1) The document discusses the rising burden of cardiovascular disease (CVD) in India, highlighting that it is occurring a decade earlier and is a leading cause of death under 70 years of age. 2) It presents data on the traditional risk factors for CVD in India, such as high rates of hypertension, diabetes, tobacco use, physical inactivity, and air pollution. These risk factors are occurring at younger ages. 3) The National Programme for Prevention and Control of Cancer, Diabetes, CVDs and Stroke (NPCDCS) aims to prevent and control non-communicable diseases through screening, early diagnosis, and management across primary healthcare centers and district hospitals in India.

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

2. 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

3. 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

4. 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

5. 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

6. Deaths below 70 Years
Deaths due to NCDs
Deaths below 70 Years age
23%
52%
• 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.
Western countries India
7

7. Estimated percentage of deaths by cause in India, 2008
Non
communicable
diseases
50%
Communicable
diseases
40%
Injuries
10%
Source: Global Health Observatory. World Heath organization 2011 8

8. Trends in estimated percentage of deaths by cause of death,
80%
70%
60%
50%
40%
30%
20%
10%
0%
South-East Asia region, 2004 and 2030
Communicable
Disease
75%
Non communicable
disease
Injuries
38%
50%
15% 16%
14%
2004
2030
Source: Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PloS Medicine, 2006, 3(11):e442.
9

9. 10
Estimated burden of CHD in India
2.5
2
1.5
1
0.5
0
1.17
1990
2.03
2010
CHDs Burden In millions
Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South
Asia. BMJ 2004; 328 : 807-10.

10. Percentage of deaths due to CVDs* of subtype CVD,
12%
9%
3%
1%
14%
12%
10%
8%
6%
4%
2%
0%
Ischaemic heart
disease
Cerebrovascular
disesases
Hypertensive heart
disease
Other
cardiovascular
diseases
India, 2008
CVDs: Cardiovascular diseases
Source: Global Health Observatory. World Heath Organization 2011.
11

11. TRADITIONAL RISK FACTORS
AGE
DIABETES
SMOKING
HYPERTENSION
DYSLIPIDEMIA
OBESITY/
LACK OF EXERCISE
PREMATURE
FAMILY HISTORY OF
CAD
12

13. Schematic representation of an iceberg for NCDs
14

14. 28%
72%
IDSP DATA
Medicine OPD LLRM MEDICAL COLLEGE,MEERUT 2012-13
NCD CD
15

15. 57%
5%
22%
16%
IDSP DATA OF MEDICINE OPD
(Aug.2012-July 2013)
HT
IHD
DM I
DM II
16

16. OPD DATA ANALYSIS UHC,COMMUNITY
MEDICINE,LLRM medical college,meerut
17%
3%
80%
2008
HT
HT+DM
OTHERS
17

17. OPD DATA ANALYSIS UHC,COMMUNITY MEDICINE,LLRM
25%
9%
66%
medical college,meerut
2009
HT
HT+DM
OTHER
18

18. TRADITIONAL RISK FACTORS
DIABETES DIABETES
DIABETES
19

19. 20
Diabetes mellitus: In India
19.3
57.2
DM in Millions
1995 2025
King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and
projections. Diabetes Care 1998; 21 : 1414-31.
20

20. 21
ICMR estimates
Prevalence of Diabetes
3.80%
Rural area
11.80%
Urban area
Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in
India. Lancet 2005; 366 : 1746-51.
21

21. Percentage of adult population with raised
12%
10%
8%
6%
4%
2%
0%
blood glucose level*, India, 2008
Males
Females
11%
11%
* 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

22. 23
Diabetes: Top 10 Countries (absolute numbers)

23. 24
PECULARITY OF CHD IN DIABETES
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

24. TRADITIONAL RISK FACTORS
HYPERTENSION HYPERTENSION
HYPERTENSION
25

25. Percentage of adult population with high blood pressure*,
36%
34%
40%
35%
30%
25%
20%
15%
10%
5%
0%
India, 2008
Males Females
Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 for comparability
*Systolic BP>140 mmHg and stroke or diastolic BP>90 mmHg or using medication to lower BP 26

26. 27
Hypertension:
40%
30%
20%
10%
0%
40%
17%
Urban Rural
• Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004; 18 : 73-8.

27. 28
Rising Chronic Disease Burdens
2000 2025
No. of Persons with
HYPERTENSION
118 Million 214 Million
No. of Persons Dying
from TOBACCO
900,000 2 Million +
Source: Jha et al, NEJM, Feb 2008 . WHO infobase

28. TRADITIONAL RISK FACTORS
SMOKING SMOKING
SMOKING
29

29. 30
Cigarette smoking
An alarming
rate of current
tobacco use of
56 % among
Indian men aged
12-60 yr.

