Non-Communicable

Diseases

Dr Satish Kumar Sah

MD Community Medicine
The Commission on Chronic Illness in USA has
defined "chronic diseases" as "comprising all
impairments or deviations from normal, which
have one or more of the following
characteristics :
a. are permanent

b. leave residual disability

c. are caused by non-reversible pathological
alteration

d. require special training of the patient for

rehabilitation

e. may be expected to require a long period of

supervision, observation or care"
 Non-Communicable Diseases

• Non-Communicable diseases (NCD) are a leading

cause of morbidity and premature mortality in the
world.

• Globally, 15 million people die prematurely due to

NCDs annually and over 85% of these deaths occur in
low and middle-income countries.
• The World Health Organization has identified NCDs
as a major public health problem.

• NCDs pose a challenge in achieving the Sustainable

Development Goals 2030 of reducing the premature
NCD related mortality by one third by 2030.
• The Burden of Non-Communicable diseases has been
steadily rising in Nepal.

• The premature mortality due to NCDs has risen from

51% in 2010 to 71% in 2019.

• The proportional mortality of NCDs is ever

increasing.

• CVD is responsible for 30% deaths, cancer 9%,

diabetes 4%, chronic respiratory disease 10% and
other NCDs 13%.
• Increasing life expectancy, demographic and
epidemiological transition, rampant urbanization and
change in the lifestyle all account to this rising burden
of non-communicable diseases.

• The increasing disease burden is associated with

decreasing quality of life, increase in DALYs and
catastrophic health expenditures

• A four-year analysis of National Health Accounts

reported highest healthcare spending was on NCDs at
NPR 37.73 billion
 Risk factors

• Non Modifiable: Age, Sex, Race, Ethnicity

• Modifiable
NCD Tobacco Unhealthy Physical Harmful use Air pollution
use diet inactivity of alcohol
Cardiovascular Present Present Present Present Present
disease
Diabetes Present Present Present Present Absent

Cancer Present Present Present Present Present

Chronic Present Absent Absent Absent Present

respiratory
disease
Mental disorder Present Absent Present Present Absent
 Gaps in natural history

1. Absence of a known agent

2. Multifactorial causation
3. Long latent period
4. Indefinite onset
Multi-sectoral Action Plan for NCDs (2021-2025)

• Vision :All people of Nepal enjoy the highest

attainable status of health, well-being and quality of
life at all age, free of preventable NCDs and
associated risk factors, avoidable disability and
premature death.
• Goal: Reduce the burden of NCDs in Nepal through
“whole of government” and “whole of society”
approach

• Specific objectives
1. To raise priority accorded to the prevention and
control of non-communicable diseases in the national
agenda, policies and programs

2. To strengthen national capacity and governance to

lead multi-sectoral action and partnership across sectors
for the prevention and control of non communicable
diseases
3. To reduce risk factors for non communicable
diseases and address underlying social determinants
across sectors

4. To strengthen health systems through provision of

people-centric, comprehensive, integrated and
equitable care for improved prevention and control
of NCDs

5. To establish NCD surveillance, monitoring and

evaluation system for evidence-based policies and
programmes.
 Targets : The overarching target is to reduce premature death
from major NCDs by 25% by 2025 and by one third by 2030.

[Link] mortality and morbidity

1.1 25% relative reduction in the overall premature
mortality from cardiovascular diseases, cancer,
diabetes, or chronic respiratory diseases

2 Behavioural Risk factors

2.1 At least 10 % reduction in the harmful use of
Alcohol (heavy episodic drinking
2.2 10% relative reduction in prevalence of in sufficient
physical activities
2.3 30% relative reduction in prevalence of current
tobacco use in persons aged over 15 years
2.4 30% relative reduction in mean population intake of
salt/sodium

3. Biological Risk Factors

3.1 25% reduction in prevalence of raised blood
pressure
3.2Halt the rise in obesity and diabetes
3.3 Decrease in prevalence of raised cholesterol
4. National Health System Response
4.1 50% of eligible people receive drug therapy and
counselling (including glycemic control) to prevent
heart attacks and strokes
4.2 80% availability of affordable basic technologies and
essential medicines, including generics, required to
treat major NCDs in both public and private facilities
5. Additional areas

5.1 Cancer patients receiving palliative care with opiod

analgesics increased to x%

5.2 To increase proportion of caries free 6 years old by x%

5.3 To reduce periodontal disease among 35 to 44 years old

by x

5.4 Service coverage for mental disorders increased by 25%

5.5 Adoption of policies limiting saturated fatty acid/trans fat

5.6 Adoption of policies limiting saturated fatty
acid/trans fat

5.7 Increase in vegetable and fruit consumption

5.8 50% relative reduction in the proportion of

households using solid fuels as the primary
source of cooking
• Nepal PEN program The Package of Essential Non-
Communicable Diseases Program was developed on
a risk-based approach to be implemented in a low
resource setting in the Primary Health Care model.
• The WHO PEN Protocol was developed on risk-
based approach.

