Herqutanto Departemen Ilmu Kedokteran Komunitas FKUI

UrbanizationIndustrializationRising IncomesExpansion of EducationImproved medical & PH technologyInfectious Disease Mort. declinesFertility declinesPopulation agesChronic & NCD emergesEconomic recession & increasing inequityPersistence or reemergence of communicable diseasesDemographic TransitionEpidemiologic TransitionHealth TransitionProtracted polarized epidemiologic transitionRelationships among Demographic, Epidemiologic, and Health Transition Source: WH Mosley, JB Bobadilla and DT Jamison, 1993

BODY MASS INDEXPop. 18 yrs with over-weight and under weight by age group, NHHS 2004Proportion of respondents aged 15 years or above with Over-Weight and Obesity, NHHS 2001, 2004

GLOBAL DEATHS BY CAUSE, ALL AGES 2005**Resources: WHO and World Bank 2005CARDIO-VASCULAR DISEASESCANCERCHRONICRESPIRATORYDISEASEDIABETES17.528.0007.586.0004.057.0001.125.000MALARIATUBER-CULOSISHIV/AIDS883.0001.607.0002.830.000

WHO Statistics 2007

Age-standardized CVD mortality rate per 100.000 population (2002)0100200300400500 United States United KingdomIndiaJepangIndonesiaFilipinaVietnamTimor LesteCOUNTRIESMORTALITY RATEmortality Thailand SingaporeMalaysiaChina Srilanka Australia CanadaWHO Statistics 2007441171336274361291106314428140182141188318199

Cause of Death in Indonesia

SKRT 1992, 1995, 2001PersentaseLaporan SKRT 2001: Studi Morbiditas & Disabilitas, Litbangkes 200205101520253035Infection andLungCirculationRespirationGastroCancer AccidentPerinatal199219952001

Beberapa contoh penyakit kronis

HYPERTENSIONHypertension (HTN) is highly prevalent and is a significant risk factor for CAD, LVH, CHF, PVD, stroke, sudden death, nephropathy, and DMThe incidence of HTN increases as a function of agePatients who are normotensive at 55 yr have 90% risk of developing HTN at some point in their lives

HYPERTENSIONSKRT 20016 % HTN at 25-34 yr15 % HTN at 35-44 yr43 % HTN at > 55 yr2/3 uncontrolled HTN patients at > 60 yr will have CHD, MCI, or Stroke within 5 yearRisk of HTN is regulated by genetic background and environmental factorsFor every 20/10 mmHg increase BP above 115/75 mmHg, risk of CVD doubles (Chobanian et al, 2003)

Prevention and control of CVDRisk Factors

Modifiable Diet & Nutrition Physical activity Tobacco AlcoholNon-modifiable Age GeneticRisk Factors

Modifiable High lipids High Blood. Pressure. High Blood. Glucose. Obesity/Malnourished

CARDIO -VASCULAR DISEASE

PromotionPreventionSurveillance andEarly TreatmentSocial Determinants(Culture, Economy, Finance)Promotion and Prevention

CVDDiabetesHypertensionDyslipidemiaLow HDL, high TGHyperglycemiaHypercoagulabilityImpaired fibrinolysisEndothelialdysfunctionChange in Adipose hormonesBirth size,Childhood growthHyperuricemiaSystemicinflammationSocioeconomicstatusPhysicalInactivityGeneticpredispositionDietAbdominal obesity,Ectopic fat depositionInsulinResistanceThe Metabolic SyndromeTextbook of FM, Rakel, 07

METABOLIC SYNDROME

Patients who have ANY THREE (3) of five risk factors meet criteria for the metabolic syndrome

Risk FactorDefining LevelAbdominal obesity Men : Waist > 90 cm Women : Waist > 80 cmTriglycerides >=150 mg/dlHDL Men : < 40 mg/dl Women : < 50 mg/dlBlood Pressure >=130 / >=85 mmHgFasting Glucose >=100 mg/dl

METABOLIC SYNDROMEThe incidence of Metabolic Syndrome increases in men and women as a function of age (Ford et al 2002, Alexander et al 2003)Patients with Metabolic Syndrome had 3.77 fold increase in risk of CVD mortality compared to patients without it (Lakka et al 2002)

14.217.523%15.622.544%26.532.924%1.01.333% 9.414.150%World2000 = 151 million2010 = 221 millionIncrease of 46%84.5132.357%Global Projections for the Diabetes Epidemic: 20002010Zimmet P et al. Adapted with permission from Nature 2001; 414: 7827. www.nature.com

Onset of diabetesDeathFetaldevelopmentHyperglycemiaThe Natural History of Diabetes MellitusPrimarySecondaryTertiaryPrevention ICA- islet-cell cytoplasmic antibodies; IAA- insulin autoantibodies; anti-GAD- antibodies to glutamate decarboxylaseInsulin dependencyInsulin resistance Insulin secretionMay be presentIncreasinglyfrequentAbsentPrediabetes Diabetes Genetic susceptibilityI CA +I AA +anti-GAD +NutritionObesityPhysical inactivityAgingIDDM and NIDDM

