NON-COMMUNICABLE DISEASES

Ischemic Heart Disease

CORONARY RISK FACTORS Non Modifiable

Risk factor Remarks

Age Males> 45 years, females >55 years

Sex Males>females; after menopause risk equals

Family history History of MI / sudden death in father/first-degree male relative before 45 years is significant History of MI / sudden death in mother/first-degree female relative before 55 years is significant

Race South-Asians, Finnish have higher risk Japanese- low risk

Lipid Risk factors

Lipid factors Remarks

Total cholesterol Single most important predictor < 150 mg/dl -Low risk >200 mg/dl – Increased risk

LDL <100 mg/dl - ideal <130 mg/dl – optimum

HDL Males- should be > 40 mg/dl Females – should be >50 mg/dl

Total cholesterol / HDL ratio

Ideally, < 3 >4.5 – high risk

Triglycerides Ideally < 150 mg/dl > 200 mg/dl – high risk

Non-Lipid Risk factors Factor Remarks

Tobacco Even small amount increases the risk 10 years after stopping smoking, risk returns to the level of non-smokers.

Dietary fat and cholesterol

Saturated fats are not all equally hypercholesterolemic Myristic and palmitic acids have greatest effect on LDL n-6 PUFA and MUFA decrease total cholesterol, LDL and triglycerides Transfats increase LDL Fat intake should not exceed >1/3rd caloric intake Low fat intake (<20%) – decreases vitamin E and essential fatty acids, which leads to unfavorable changes in HDL and triglycerides. Replacing saturated and transfats with unsaturated fats is more beneficial than decreasing fat intake.

Non-Lipid Risk factors

Dietary salt Salt intake of < 5 gm. is appropriate

Fruits and vegetables

Daily intake of 400 gm. may be protective

Physical inactivity

Physical activity leads to weight loss, glycemic control, improved BP, lipid profile and insulin sensitivity. Ideally, every adult should spend by physical activity, 2500 calories / week

Overweight Obesity leads to hypertension, glucose intolerance, type-2 Diabetes mellitus and dyslipidemia.

Non-Lipid Risk factors

Alcohol Shows U-shaped/ J-shaped association. Low to moderate drinking has been found beneficial, but not recommended in view of lack of clear epidemiological data and other problems associated with alcohol.

Hypertension Significantly associated with IHD

Diabetes / IGT/IFG

Risk of IHD is 2-3 times higher in diabetics.

Non-Lipid Risk factors

Metabolic syndrome*

WHO criteria are- Diabetes/IFG/IGT or evidence of insulin resistance Plus any two of the following- Obesity Dyslipidemia Hypertension Microalbuminuria

Hormone replacement therapy

Combined continuous HRT leads to increased risk of IHD and venous thromboembolism, stroke, breast cancer and gallbladder disease.

Metabolic Syndrome – WHO Criterion

“Diabetes or IFG or IGT or evidence of insulin resistance PLUS any two of the following:

• Obesity as defined BMI > 30 or WHR > 0.9 for males or > 0.85 for females (>0.80 for Indian females)

• Hypertension as defined as blood pressure > 140 systolic or > 90 diastolic

• Dyslipidemia as manifested by triglycerides > 150 mg / dl or HDL < 35 mg / dl for males or < 40 mg / dl for females

• Microalbuminuria defined as albumin excretion > 20 microgram albumin excretion / mt.

Hypertension

Classification of Hypertension

Blood Pressure

category

Systolic BP

(mm of Hg)

Diastolic BP

(mm of Hg)

Normal <120 <80

Elevated 120-129 <80

Hypertension stage 1 130-139 80-89

Hypertension stage 2 ≥140 ≥90

Non-modifiable Risk factors Risk factor Remark

Age Systolic BP increases till 8th decade, Diastolic BP increases till 5th decade Older than 55 years for men and 65 years for women

Sex Adolescence onwards, BP is higher in males After menopause, equals

Heredity Strong risk factor Family history of premature cardiovascular disease- men aged < 55 years and women aged < 65 years)

Genetic factors Polygenic

Ethnicity Blacks and south Asians have higher risk

Modifiable Risk factors Dietary salt More than 6 gm.

Dietary potassium Protective, should equal sodium intake

Weight Overweight is a strong and consistently associated factor

Lack of physical activity Significantly associated

Socio-economic status In developed countries, low SES is associated with hypertension In developing countries, high SES is associated with hypertension

Alcohol Significantly associated

Diabetes

Definition

• Diabetes is defined as a metabolic disorder characterized by presence of hyperglycemia due to defective insulin secretion, insulin action or both.

Type 1 diabetes

• Also called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes

• It accounts for 5- 10 % of cases of diabetes.

