 0.5 Source: World Health Statistics 2011, World Health Organization 2011 *per 10 000 population Health workforce in India 47

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Source: Global Health Observatory. World Heath organization 2011 All India Uttar Pradesh Medical Colleges 381 27 M.B.B.S seats 44,418 2909 M.D- General Medicine 2266 122 D.M- Cardiology 269 23 Mch - Cardio- thorasic surgery 80 3 Annual Intake of medical students in India and Uttar Pradesh Source: Medical Council of India

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49 National Programme for Prevention and Control of Cancer, Diabetes, CVDs and Stroke (NPCDCS) Ministry of Health & Family Welfare GOI

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50 Objectives of NPCDCS 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,

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51 Train human resource within the public health setup viz doctors, paramedics and nursing staff to cope with the increasing burden of NCDs, and Establish and develop capacity for palliative & rehabilitative care. Objectives of NPCDCS

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52 India Map showing the States to implement NPCDCS 21 STATES 100 DISTRICTS

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53 Packages of services to be made available at different levels under NPCDCS At Sub Center Level : Health promotion for behavior change ‘Opportunistic’ Screening using B.P measurement and blood glucose by strip method Referral of suspected cases to CHC

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54 At CHC Level: 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.)

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55 At CHC Level: 55 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 to District Hospital/ higher health care facility

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At District Hospital Level: 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 ) 56

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57 At District Hospital Level: Follow up and care of bed ridden cases Day care facility Referral of difficult cases to higher health care facility Health promotion for behavior change

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58 Cardiac Care Unit (CCU) Support of Rs. 1.5 crores Functional in 20 districts so far 58 CCU at Pattanamthita, Kerala CCU at Kupwara, J&K Issues: Procurement of equipments Non availability of specialists Lack of space in some district hospitals

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State NCD cell District NCD cell Block CHC ( Rogi Kalyan Samiti ) Village Health Committee 59

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60 During 2010-12: The strategies proposed will be implemented in 20,000 Sub Centres and 700 Community Health Centre in 100 Districts across 21 States

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61 Districts Covered during 2010-11 TOTAL States- 21 Distt.- 30 CHCs- 205 Sub Centers- 6482

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62 Uttar Pradesh Distt . Rae Bareli CHCs-11 Sub Centers-377 Distt . Sultanpur CHCs-14 Sub Centers-403

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63 Screening for Diabetes and Hypertension -1 Logistics & training provided: 63 2010-11 2011-12 Total Glucometers 6617 21500 28117 Glucostrips 1.3crore 4.3 crore 5.6crore Lancets 1.6crore 4.9crore 6.5crore Training to Health Workers : completed in 82 districts (out of 100 districts, 4 districts of TN : logistics not required) Target population : 5.6 crore Screened: 1.02 crore, 3.48 to be screened Suspected for diabetes : 7.5 lakh (7.4%) Suspected for hypertension :6.5 lakh (6.5%)

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64 MISSING LINK Stress Strength Traffic control Redesign Erase Share Surrender to God STRESS

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“Live sensibly - among a thousand people, only one dies a natural death; the rest succumb to irrational modes of living.” - Maimonides 65

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66 Avoid alcohol Be physically active Cut down on salt and sugar Don’t use tobacco products Eat plenty of fruits and vegetables Being healthy is as easy as ABCDE

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