Non

Communicable
Diseases

By Sudha Poudel
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 Global Scenario
• Non-communicable diseases are a major public
health problem in Nepal accounting for around 60%
of the total annual deaths in 2014 (WHO).
• The Package of Essential Non-communicable
Diseases (PEN) has been introduced to screen,
diagnose, treat and refer Cardio Vascular Diseases,
COPD, cancer, diabetes, and mental health at health
posts, primary health care centers and district
hospitals for early detection and management of
chronic diseases within the community

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Prepared by Sudha Poudel
Prepared by Sudha Poudel
Prepared by Sudha Poudel
 Global Scenario
• Non-communicable diseases (NCDs) are emerging
as the leading cause of death globally and also in
the South East Asia region due to many social
determinants like unhealthy lifestyles, globalization,
trade and marketing, demographic and economic
transitions.
• The change in the status of these determinants has
affected behavioral and metabolic risk factors of the
general population to the NCDs.

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 Global Scenario

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 National

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 National

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 National

•Cardiovascular diseases (CVD), Chronic non-infectious

respiratory diseases (like COPD), Cancers and Diabetes
Mellitus are referred as essential non-communicable disease
with well-established common modifiable risk factors.

•Oral health, Mental Health and Road traffic Injuries are other
NCDs in Nepal that has been growing at an alarming rate
posing as major threats to public health.

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 National
•Behaviors like tobacco use, harmful use of alcohol,
intake of high proportion of unhealthy diet like -
consuming less fruits and vegetables, high salt and trans-
fat consumption, and physical inactivity are the common
modifiable risk factors of NCDs while overweight and
obesity, raised blood pressure, raised blood glucose and
abnormal blood lipids are the metabolic risk factors.
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 National
•Such behaviors are determined by social structures,
economic disparities, and market forces that entice the
people into buying and consuming unhealthy products
such as ultra-processed foods and drinks, among other
examples.

•Indoor air pollution is another important modifiable

behavioral risk factor for the region and the country.
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 National

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Risk Factors
 Modifiable
•Refer to characteristics that societies or individuals can change to
improve health outcomes. Modifiable behaviors, such as tobacco use,
physical inactivity, unhealthy diet and the harmful use of alcohol, all
increase the risk of NCDs.
 Tobacco accounts for over 8 million deaths every year (including
from the effects of exposure to second-hand smoke).
 1.8 million annual deaths have been attributed to excess salt/sodium
intake.
 More than half of the 3 million annual deaths attributable to alcohol
use are from NCDs, including cancer.
 830 000 deaths annually can be attributed to insufficient physical
activity.
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 Metabolic
Contribute to four key metabolic changes that increase the risk of
NCDs:
 raised blood pressure;
 overweight/obesity;
 hyperglycemia (high blood glucose levels); and
 hyperlipidemia (high levels of fat in the blood).

In terms of attributable deaths, the leading metabolic risk factor globally

is elevated blood pressure (to which 19% of global deaths are
attributed), followed by raised blood glucose and overweight and
obesity.
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 Environmental
•Several environmental risk factors contribute to NCDs.

•Air pollution is the largest of these, accounting for 6.7 million

deaths globally, of which about 5.7 million are due to NCDs,
including stroke, ischemic heart disease, chronic obstructive
pulmonary disease, and lung cancer.

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 Nonmodifiable
•Non- modifiable risk factors refer to characteristics that
cannot be changed by an individual (or the environment) and
include, age, sex and genetic make-up.
•Although, they cannot be the primary targets of interventions,
they remain important factors since they affect and partly
determine the effectiveness of many prevention and treatment
approaches.

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Socio-economic
impact
 Socioeconomic impact
• NCDs threaten progress towards the 2030 Agenda for
Sustainable Development, which includes a target of
reducing the probability of death from any of the four main
NCDs between ages 30 and 70 years by one third by 2030.
• Poverty is closely linked with NCDs. The rapid rise in NCDs
is predicted to impede poverty reduction initiatives in low-
income countries, particularly by increasing household costs
associated with health care.