30. 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

31. 70%
60%
50%
40%
30%
20%
Percentage of adults, who are current users of tobacco
products, by education, India, 2009
0% Females
Males
10%
No formal
schooling
Less than
Primary
Primary
but less
than
secondary
Secondary
and above
68%
61%
49%
30%
32%
22%
11%
4%
Males
Females
Source: India Global Adult Tobacco Survey 2009
32

32. TRADITIONAL RISK FACTORS
NUTRITIONAL
DYSLIPIDEMIA
FAMILIAL
DYSLIPIDEMIA
METABOLIC
DYSLIPIDEMIA 33

33. Percentage of adult population with raised total cholesterol,
30%
25%
20%
15%
10%
5%
0%
26%
29%
India, 2008
Males Females
Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 for comparability
34

34. TRADITIONAL RISK FACTORS
FAMILIAL METABOLIC
OBESITY
ENDOCRINAL 35

35. 36
OBESITY RUNS IN THE FAMILY
NO BODY RUNS IN THE FAMILY

36. Percentage of adult population that is overweight and obese,
14%
12%
10%
8%
6%
4%
2%
0%
Overweight(BMI>=25
kg/m2)
Overweight(BMI>=30
kg/m2)
10%
1.30%
13%
2.50%
11%
1.90%
India, 2008
Male
Female
Both sexes
Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 for comparability 37

37.  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

38. 39
NUTRITIONAL STATUS OF CHILDREN (5-15 YRS)
IN URBAN MEERUT
48%
38%
10%
4%
Under weight
Normal weight
Over weight
Obese

39. 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.

40. Percentage of adults with insufficient
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
physical activity, India, 2008
14%
19%
Male Female
Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 based for comparability
41

41. Percentage of adults consuming
alcohol*, by sex, India, 2007
21%
2%
25%
20%
15%
10%
5%
0%
Males Females
Source: National NCD risk-factor surveys in Member countries
*People who have consumed alcohol in the past 30 days.
42

42. Projected mid-year population, residing
60%
50%
40%
30%
20%
10%
0%
in urban areas,
India, 2010-2050
30%
55%
2010 2050
2010
2050
Source: World Urbanization Prospects. The 2007 Revision. Highlights. Department of Economic and Social Affairs
Population Division.United Nations New York, 2008.
43

43. 20
16
12
8
4
0
2006 2015 Cumulative GDP
loss by 2015
1.35 1.96
17
Foregone GDP*(US$ billions)
Projected cost of cardiovascular disease in terms of lost GDP,
India, 2006 and 2015
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

44. 140
120
100
80
60
40
20
0
Cardiovascular
disease
Hypertension Diabetes
80
130
110
42
32
55
20
0 1
Income loss (billion rupees)
Annual income loss from missed work, time for caregiving,
and premature death among household with a member
suffering from NCD, India, 2004
Missed work
Caregiving
Premature
death
45

45.  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

46. Physicians
2000-2010
Health workforce in India
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
47

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

48. 49
National Programme for Prevention and Control of
Cancer, Diabetes, CVDs and Stroke
(NPCDCS)
Ministry of Health & Family Welfare
GOI
c.

49. 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,

50. 51
Objectives of NPCDCS
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.

51. 52
India Map showing the States
to implement NPCDCS
21 STATES
100 DISTRICTS

52. 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

53. 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.)

54. 55
At CHC Level:
 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

55. 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

56. 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

57. 58
Cardiac Care Unit (CCU)
 Support of Rs. 1.5 crores
 Functional in 20 districts so far
CCU at Pattanamthita, Kerala CCU at Kupwara, J&K
Issues:
Procurement of equipments
 Non availability of specialists
 Lack of space in some district hospitals

58. 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

59. 61
Districts Covered during
2010-11
 TOTAL
States- 21
Distt.- 30
CHCs- 205
Sub Centers- 6482

60. 62
Uttar Pradesh
 Distt. Rae Bareli
 CHCs-11
 Sub Centers-377
 Distt. Sultanpur
 CHCs-14
 Sub Centers-403

61. 63
Screening for Diabetes and Hypertension -1
Logistics & training provided:
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%)

62. 64
MISSING LINK
Traffic
control
SStrtenrgetshs
RSEeuSdrrrhaeesasnirgedener
STRESS
to God

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

64. 66
Being healthy is as easy as ABCDE
Avoid alcohol
Be physically active
Cut down on salt and sugar
Don’t use tobacco products
Eat plenty of fruits and vegetables

65. 67