IDDM

NIDDMComplication

Onset ofDiabetesComplicationsDeathDisabilityGeneticsusceptibilityInsulin resistanceHyperinsulinemiaHDL HyperglycemiaHypertensionRetinopathyNephropathyAtherosclerosisNeuropathy Blindness Renal failure Cor.Heart Disease AmputationIGTEnvironmentalfactorse.g. nutrition obesity physical inactivityThe Natural History of Non-insulin-Dependent Diabetes Mellitus a HDL- High density lipoprotein; IGT- Impaired Glucose Tolerance

CIGARETTE SMOKINGCigarette smoking significantly raises risk of atherosclerotic disease and potentiates MISmoking cessation reduces the risk of MI and mortality by 36%Smoking cessation is facilitated by patient education about the danger of smoking and pharmacologic intervention with nicotine replacement and bupropionRelapse rate are high in the absence of education and encouragement.

A man, 58 years old, sees his family doctor because of chest pain. He had been well until 2 weeks ago, when he noticed tightness in the center of his chest when he was walking uphill. Questions : Is he sick ? What is the appropriate diagnosis ? Causal of the illness ? How is the treatment and prognosis ? Remember Risk Factors (Biopsychosocial)58 Died 60 of CVDDied ? of DM

THERAPYPharmacologyDrugs

Non Pharmacology (health education/ counseling) on :Diet, Exercise, Smoking Cessation, drugs compliance

BEHAVIORAL INTERVENTIONChanges in patients knowledge does not guarantee changes in patients behavior

Understanding the stages of change

Behavioral changes do not occur rapidly, may be months or years required

Stage-specific counseling

Prochaskas Model of Behavior ChangePrecontemplationPatient is not even thinking about changing the behavior within the next 6 monthsContemplationPatient is considering a behavior change within the next 6 months but not within the next 1 monthPreparationPatient has stated that he or she will change his or her behavior in the next 1 monthActionPatient has actually implemented the behavior change and contracting has occurredMaintenanceThe behavior change has been in place for at least 6 months and is being incorporated into patients lifestyleRelapseNot a specific stage, but something that can occur at any time during the process

Associations between behavior, family, occupation, environment and culture in individual healthThe Mandala of HealthA model of human ecosystemculturecommunitylifestyleworkSickcaresystemHuman-Made EnvironmentbiospherespiritbodymindfamilyPsycho-socio-EconomicEnvironmentPhysicalenvironmentHuman biologyPersonalbehavior

Person(Experience & behavior)Two personFamilyCommunityCulture-subcultureSociety-nationBiosphereNervous-systemOrgan/organs systemsTissuesCellsOrganellesMoleculesAtomsSubatomic particlesSystems hierarchyFrom: Engel ,GL: The clinical application of the biopsychosocial model. Am J Psychiatry

* Perilaku sehatGaya HidupSehatLingkungansehatAkses yankesBermutu &MerataStatuskesehatanoptimal

AZRUL AZWAR

*VARIABEL & INDIKATORGaya hidup sehatOlahragaTdk merokokTdk minum alkoholDll

Lingkungan sehatAir bersihRumah sehatBuang limbah sehatDll

Akses yankesImunisasiAnte natal careKBDll

Status KesehatanAKBAKBALITAAKIDll

Azrul Azwar

Behaviour change Health promoting environmentsCommunication and educationEnvironmental/policy/ behaviouralTraining High risk and identified groups

Age-standardised incidence and age-specific prevalence rates of diabetesIncidence rates for CHDPrevalence of overweight and obesityRates of non-participation in regular sustained moderate aerobic exercise Prevalence of a high fat diet Awareness of the early symptoms of and risk factors for diabetes

Access to factors which maintain health:Opportunities for increased physical activity availability and access to healthy food choices adoption of health promoting organisational policies

Thank You

***Overall, noncommunicable conditions will account for almost 70% of all death in 2030. The four leading causes of death globally in 2030 are projected to be ischemic heart disease, cerebrovascular disease (stroke), HIV/AIDS, and COPD***Dari gambar di atas tampak bahwa didalam masnusis rantai hirarki ini tidak bisa diputus beitu saja. Antara sistem satu ke sistem lainnya dihubungkan dengan rantai fungsi dan aplikasi pada saat ini.Pada modul medical sciences, tampak bahwa bagian bawah dari person tersebut*1. Brief interventions - DACIT

2. Bike paths, changes at food outlets

3. Mass media campaigns

4. Workplace, School based

5. For health professionals

6. Gestational Diabetes, Indigenous Populations*General Message - You will note that each of these categories has specific targets for example - Refer summary document