CHAPTER TWO

NON-
COMMUNICABLE
DISEASES
Chapter two: Non –communicable diseases
Non –communicable diseases

"Chronic diseases & conditions defined as " an impairment of bodily structure and\or
function that necessitates a modification of the patient's normal life and has persisted
over an extended period of time "

Also defined as compromising all impairment or deviations from normal which have
one or more of the following characteristics :
1-are permanent 2- leave residual disability
3-are caused by non-reversible pathological alteration
4-require special training of the pt for rehabilitation
5- may be expected to require a long period of supervision , observation or care.
 Non communicable diseases "NCD" include : cardiovascular , renal disease ,
DM , obesity , cancer and blindness.

Risk factors of NCD :

1- Smoking. 2-Alcohol abuse 3- Life style change.
4- Failure or inability to obtain preventive health services
5- Environmental risk factors 6-Stress factor.

Gap in natural history :

There are many gaps in our knowledge about the natural history of diseases these gaps
are :
1- Absence of known agent 2-Multifactorial causation
3-Long latent period 4-Indefinite onset

Prevention :
Can be primary by preventing risk factors or tertiary prevention .

Bwasiq 86 105
Chapter two: Non –communicable diseases
Coronary heart disease
 Impairment of heart function due to inadequate blood flow to the heart compare
to its need caused by obstructive coronary circulation to the heart.
 Manifestation of chronic heart disease : angina , myocardial infarction ,
irregularities of the heart , cardiac failure and sudden death .
 Measuring the burden of disease
1- Proportional mortality ratio 2- loss of life expectancy
3-CHD Incidence rate 4-prevalance rate
5-age specific rate 6-case fatality rate
7-medical care 8-measurement of risk factor level
Risk factors :
1- Smoking 2- hypertension 3- serum cholesterol
2- Other risk factors : diabetes , genatic , physical activity , hormones , type A
personality , alcohol , oral contraceptive and miscellaneous .

Prevention :
a- population strategy :
1-prevention in whole population
 control of underlying or risk factors in whole population.
 Diatery change : reduction of fat intake to 20-30 % of total energy intake
Consumption of saturated fat to limit less than 10 % of total energy intake
Reduction of cholesterol
Increase in complex carbohydrates
Avoidance of alcohol consumption and reduce salt intake
Cessation of smoking and reduction of blood pressure
2-primordial prevention.
The novel approach to primary prevention of CHD, It involves preventing
the emergence and spread of CHD risk factors and life style that have not
yet appeared.

b- High risk strategy

1- Identifying the risk 2- specific advice take positive action against all
identifying risk factores
c-secondary prevention.
 The aim is to prevent recurrence and progression of CHD.

Bwasiq 86 106
Chapter two: Non –communicable diseases

Hypertension
Classification of blood pressure measurements:
1-normal <130 <85
2- high normal 130 – 139 85-90
3- mild hypertension 140-159 90-99
4- moderate 160-179 100-109
5- severe >180 >110
Classification; primary ' essential " or secondary .

Blood measurements error :

1- observer error , 2- instrumental error 3- subject error
magnitude of the problem :
 HTN is an iceberg disease , use rue of haves .
Risk factors :
1- non modifiable: age , sex" in young and middle age male more but after
menopause there is equalization ' genetic factors & ethnicity.
2- Modifiable : obesity , salt intake , saturated fat , alcohol , heart rate , physical
activity , environmental , socioeconomics.
3- Rule of halves : 1- the whole population 2- normotensive subjects
3-hypertensive subjects 4- undiagnosed HTN 5-Diagnosed HTN
6-diagnosed but not treated 7- diagnosed and treated
8-inadequately treated 9- adequately treated.
Prevention :
1-Primary prevention: reduce the incidence by reducing the risk of onset.
a-population strategy : the goal is to shift the community distribution of blood pressure
towards lower level or "biological normality "
i-Nutritional ii-weight reduction iii-exercise promotion iv-behavioral change
v-health education vi-self care
b-high risk strategy :
to prevent the attainment of levels of blood pressure at which the institution of treatment
would be considered .
2-Secondary prevention
The goal is to detect and control high blood pressure in affecting people
i-early case detection
ii-treatment
iii-patient compliance.

Bwasiq 86 107
Chapter two: Non –communicable diseases

Diabetes mellitus
Heterogeneous group of diseases characterized by a state of chronic hyperglycemia
resulting from diversity oFetiologies ,environmental and genetic acting jointly.

Classification :
1- DM
a- (IDDM ,Type 1
b- (NIDDM,Type 2)
c- Malnutrition related DM
d- Secondary to disease or drug.
2- Impaired glucose tolerance
3- Gestational DM.

Problem statement :
 Diabetes is an iceberg disease.
 Now type 2 DM seen in all age group .
 There is increase of prevelance of DM due to : population growth,
urbanization & age structure.

Natural history :
Epidemiological determinants :
1- Agent : pancreatic defect , destruction of beta cell , defect in insulin synthesis ,
decrease insulin sensitivity & auto immune
2- Host factors : age , sex , genatic factors , genatic markers , immune
mechanism , obesity & maternal diabetes
3- Environmental factors : sedentary life style , diet , malnutrition , alcohol , viral
infection , chemical agents , stress

Screening of DM :
1- Urine examination 2-blood sugar examination.
Target population :
1- age of 40 or above 2-family history 3- obese 4-woman who had baby
weighting 4.5 kg or more. 5-woman who had excess weight gain during
pregnancy
6- Pt with premature atheroscelarosis.