• Usually affects children and young adults

• May be genetic or auto-immune in origin

Type 2 diabetes

• Non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes

• It accounts for 90% to 95% of all diagnosed cases of diabetes.

• It starts usually in middle age

• It is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity.

Gestational diabetes

• Diagnosed in some women during pregnancy

• It is more common among certain races, obese women and women with a family history of diabetes.

• During pregnancy, gestational diabetes requires treatment to normalize maternal blood glucose levels to avoid complications in the infant.

• After pregnancy, 5% to 10% of women with gestational diabetes are found to have type 2 diabetes.

• Women who have had gestational diabetes have a 20% to 50% chance of developing diabetes in the next 5-10 years.

Diagnostic criteria of Diabetes Diabetes

mellitus

Impaired glucose tolerance

Impaired fasting glucose

Fasting 126 or more OR

<126 AND

110-125

Post-prandial 200 or more 140-199 <140

Non-Modifiable risk factors

Factor Remarks

Genetic factors Polygenic association. History of diabetes among parents, grandparents and first degree relatives predisposes a person to high risk of developing diabetes.

Age Increasing age increases the risk.

Race Some races are known to be at high risk as Polynesians, Eskimos, Pima Indians,

Modifiable risk factors

Factor Remark

Obesity Obesity has been proven to be a very strong risk factor for diabetes type 2. Central distribution of body fat is upheld to be an important risk factor, independent of total body weight.

Lack of physical activity

The protective effect of physical activity is independent of obesity;

Dietary factors Increased dietary intake of saturated fat and decreased intake of fibre can result in lowered insulin sensitivity and impairment of glucose tolerance.

Cancers

• Cancer is the second leading cause of death globally

• Around one third of deaths from cancer are due to the 5-leading behavioral and dietary risks: high body mass index, low fruit and vegetable intake, lack of physical activity, tobacco use, and alcohol use.

• Tobacco use is the most important risk factor for cancer and is responsible for approximately 22% of cancer deaths

Most common causes of cancer death

• Lung (1.69 million deaths)

• Liver (788 000 deaths)

• Colorectal (774 000 deaths)

• Stomach (754 000 deaths)

• Breast (571 000 deaths)

• Worldwide, the 5 most common types of cancer that kill men are (in order of frequency): lung, stomach, liver, colorectal and esophagus.

• Worldwide, the 5 most common types of cancer that kill women are (in the order of frequency): breast, lung, stomach, colorectal and cervical.

Screening For Breast Cancer

• Biennial screening mammography for women aged 50 to 74 years.

• There is recommendation against teaching breast self-examination (BSE).

Screening for cervical cancer

• Screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.

According to the WHO the STEPS approach is used for

surveillance of which of the following? (AIIMS 2010)

a)Risk factors for communicable diseases

b)Risk factors for non-communicable diseases

c)Mortality of non-communicable diseases

d)Mortality of communicable diseases

Most common form of substance abuse in India (AIIMS 2010)

a) Tobacco

b) Alcohol

c) Cannabis

d) Opioids

Which one of the following statements about influence of smoking on risk of coronary heart disease is not true? (AIPGME 2005)

a) Risk of death from CHD decreases from cessation of smoking

b) Filters provide a protective for CHD

c) Influence of smoking is synergistic to other risk factors for CHD

d) Influence of smoking is directly related to number of cigarettes smoked per day

Following dietary changes are advised to reduce prevalence of coronary heart disease except- (AIPGME 2004)

a) Increased complex carbohydrate intake

b) Saturated fat intake less than 10% of total energy intake

c) Salt intake less than 20 gm/day

d) Reduce fat intake to 20-30% of total energy intake

Which of the following statements is false? (UPSC CMS 2015)

a) Gestational diabetes can lead to Type-II diabetes after delivery

b) Gestational diabetes is always transient and cured after delivery

c) Gestational diabetes is a risk factor for diabetes in children born to mothers with GDM

d) Screening for gestational diabetes should be included in antenatal care

Which of the following is the most common malignant tumour in adult males in India? (UPSC CMS 2015)

a) Lung cancer

b) Oro-pharyngeal carcinoma

c) Gastric carcinoma

d) Colo-rectal carcinoma

Which one of the following statements is correct regarding diabetes epidemiology? (UPSC CMS 2014)

a) Its prevalence is not affected by age

b) Females are 2.5 times more at risk

c) Maternal diabetes increases the risk of subsequent diabetes.