• Those people who are under high risk with

high symptoms will get medicine

• Those people who are under low risk even

symptoms present will go through life style
• The PEN Intervention has Four protocols:
• Protocol I: Prevention of heart attack, stroke and
kidney disease through integrated management of
diabetes and hypertension.

• Protocol II: Health education and Counseling on

Healthy Behavior (For All)

• Protocol III: Management of chronic obstructive

pulmonary disease (COPD) and Asthma

• Protocol IV: Assessment and referral of women with

suspected cancer (Breast & Cervix)
Goals
• Achieve universal access to high quality diagnosis & patient-
centred care

• Reduce suffering & socio-economic burden of major NCDs

• Protect poor & vulnerable populations from major NCDs

• Provide effective & affordable prevention & treatment

through PHC approach

• Support early detection, community engagement and self-

care
Objectives
• To timely diagnose, treat and management of NCDs.
• To prevent and control risk factors of NCDs.
• To bring uniformity in treatment of NCDs.
• To increase coordination between health facility and
community.
• To increase accessibility for Universal Health Coverage
(UHC).
 Prevention and Control of Non-
Communicable Diseases (NCDs)
• Population strategy:
– Focus on control of underlying causes (risk factors) in whole
populations, ‘not merely by individuals’

– Principle: Small changes in risk factor levels in total

populations can achieve the biggest reduction in mortality,
thus aim should be ‘to shift the whole curve or risk factors
towards biological normality’

– Specific interventions/ Dietary changes: Dietary

modification is the principal
• preventive strategy in the prevention of CHD; WHO
recommended changes (PRUDENT DIET- DIETARY
GOALS):
- Reduction of fat intake to < 20 – 30 % of total energy
intake
- Consumption of saturated fats < 10 % of total energy
intake [<7% NEW GUIDELINE]
- Reduction in dietary cholesterol to < 200 mg/ day
- Increase in complex carbohydrate consumption
- Reduction of salt intake to < 5 gms per day
- Avoidance of alcohol consumption
– Primordial prevention
• High risk strategy:
– Identifying risk: By using simple tests for blood
pressure, serum cholesterol Measurement

– Specific advice: To those identified at high risk

• Secondary prevention:
– Aim: to prevent reoccurrence and progression of NCDs
• WHO STEPwise Approach
STEP wise approach to Surveillance (STEPS): Is a simple,
standardized method by WHO for surveillance Is of two
types:
– STEP wise approach to chronic disease risk factor
surveillance

– STEP wise approach to Stroke surveillance

 Gaps in natural history

1. Absence of a known agent

2. Multifactorial causation
3. Long latent period
4. Indefinite onset
 Prevention
1. Protecting people from tobacco smoke and banning
smoking in public places, warning about the dangers
of tobacco use, enforcing bans on tobacco advertising,
promotion and sponsorships and raising taxes on
Tobacco

2. Restricting access to retailed alcohol, enforcing bans

on alcohol advertising and raising taxes on alcohol

3. Reduce salt intake and salt content o

4. Replacing trans-fat in food with polyunsaturated fat;

5. Promoting public awareness about diet and physical

activity, including through mass media
In addition, there are many other cost-effective and low cost
population-wide interventions that can reduce risk
factors for NCDs.

1. Enforcing drink-driving laws

2. Restrictions on marketing of foods and beverages

high in salt, fats and sugar

3. Food taxes and subsidies to promote healthy diets.

4. Healthy nutrition environments in schools

5. Nutrition information and counselling in health care

6 National physical activity guidelines (school based

physical activity programmes for children and
workplace programmes for physical activity and
healthy diets).
Which one of the following is NOT a characteristic of non-
communicable disease:
(a) Well-defined etiological agent
(b) Multifactorial causation
(c) Long latent period
(d) Variable onset

The preferred public health approach to control non

communicable diseases is:
(a) Shift the population curve of risk factors by a
population based approach
(b) Focus on high risk individuals for reducation of risk
(c) Early diagnosis and treatment of indentified cases
(d) Individual disease based vertical Programmes
WHO STEPS is used for:
(a) Communicable diseases
(b) Non- communicable diseases
(c) Immuno- deficient diseases
(d) Auto-immune diseases.

Rural and urban population differ in incidence in all

diseases except:
(a) Bronchitis (b) TB
(c) Lung Cancer (d) Mental illnes
THANK YOU

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