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 Prevention and Control

Focus on reducing the risk factors

Collaborate to reduce the risks associated with

NCDs

High impact essential NCD interventions can be

delivered through a primary health care approach

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 WHO Response
The 2030 Agenda for Sustainable Development
recognizes NCDs as a major challenge for sustainable
development.
As part of the agenda, heads of state and government
committed to develop ambitious national responses,
by 2030, to reduce by one third premature mortality
from NCDs through prevention and treatment (SDG
target 3.4).

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 WHO Response
•In 2019, the World Health Assembly extended the
WHO Global action plan for the prevention and control
of NCDs 2013–2020 to 2030 and called for the
development of an Implementation Roadmap 2023 to
2030 to accelerate progress on preventing and
controlling NCDs.
•The roadmap supports actions to achieve a set of nine
global targets with the greatest impact towards
prevention and management of NCDs.

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 Hypertension
Blood pressure measurement and control is particularly
important in adults who:
 Have or had heart attack or stroke
 Have diabetes
 Have (Chronic Kidney Disease)CKD
 Are obese
 Use tobacco
 Have a family history of heart attack or stroke

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 CVD Risk assessment and
Management
1. Ask About 2. Assess (physical exam)
•Diagnosed heart disease, stroke, Transient Ischaemic Attack (TIA), DM, • Measure BP
kidney disease
•Angina, breathlessness on exertion and lying flat, numbness or • Look for pitting
weakness of limbs, loss of weight, increased thirst, polyuria, puffiness oedema
of face, swelling of feet, passing blood in urine etc
•Medicines that the patient is taking • Palpate apex beat for heaving
•Current tobacco use (yes/no) (answer yes if tobacco use during the last 12 and displacement
months • Auscultate heart (rhythm and
•Alcohol consumption (yes/no) (if “Yes”, frequency and amount)
murmurs)

Occupation (sedentary or active)

• Auscultate lungs (bilateral
•Engaged in more than 30 minutes of physical activity at least 5 days a basal crepitations)
week (yes/no) • Examine abdomen (tender
•Family history of premature heart disease or stroke in first-degree liver)
relatives
• In DM patients examine feet;
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 Diagnosis
In general, hypertension is diagnosed if, on two
• Systolic BP on both days is ≥ 140mg or
• Diastolic BP in both days is ≥ 90mg or

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 Treatment Goal
For most patients, blood pressure is considered
controlled when SBP
• < 140 mmHg and DBP < 90 mmHg.
However, for patients with diabetes or a high risk of
CVD, certain
• guidelines recommend lower targets:
• SBP < 130 mmHg and DBP < 80 mmHg.

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 Nonpharmacologic
management
• Lifestyle counselling (on healthy diet, physical
activity, the harms of tobacco use, and harmful use of
alcohol) is a critical component of good hypertension
management and is often recommended pressure of
SBP 130–139 mmHg and /or DBP 80–89 mmHg
who do not have other CVD risk factors
• REPLACE package for avoiding trans fatty acid
(TFA).
• SAFER Action Package for free from alcohol related
harms.

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 SAFER

SAFER is a World Health

Organization (WHO)-led initiative to
reduce death, disease and injuries
caused by the harmful use of alcohol
using high-impact, evidence-based,
cost-effective interventions.

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 Implementing SAFER will

3. Protect billions 4. Contribute to

2. Provide more
of people from the advancing the
1. Save 100,000 than USD 9 in
socioeconomic Sustainable
lives by 2030; return for every
impact of harmful Development
USD 1 invested;
alcohol use; and Goals (SDG).

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 Pharmacologic management
• There are four main classes of antihypertensive
medications:
1. angiotensin converting enzyme (ACE)
inhibitors
2. angiotensin receptor blockers (ARB)
3. calcium channel blockers (CCB)
4. thiazide and thiazide-like diuretics

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 DIABETES

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 Introduction
• Diabetes is a chronic, metabolic disease
characterized by elevated levels of blood glucose
(or blood sugar), which leads over time to serious
damage to the heart, blood vessels, eyes, kidneys,
and nerves.