d) Central obesity is not linked with diabetes

LDL cholesterol in blood recommended to prevent coronary artery disease is below-(JIPMER 2001)

a) 130mg/dl

b) 160mg/dl

c) 100mg/dl

d) 180mg/dl

Which of the following is a non-modifiable risk factor for coronary heart disease? (UPSC CMS 2012)

a) Cigarette smoking

b) Elevated serum cholesterol

c) Alcoholism

d) Age

Best-known large sample study program for CHD is

a) Framingham Study

b) North Kerelia Project

c) Stanford Study

d) Oxford Study

As per American Diabetes Association and WHO, the diagnostic criteria for Diabetes Mellitus using Plasma levels (mg/dl) are-

a) Fasting 126 or more or Post-prandial 200 or more

b) Fasting 110 or more or Post-prandial 180 or more

c) Fasting 110 or more or Post prandial 200 or more

d) Fasting 126 or more or Post prandial 180 or more

Metabolic Syndrome does not include

a) WHR > 0.9 for males or > 0.85 for females

b) Albumin excretion < 20 microgram

c) Low levels of HDL cholesterol: <40 mg/dL in men, <50 mg/dL in women

d) Elevated blood pressure levels: ≥140 mm Hg SBP or ≥90 mm Hg DBP

All of the following sites are used for measuring skin fold thickness to assess obesity except-

a) Mid-triceps

b) Biceps

c) Subscapular

d) Anterior abdominal wall

VISUAL IMPAIRMENT AND BLINDNESS

The causes of visual impairment

• Globally the major causes of visual impairment are:

• uncorrected refractive errors (myopia, hyperopia or astigmatism), 43 %

• unoperated cataract, 33%

• glaucoma, 2%.

Causes India

Cataract 62.6%

Refractive Error 19.7%

Corneal Blindness 0.9%

Glaucoma 5.8%

Posterior Segment disorder 4.7%

Surgical complication 1.2%

Others 4.2%

Definition

International Classification of Diseases -10

• normal vision

• moderate visual impairment

• severe visual impairment

• blindness.

Moderate visual impairment combined with severe visual impairment are grouped under the term “low vision”: low vision taken together with blindness represents all visual impairment.

NPCB Definition

The definition of Blindness under the National Programme for Control of Blindness (NPCB) is hereby modified in line with WHO Definition:

"Presenting distance visually acuity less than 3/60 in the better eye and limitation of field of vision to be less than 10 degrees from center of fixation ".

WHO-ICD Visual Acuity (with best correction)

Low Vision

Category 1 <6/18- 6/60 in better eye

Category 2 <6/60-3/60 in better eye

Blindness

Category 3 <3/60-1/60 in better eye

Category 4 <1/60 in better eye- perception of light

Category 5 No perception of light

Vision 2020 – The Right to Sight Target diseases

• Cataract

• Refractive Errors

• Childhood Blindness

• Corneal Blindness (Trachoma, Onchocerciasis)

• Glaucoma

• Diabetic retinopathy

According to WHO, the definition of blindness is- (AIPGME 2006, AIIMS 2005)

a) Visual acuity <6/60 in the better eye with available correction

b) Visual acuity <3/60 in the better eye with available correction

c) Visual acuity <6/60 in the better eye with best correction

d) Visual acuity <3/60 in the better eye with best correction

Under the national program of control of blindness in India, medical colleges are classified as eye centers of- (AIIMS 2003)

a) Primary level

b) Secondary level

c) Tertiary level

d) Intermediate level

The commonest cause of low vision in India is (AIPGME 2003)

a) Uncorrected refractive errors

b) Cataract

c) Glaucoma

d) Squint

The screening strategy for prevention of blindness from diabetic retinopathy according to the NPCB involves: (AIPGME 2010)

a) Opportunistic screening

b) High risk screening

c) Mass screening

d) Screening by primary care physician

Vision 2020 Right to sight includes all except- (AIIMS 2010)

a)Trachoma

b)Onchocerciasis

c)Epidemic conjunctivitis

d)Cataract

In Vision 2020, the target for a Service Center is for how much population? (AIIMS 2012)

a) 10,000

b) 50,000

c) 1 lac

d) 5 lacs

In Vision 2020, Ophthalmologist per population ratio is (AIIMS 2012)

a) 10,000

b) 50,000

c) 1 lac

d) 5 lacs

All of the following are given global prominence in the Vision 2020 goals, except- (AIIMS 2007)

a) Refractive errors

b) Cataract

c) Trachoma

d) Glaucoma

The most common cause of blindness in India is- (AIIMS 2005)

a) Cataract

b) Trachoma

c) Refractory errors

d) Vitamin A deficiency

In the grading of trachoma, Trachomatous inflammation-follicular is defined as the presence of (AIPGME 2004)

a) Five or more follicles in the lower tarsal conjunctiva

b) Three or more follicles in the lower tarsal conjunctiva

c) Five or more follicles in the upper tarsal conjunctiva

d) Three or more follicles in the upper tarsal conjunctiva

Azithromycin mass treatment is given in community when prevalence of Trachoma is more than (AIIMS 2011)

a) 5%

b) 6%

c) 8%

d) 10%