Non communicable diseases

sri lanka

1. NON COMMUNICABLE DISEASES

2. Non Communicable Diseases Chronic disease Not passed from person to person Leading cause of death in the world

3. Non communicable diseases are ;

4. In Sri Lanka; Percentage of mortality by cause in Sri Lanka 2014

5. Impact of NCDs Premature Death Quality of life Family Economy of the country Health Service Society

6. NCD Risk Factors Non Modifiable Modifiable Unhealthy eating Physical inactivity Tobacco use Hazardous use of alcohol ↑ blood pressure ↑ blood glucose Over weight Raised blood cholesterol Age Gender Hereditary

7. Prevalence of four main metabolic risk factors for NCDs in Sri Lanka

8. Prevalence of four main behavioral risk factors for NCDs in Sri Lanka

9. Why ?? NCD Screening Long pre symptomatic phase before diagnosis Simple test to detect pre clinical disease are readily available The duration of the disease is a strong predictor of adverse outcomes Effective interventions are available to prevent disease progression & reduce the complication

10. Who should be screened ? Individuals who are ≥ 35 years of age Between 20-35 years of age *Overweight *Smoking *Symptoms suggestive of diabetes *Raised blood pressure *History of premature CVD or Diabetes in first degree relatives *Familial Dyslipidemia

11. How do you screen ? History : Inquiry about risk factors, past illnesses, family history Examination : Check height, weight and waist circumference , measure blood pressure Calculate body mass index (BMI ) BMI = Body Weight (Kg ) (Height) 2 m

12. Prevention of NCDs Main areas to target in the prevention of NCDs; Healthy diet Physical activity Stop smoking and alcohol use Healthy body image This is achieved though health education, continued support and making facilities and resources available to the individual and society, free access to essential healthcare

13. DIABETES MELLITUS

14. Diabetes Mellitus Is a ; group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Can be classified; Type 1-diabetes :-autoimmune beta-cell dysfunction Type 2-diabetes :-progressive loss of beta-cell Gestational diabetes :-diagnosed in the second or third trimester of pregnancy Specific types of diabetes due to other causes

15. Diabetes can be diagnosed ; Diagnosis FBS(FBG) mg/dl mmol /L 2 hour PPBS mg/dl mmol /L HbA1C Normal <100 <5.5 <140 <7.8 <5.7 Diabetes ≥126 ≥ 7.0 ≥200 ≥11.1 ≥6.5 Pre diabetes 100-125 5.5-6.9 140-199 7.8-11 5.7-6.4

16. DIABETES IN PREGNANCY

17. Diabetes in Pregnancy Gestational Diabetes M ellitus (GDM) P re-existing type 2 DM

18. What is GDM? Due to Hormonal changes in pregnancy Diabetes onset or first recognition during pregnancy, is called gestational diabetes mellitus Usually diagnosed between 24th and 28th week of pregnancy Normal blood glucose levels before pregnancy and after delivery

19. Adverse effects of diabetes on baby Congenital malformations such as congenital heart diseases, anencephaly and microcephaly Spontaneous miscarriages Sudden fetal death Macrosomia leading to birth injury Premature delivery Neonatal hypoglycaemia Neonatal jaundice Childhood obesity and metabolic syndrome Increased risk of developing diabetes in early life

20. Adverse effects of diabetes on mother Increased risk of pre- eclampsia Worsening of pre-existing diabetic retinopathy and nephropathy Increased tendency to develop infections such as urinary tract infections Increase in the need for caesarean delivery Increased risk of developing type 2 diabetes mellitus later in life

21. Tips for management of a female with diabetes planning a pregnancy Diabetes needs to be optimized at least three months prior to planning pregnancy Metformin and insulin are preferred Satisfactory blood glucose control is essential prior to conceiving (HbA1c to a value of <7% and closer to 6 %) Maintain ideal body weight Folic acid 5 mg per day at least one month prior to conception , after first trimester reduced to1 mg Statins, ACE inhibitors, angiotensin receptor blockers are contraindicated Diabetic retinopathy and nephropathy screening (urine albumin:creatinine ratio and serum creatinine ) prior to conception

22. Screening for diabetes in pregnancy All pregnant females should be screened for diabetes in pregnancy at the first contact If the screening test becomes negative, retest at a POA of 24 -28 weeks Screening need not be done in already diagnosed patients with diabetes mellitus. The recommended screening test is 2-hour oral glucose tolerance test (OGTT)

23. Assessment Pre pregnancy BMI Pre pregnancy and Current weight Weight gain during pregnancy and rate of weight gain 24 Hour dietary recall +/- food Frequency questionnaire to determine meal trends, food Preferences and nutritional adequacy Physical activity