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 TREATMENT OPTIONS
• A healthy diet to achieve or maintain normal body weight and
regular physical activity are the mainstay of diabetes management.
All patients should be advised on avoidance of tobacco use and
harmful use of alcohol.
• Management of risk factors and referral as appropriate.
• Oral hypoglycaemic agents for type 2 diabetes, if glycaemic.
• Other classes of antihyperglycaemic agents, added to metformin.
• if glycemic targets are not met.
• Statins are recommended for all people with type 2 diabetes older
than 40 years, but only if this does not negatively impact access to
glucose-lowering and blood pressure lowering medication.

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 PREVENTION OF
COMPLICATIONS
• FOOT COMPLICATIONS
• Regular (3–6 months) visual inspection and examination
of patients’ feet by trained personnel for the detection of
risk factors for ulceration (assessment of foot sensation,
palpation of foot pulses, inspection for any foot deformity,
inspection of footwear).
• PREVENTION OF ONSET AND PROGRESSION
OF CHRONIC KIDNEY DISEASE:
• Optimal glycaemic control
• Angiotensin-converting enzyme inhibitor for persistent
albuminuria
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 PREVENTION OF
COMPLICATIONS
• PREVENTION OF ONSET AND
PROGRESSION OF DIABETIC
RETINOPATHY
• Screening for diabetic retinopathy and referral for
laser treatment if indicated
• Optimal glycaemic control and blood pressure
control
• PREVENTION OF ONSET AND
PROGRESSION OF NEUROPATHY:
• Optimal glycaemic control.
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 Assess
Polyphagia
Unexplained
(excessive
weight loss
hunger)

Polydipsia
Vision
(excessive
changes
thirst)

Polyuria
(excessive
passing of Symptoms Fatigue
urine)

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 Assess
Acute
metabolic
deterioration
and/or

Complications
(acute coronary acute
disease, stroke, presentation
kidney disease, of chronic
vision loss, complications
diabetic foot)

Signs
Altered level
of
Severe
consciousness dehydration

Kussmaul’s

respiration

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 Test adults who are symptomatic
or aged greater than 40 or who
are overweight i.e. greater than
25 BMI or obese greater than 30
BMI or follow national guidelines

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 Diagnose
• Fasting plasma glucose (FPG) is the most practical test for
low-resource settings, given its low cost. HbA1c can also be
used, but is more costly.
• Plasma glucose 2 hours after a 75 g oral glucose load
(OGTT) can also be used to screen for and diagnose
diabetes, but is less practical and more costly.
• If patient is not fasting and has symptoms, a random
plasma glucose (RPG) test can also be performed. It is the
least accurate of the diagnostic with symptoms; however, a
negative test does not rule out the diagnosis of diabetes .

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 Diagnose
TEST mmol/L mg/dl

• Fasting blood • ≥7 • ≥126

glucose(FPG)
• Random blood • ≥11.1 • ≥200
glucose(RBG)
• Plasma glucose 2 hours • ≥11.1 • ≥200
after75 g of oral glucose
load(OGTT)
• ≥48 • ≥6.5%
• HbA1C

Fasting no food and only water before 8-14 hours before the test.
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 Treatment Goal
• HbA1C<7% is generally considered to be adequate
glycemic control

• If HbA1C isn’t available, fasting plasma

glucose(FPG< 7.0 mmol/l or <126mg/dl.

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 Pharmacological

Metformin
• in the treatment of diabetes.

Sulfonylurea (e.g. gliclazide)

• is recommended as the second-line treatment, and

human insulin as the third-line treatment.

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 Pharmacological
Patients may require two or three medicines.
• Although there are other medicine classes usually
• used as second- and third-line treatment, including
• thiazolidinediones (TZDs), DPP-4 inhibitors, SGLT2
• inhibitors, and GLP-1 receptor agonists, these medicines
• tend to be more costly than metformin, sulfonylurea
• and insulin, with currently limited evidence of superior

• NOTE: Hypertension treatment is indicated when SBP people

with type 2 diabetes older than 40 years, but only if this does not
negatively impact access to glucose- lowering and blood pressure-
lowering medication.
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 Non-Pharmacological

Patients should receive counselling and support on

lifestyle change including diet, physical activity and
smoking cessation at the time of diagnosis, then
annually and whenever changes in treatment occur.

Group education is less effective and less costly than

individual programs.

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 Screening for Complications
blood pressure at every scheduled visit,
Measure BP at every visit review medication as per hypertension
protocol
Refer the dilated pupil retinal exam upon diagnosis and every 2
years there after or as per ophthalmologist recommendation
Examine feet for ulcers at every visit. Refer to higher level of
care if ulcer is present.
Assess risk of lower limb amputation annually(foot pulses,
sensory neuropathy or monofilament, presence of healed or open
ulcers, calleus.
Refer to higher level of care if ulcer present or pulse absent.
Test for proteinuria annually- Refer to higher level of care if
positive.
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(foot pulses, sensory neuropathy by mono
56
 MANAGEMENT OF ACUTE
COMPLICATIONS
Measure blood pressure at every scheduled visit,

SEVERE HYPOGLYCAEMIA OR SIGNS

• (plasma glucose < 50 mg/dl or 2.8 mmol/L)
• If conscious, give a sugar-sweetened drink
• If unconscious, give 20–50 ml of 50% glucose (dextrose) IV
• over 1–3 minutes

SEVERE HYPERGLYCAEMIA OR SIGNS AND SYMPTOMS

• (plasma glucose > 18 mmol/L (325 mg/dl) and urine ketone 2+)
• Set up intravenous drip 0.9% NaCl 1 litre in 2 hours;
• continue at 1 litre every 4 hours
• REFER to hospital(foot pulses, sensory neuropathy by monomen,
• presence of healed or open ulcers, calluses)
• REFER to higher level of care if ulcer present or pulse absent
• Test for proteinuria annually – REFER to higher level of care

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 Follow up
• Measure blood pressure at every scheduled visit,
• When diabetes is diagnosed, monitor glycemic control every 3 months
until diabetes is controlled, then every 6 months after that
• HbA1c is the most accurate measurement of long-term glycaemic control
and represents the average blood glucose over the previous two to three
months, HbA1C<7% is generally considered to be adequate glycaemic
control. In people with frequent severe hypoglycaemia, severe complications
and low life-expectancy, the goal for HbA1c could be relaxed, e.g. to <8%

• Fasting Plasma Glucose (FPG <7 mmol/l or <126mg/dl )can also be used to
monitor control when HbA1c testing is not available.
pulse absent
• Test for proteinuria annually – REFER to higher level of care

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 Follow up
• REFER to higher level of care if goal isn’t achieved
in 3 months, if ketones are 2+ and if there is no
improvement in urine ketones after pharmacological
intervention, diet and exercise modification.

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 COPD

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 Introduction
Chronic respiratory diseases (CRDs) are chronic
diseases of the airways and other structures of the
lung.

WHO PEN focuses particularly on bronchial asthma

and chronic obstructive pulmonary disease (COPD),
which are burden of morbidity and mortality in low-
and middle- income countries.

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 Patient presents with (cough, difficulty
in breathing tight chest and wheezing
Diagnosis of Asthma likely Diagnosis of COPD likely
• Previous diagnosis of COPD
• Previous diagnosis of asthma
• Symptoms since childhood or • History of heavy smoking i.e greater
than 20 cigarettes/day for >15 years.
early adulthood
• History of hey fever, allergies and • History of heavy exposure to burning
fuels
eczema
• Intermittent symptoms with • Symptoms started late or middle 40
symptomatic patient • Symptoms worsened slowly over a
• Symptoms worse at night or early period of time
morning • Long history of cough and sputum
• Symptoms triggered by production
Respiratory infections, exercise, • Symptoms persistent with little day to
stress and weather changes day.
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 Introduction
Measure peak expiratory flow rate(PEFR)
If PEFR improves by