24. How do you perform an OGTT? No diet restriction in the previous 3 days Overnight fasting Minimum time required for fasting is 8 hours and should not exceed 14 hours. On arrival, a blood sample is drawn for FBS 75 grams of glucose powder dissolved in a 300 ml of water, should be taken within 5 minutes. Blood samples are drawn at one hour and two hours, after the glucose load

25. How to diagnose pre- gestational DM/GDM based on blood tests? Booking visit FBS ≥ 126 mg/ dL PPBS ≥ 200 mg/ dL HbA1c ≥ 6.5% If, FBS is 100 -125mg/ dL OR PPBS is 140-199 mg/ dL proceed to OGTT 24 -28 weeks (GDM) If any one of the three cut-off values are exceeded, GDM can be diagnosed . Diagnose Pre gestational DM Fasting 1 hour 2 hour Plasma glucose cut-offs ≥100mg/ dL (5.1 mmol /L) ≥180mg/ dL (10.0 mmol /L) ≥140mg/ dL (8.5 mmol /L)

26. Management of diabetes during pregnancy Educate the mother Refer to VOG for antenatal care Involves multi-disciplinary care GDM care has three stages (a) before delivery, (b) during delivery/immediate postpartum and (c) after delivery .

27. Care before delivery Management initiated with medical nutrition therapy (MNT). Keep the blood sugar levels within the target range Fasting PG : < 95mg/ dL 2h postprandial PG : <120mg/ dL Check blood glucose (SMBG) fasting state two hours after each meal on daily basis. Failing to do SMBG, both FBS and PPBS should be carried out.

28. MNT Diet-based approach to patients, considering their medical, psychological and dietary history, body weight and POA Goals of MNT Adequate caloric and nutrients intake healthy and steady weight gain, glycaemic control healthy habits and lifestyle modification after delivery Factors o be considered with MNT The current nutritional status ( Underweight/normal/Overweight/obese ) Nutritional needs during pregnancy Dietary habits and food preferences

29. Tips on MNT An ideal dietary composition 45-55% carbohydrates ,15-20 % protein , 20-30 % fat, less than 10% of saturated fat Consistent carbohydrate diet throughout the day Adjusting the type and amount of carbohydrate to achieve the desired postprandial blood glucose is important Complex carbohydrates are preferred. Plate model Calorie allowance varied according to the nutritional status To space out food throughout the day Meal plan with 3 main meals alternating with 2-3 snacks To consume smaller portions of meals or snacks To avoid skipping main meals. To allow a variety of food every day from each food group. Limit foods with simple sugars.

30. Management of Diabetes Mellitus

31. Management of Diabetes Non pharmacological management Lifestyle modification Pharmacological management Oral drugs therapy and Insulin therapy

32. Important component of patient education Nutritional management Physical activity How to use antidiabetic medication Monitoring blood glucose Preventing, detecting and treating acute complications. Ex: Hypoglycemia Chronic complications such as Eye, foot problems Integrating psychological adjustment to daily living Promoting care prior to and d uring pregnancy

33. Lifestyle Modification for Management of Diabetes

34. HEALTHY DIET

35. Dietary advices in Diabetes S Simple M Measurable plate method A Acceptable culturally R Reproducible over a long time T Time bounded to able to maintain over a long period of time

36. Glycaemic Index and Glycaemic load Glycaemic index (GI) is; foods according to their potential for raising blood glucose or it is an index of postprandial glycaemia Glycaemic load (GL) is ; estimates the impact of carbohydrate consumption using the GI while taking into account the amount of carbohydrate that is consumed. GL= (GI × grams of carbohydrates) /100

37. Glycaemic Index and Glycaemic load ctd .. GL is more useful than GI in clinical practice Some low GI foods may have relatively high GL depending on the serving size A high GI food consumed in small quantities would give the same effect as larger quantities of a low GI food on blood sugar So, both quality and quantity of what is eaten would matter

38. Some food items according to GI ; Low GI foods Medium GI foods High GI foods Peanut (14%) Parboiled rice (56%) Popcorn (72%) Apple (38%) Ice cream (61%) Watermelon (72%) Pittu (43.7%) White rice (64%) Pumpkin (75%) Carrot (47%) Macaroni + cheese (64%) Doughnut (75%) String hoppers (50%) Table sugar (65%) French fries (76%) Rusk (50%) Samba rice (66.6%) Baked potato (85%) Banana (52%) Wheat flour bread (68%) Glucose (100%)

39. Food Groups Grains Vegetables Fruits Protein foods Dairy

40. Carbohydrates What are carbohydrates? Starch, sugar and fiber Carbohydrates turn into sugar in the body, which will then raise your blood sugar level Limit carbohydrates

41. What foods contain carbohydrates?

42. Grains Limit rice to 1-2 tea-cups per meal Limit bread to 2-3 slices per meal Try to have whole grains (e.g. unpolished rice)