20%:
<20%:
Asthm
COPD
a
likely
Likely

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 Common WORLD NCD
1. Cardiovascular Diseases (e.g., heart attacks, stroke)
2. Cancers
3. Chronic Respiratory Diseases (e.g., chronic obstructive pulmonary disease,
asthma)
4. Diabetes
5. Chronic Kidney Disease
6. Alzheimer’s Disease and Other Dementias
7. Liver Cirrhosis
8. Digestive Diseases (e.g., peptic ulcer disease, inflammatory bowel disease)
9. Mental Health Disorders (e.g., depression, anxiety)
10. Musculoskeletal Disorders (e.g., arthritis, osteoporosis)

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 Common China NCD
1. Cardiovascular Diseases: Leading cause of death, accounting for a significant portion
of NCD-related mortality.
2. Cancer: Particularly lung cancer, which is the leading cause of cancer-related deaths.
3. Chronic Respiratory Diseases: Including chronic obstructive pulmonary disease
(COPD), largely due to high smoking rates.
4. Diabetes: Rapidly increasing in prevalence, with significant economic and health
impacts.
5. Hypertension: High prevalence but low rates of effective treatment and control.
6. Obesity: Rising rates, especially in urban areas.
7. Dyslipidemia: High levels of cholesterol and other lipids in the blood.
8. Stroke: A major health concern linked to high rates of hypertension and
cardiovascular diseases.
9. Chronic Kidney Disease: Often a complication of diabetes and hypertension.

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 Common Nepal NCD
1. Cardiovascular Diseases (CVD): This includes conditions like hypertension, heart
attacks, and strokes.
2. Chronic Respiratory Diseases: Such as chronic obstructive pulmonary disease
(COPD) and asthma.
3. Cancers: Various types, including oral, lung, and breast cancer.
4. Diabetes Mellitus: Both Type 1 and Type 2 diabetes.
5. Chronic Kidney Disease (CKD): A significant health concern in Nepal.
6. Mental Health Disorders: Including depression and anxiety.
7. Liver Diseases: Such as cirrhosis and hepatitis.
8. Neurological Disorders: Including epilepsy and Alzheimer’s disease.
9. Musculoskeletal Disorders: Such as arthritis and osteoporosis.
10. Gastrointestinal Diseases: Including peptic ulcer disease and inflammatory bowel di
sease
.
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 Common India NCD
Cardiovascular diseases (like heart attacks and
strokes)

Cancers

Chronic respiratory diseases (such as chronic

obstructive pulmonary disease and asthma)

Diabetes

Mental health conditions

Injuries

Chronic kidney disease

Liver diseases

Neurological disorders

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 Common Cancer in Nepal

Lung Cancer

Breast Cancer

Cervical Cancer

Stomach Cancer

Colorectal Cancer

Esophageal Cancer

Liver Cancer

Prostate Cancer

Oral Cancer

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 Common Cancer in Nepal
among females
Cervical Cancer: The most prevalent cancer among women in Nep
al1
.
Breast Cancer: Particularly common in urban areas like Kathmand
u
.

Ovarian Cancer

Uterine Cancer

Lung Cancer.

Gallbladder Cancer.

Stomach Cancer

Colorectal Cancer

Liver Cancer

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 Common Cancer in Nepal
among Males
Lung cancer

Stomach cancer

Esophageal cancer

Lip and oral cavity cancer

Prostate cancer

Colorectal cancer

Liver cancer

Bladder cancer

Non-Hodgkin lymphoma

Leukemia

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 National strategic planning
GoN has prioritized NCDs and has strategic planning
based on National Multi-sectoral Action Plan II (MSAP
II) for NCDs (2021-2025).

The goal of MSAP II is to reduce burden of NCDs

through “whole of government” and “whole of society”
approach.

The overarching target is to reduce premature death from

major NCDs by 25% by 2025 and by one third by
2086/87 (2030).
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 Specific Objectives
1. To raise priority accorded to the prevention and control of NCDs 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 NCDs.
3. To reduce risk factors for NCDs 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 programs.
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 Specific Interventions

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 Specific Interventions

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 Specific Interventions

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 Specific Interventions

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 Specific Interventions

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