43. Vegetables Fill half your plate with vegetables Limit starchy vegetables like jack fruit, bread fruit, potatoes and sweet potatoes Have vegetables boiled, steamed, raw or cooked (without coconut milk),

44. Fruits Eat fruits for snacks Don’t eat fruits with the main meal Limit fruits to the size of one tea-cup per serving ( e.g. one banana)

45. Protein Food Include protein foods in each main meal Limit red meats (beef and pork)

46. Dairy Choose non-fat milk

47. High-calorie foods (compare with calorie requirement of 1800 / day) Coconut milk ( 1 medium coconut – 1500 kcal) Chocolate cake (3”X3”X2”): 550 kcal Beer 750ml – 320 kcal Liquor 100ml – 280 kcal

48. Tips for promoting Healthy body image

49. Step 1 – Follow the “Health Plate” Non- starchy Vegetables Grains Protein food

50. Step 2 – Fruits Don’t eat fruits with the main meal Instead, eat fruits at least 2 hours after the breakfast , lunch or dinner

51. Step 3 – Avoid / Limit Deep fried food (short-eats, mixture, chips) Sweets (biscuits, cake, pudding, ice-cream, chocolate) Sugar, juggary , honey / treacle Sugary drinks

52. Step 4 – Physical Activity Be physically active and limit inactivity 30 minutes Moderate intensity (e.g. brisk walking) 5 days / week Can be done in 10-minute bouts

53. Step 5 – Manage your weight Maintain your weight If BMI >23, Lose 10% weight in 6 months

54. Tips to Achieve a Healthy Weight

55. Tips to Achieve a Healthy Weight Choose a variety of colorful fruits and vegetables daily (4-5 cups / day) cooked without coconut milk

56. Tips to Achieve a Healthy Weight ctd … Select whole-grain cereals and bread

57. Tips to Achieve a Healthy Weight ctd … Drink water instead of sugar-sweetened beverages

58. Tips to Achieve a Healthy Weight ctd ... Grill or broil instead of deep-frying food

59. Tips to Achieve a Healthy Weight Replace Full-cream milk with non-fat milk

60. Tips to Achieve a Healthy Weight ctd …. Reduce portion sizes

61. Complications of Diabetes Mellitus

62. Complications of Diabetes mellitus Microvascular and macrovascular complications of diabetes Major results of microangiopathy are Retinopathy 2. Diabetic Kidney Disease (Nephropathy) Neuropathy Macroangiopathy leads to, 1. Coronary artery disease 2. Peripheral arterial disease 3. Stroke

63. Diabetic Retinopathy

64. Diabetic Retinopathy Commonest cause of blindness among adults As diabetic retinopathy is asymptomatic in its initial period, eye screening with dilated fundoscopy is the gold standard to prevent the loss of vision Risk factors for Diabetic retinopathy are; Duration of diabetes, Chronic hyperglycaemia , High blood pressure, Renal disease, Hyperlipidaemia , Pregnancy, Puberty Anaemia

65. Management of diabetic retinopathy Optimization of glycemic control Treatment of hypertension and dyslipidaemia Ophthalmological referral when necessary for specific management.

66. Diabetic Kidney Disease ( DKD)

67. Diabetic Kidney Disease(DKD) 20–40% of patients with diabetes The leading cause of end-stage renal disease The earliest clinical evidence of nephropathy is the appearance of albuminuria Albuminuria is a marker of greatly increased cardiovascular disease risk as well. Screening for DKD :- Assess annually in, All Type 2 DM patients since the time of diagnosis Type 1 DM patients with duration more or equal to 5 years or from puberty

68. Screening for Diabetic kidney disease Urine for protein excretion Urine for Albumin or Spot urinary Albumin: Creatinine ratio (Urine for Microalbumin - UMA ) Renal function testing Serum creatinine ± Estimated GFR UACR >30µg/mg creatinine is considered as microalbuminuria UACR 30 -300µg/mg creatinine is albuminuria Should be repeated and confirmed 3-6 months apart Exclude other causes of albuminuria

69. Management of DKD Optimize BP Optimize glycaemic control * Drugs therapy * Life style modification Oral drugs therapy -ACEI/ARB

70. Diabetic neuropathy

71. Diabetic neuropathy One of the commonest and troublesome complication which reduce quality of life in a diabetic patient Screening type 1- after 5 years Type 2 – at the time of diagnosis

72. Clinical manifestations of diabetic neuropathy

73. Other Non Communicable Diseases

74. Other Non Communicable Diseases Hypertension Dyslipidaemia Ischemic Heart Disease Stroke

75. Hypertension

76. Hypertension Usually asymptomatic A risk factor for Cerebrovascular disease Coronary disease Renal disease Premature mortality

77. Hypertension is ; Blood pressure values measured two times above the cut-offs will need clinical assessment and management. SBP mmHg DBP mmHg Normal blood pressure < 120 < 80 prehypertension 120-139 80-89 Stage 1 140-159 90-99 Stage 2 >160 >100

78. Hypertension can be categorized as ………… • Primary Hypertension (Essential hypertension) (90-95%) Usually idiopathic, and may indicate a) risk for or b) the existence of another disease – notably CHD, CVD, renal disease, diabetes. • Secondary hypertension (5-10%) As part of another disease process (renal failure, drugs)

79. Complications of hypertention

80. Treatment of hypertension To prevent target organ damage and reduce the overall cardiovascular risk C ommonly used anti-hypertensive medications are thiazide diuretics, angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB) long acting calcium channel blockers

81. Blood pressure goals

82. Tips on management of hypertension Screen all patients for active or passive smoking Encourage a healthy diet Reduce harmful use of alcohol Reduce salt intake to less than 5g/day (1 tea spoon) Encourage moderate to vigorous physical activity Educate patients on harmful effects of uncontrolled high blood pressure Check compliance with anti-hypertensive medications Refer Females who are planning for a pregnancy may need modification of their treatment

83. Blood pressure measurement 1. Seat the patient & Explain 2.Ask patient not to speak 3.Ensure patient’s back is supported 4.Ensure patient’s legs are uncrossed 5.Ensure patient’s feet are flat on the floor 6.Ensure patient’s arm is supported 7.Place the cuff mid-arm at heart level 8.Place bottom of cuff 3 cm from the fold of the elbow on bare arm

84. Dyslipidaemia

85. Dyslipidaemia Dyslipidaemia is one of the major contributors of acute myocardial infarction (MI) Elevated levels of LDL-C are strongly associated with atherosclerosis and cardiovascular disease Increased levels of HDL have a protective effect

86. Causes of dyslipidemia Primary (genetic disorders) Diabetes mellitus, hypothyroidism and certain medications. Sedentary lifestyle Excessive dietary intake of saturated fat, cholesterol and trans fats.

87. Diagnosis of dyslipidaemia L ipid profile ( 12 hours fasting) Includes Total cholesterol (TC) LDL-C, HDL TG Total cholesterol/HDL ratio

88. Treatment of dyslipidaemia WHO cardiovascular risk prediction charts applicable to Sri Lanka

89. several risk factors are taken in collection to calculate and predict the 10-year risk of future cardiovascular disease Depending on 10 year cardiovascular risk status, primary preventive strategies are applied

90. Treatment of dyslipidaemia cont…. Risk catogories

91. Tips on management of dyslipidaemia Educate patients that dyslipidaemia usually causes no symptoms but leads to serious outcomes Treatment reduces CVD risk Healthy diet and adequate physical activity Discuss the side effects of their medications Statins are contraindicated in pregnancy and lactation

92. Ischaemic Heart Disease (IHD)

93. Ischaemic heart disease (IHD) Characterized by reduction of blood supply to the cardiac muscles. Usually due to atherosclerosis. The greatest single cause of mortality and loss of disability-adjusted life years worldwide

94. Pathogenesis of IHD

95. Prevention of IHD Control hypertension, diabetes , dyslipidaemia Stop smoking Regular exercise Healthy diet Maintain healthy weight Using medications such as statins and aspirin depending on individual patient’s risk assessment

96. Stroke and TIA

97. Definition of Stroke / Transient ischaemic attack (TIA) Stroke : A clinical syndrome of rapidly developing focal (or global) cerebral dysfunction, lasting more than 24 hours or leading to death, of presumed vascular origin

98. Definition of stroke / Transient ischaemic attack (TIA) TIA (Transient Ischaemic Attack) : TIA is traditionally defined as a clinical syndrome of rapidly developing focal cerebral or retinal dysfunction, lasting less than 24 hours, of presumed vascular origin ( A new tissue based definition of ‘a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia , without acute infarction has been suggested for TIA, but this has not been universally accepted as it requires immediate MRI scanning of the brain )

99. Prevention of stroke Primary Prevention Risk assessment and modification of risk factors. Treat Hypertension, diabetes, dyslipidaemia , other cardiovascular and thrombogenic risk factors appropriately . Anti platelet therapy and anticoagulants

100. Secondary Prevention of S troke

101. Long term follow up of stroke

102. Management of a stroke patient in primary care level BP control Glycaemic control Drug compliance Life style modification Disability status: Motor power, speech, activities of daily living

103. Pain management Psychological status: Depression Sexual problems Recovery of social/ financial status Refer back to specialist care whenever needed Management of a stroke patient in primary care level

104. THANK YOU