Bwasiq 86 108
Chapter two: Non –communicable diseases
Prevention &care :
1-Primary prevention :
a- Population strategy : prevent the risk factors
b- High risk strategy

2-secondary prevention :
 When diabetes is detected should treated. The aim of treatment : i- to maintain
blood glucose within normal ii-to maintain ideal body weight
 Treatment : i- diet only ii- diet and insulin.
 Follow up : i- glycosylated hemoglobin ii- self care iii-home blood glucose
monitoring

3-Tertiary prevention : treat the complication and disability in specialized centre.

Obesity
 Abnormal growth of adipose tissue due to enlargement of fat cell size "hypertrophic
obesity" or increase in fat cell number "hyperplastic obesity".
 Is expressed in BMI.
 Android obesity : abdominal fat distribution. Has more cells per unit ,higher blood
flow , more cortisol receptor, more androgen receptors, lead to development of
insulin resistant and metabolic syndrome.
 Gynoid obesity: peripheral fat distribution.

Epidemiological determinant :
- Socio economic status - The aetiology of obesity is
- Eating habits complex ,and one of multiple
- Psycholosocial factors causation :
- Family tendancy - Age : occur at any age
- Endocrine factors - Sex : obesity more in women
- Education but overweight is common in
- Smoking men.
- Ethinicity - Genatic factors
- Dru - Physically inactivity

Bwasiq 86 109
Chapter two: Non –communicable diseases
Classification BMI RISK of comorbidity
Underweight <18.5 low
Normal range 18.50 – 24.99 average
Overweight >= 25.00
Pre-obese 25- 29.99 increased
Obese class 1 30.00-34.99 moderate
Obese class 11 35.00-39.99 severe
Obese class 111 >= 40.00 Very severe
 BMI values are age independent and same for both sex.

Asessment of obesity ;
1- Body weight :
 Widely used but not an accurate .
( )
a- Body mass index (Quetelet's index)= ( )
( )
b- Ponderal index = ( )
c- Borca index = height (cm)-100
( )
d- Lorentz's formula = Ht (cm) -100 - ( ) ( )

e- Corpulence index =
2- Skin fold thickness: rapid and non-invasive, may taken from: mid triceps ,
biceps , sub scapular and supra iliac joint.
3- Waist circumference and waist : hip ratio

Hazards of obesity :
A)increased morbidity : hypertension , diabetes , gall bladder , heart disease.
B)increased mortality

Prevention &control :
Weight control is maintaining weight within healthy range of BMI (18.5-24.9 )
Prevention of obesity achieved by :
1-diatery change 2- increase physical activity 3-other " appetite
suppressing agent.

Bwasiq 86 110
Chapter two: Non –communicable diseases

Blindness
Visual acuity of less than 3\60 (snellen) or its equivalent. "Inability to count fingers in
day light at a distance of 3 meters.
Causes of blindness:
In developed countries: Accidents , glaucoma , diabetes , vascular diseases , cataract
and degeneration of ocular tissue.
In developing country : cataract , vitamin A deficiency ,corneal ulcer , glaucoma and
macular degeneration .
In childhood :xerophthalmia , congenital cataract & glaucoma , optic atrophy and
refractory error .

Epidemiological determinants :
1-age 2-sex "more in female"
3-malnutrioun 4-occupation 5-social class and social factors.

Changing concepts in eye health care :

 Primary eye care : increase the coverage & quality of eye health care.
 Epidemiological approach : measurement of incidence &prevelance of
diseases and risk factors.
 Team concept .
 Establishment of national programme

Prevention of blindness :
The component of prevention of blindness in national programme :
1- Initial assessment : assess magnitude , geographic distribution & causes of
blindness.
2- Methods of intervention :
a-primary eye care :promotion of personal hygiene, sanitation , good dietary
habits.
b-secondary care : definitive management of common blinding conditions.
c-tertiary care:
d-specific programe: trachoma control , vitamin A prophylaxis.
3- Long term management :
4- Improving the quality of life.
5- Evaluation
Vision 2020 : the right to sight
 The objective is to assist member countries in developing sustainable systems
which enale them to eliminate avoidable blindness.

Bwasiq 86 111
Chapter two: Non –communicable diseases

Cancer
 Group of disease characterized by abnormal growth of cells , ability to invade
tissues and can lead to death .
 Major categories :carcenomas , sarcomas , lymphomas.
 It is a second common cause of death.
 Uterine and oropharynx cancer are predominantly environmental related.

Causes of cancer :
Environmental factors : tobacco , alcohol , diatery factors , occupational , viruses ,
parasites , customs and life style.
Genetic factors.

Cancer control:
1- Primary prevention : control of tobacco and alcohol , personal hygiene , reduce
exposure to radiation , immunization , control air pollution , treatment of
precancerous conditions , legislations & cancer education.
Early warning sign :
Lump or hard area in breast
Change in wart , persistent change in bowel habits , persistant cough ,
excessive loss of blood & loss of weight

2- Secondary prevention :
a- Cancer registration
b- Early detection of cases
c- Treatment
Cancer screening :
 Defined as " search for unrecognized malignancy by means of rapidly
applied test "
 Methods of screening :
1-Mass screening by comprehensive cancer detection examination
2-mass screening at single sites
3-selective screening.
 Screening for cancer cervix : by Pap smear.
 Screening for breast cancer: breast self examination , palpation by
physician , thermography & mammography.

Oral cancer :
Risk factors :Tobacco , alcohol , precancerous condition.
Cancer of cervix :

Bwasiq 86 112
Chapter two: Non –communicable diseases
Normal epithelium dysplasia cancer in situ
invasive cancer
 Caused by HPV.
 Risk factors :Age (25-45 ) , genital warts , marital status , oral
contraceptive pills , socioeconomic class.
Breast cancer :
Risk factors :Age >35 years , family history , parity , early menarche and late
menopause , hormonal factors , prior breast biopsy , diet , socioeconomic status
.
Prevention of Lung cancer:
1- Primary prevention :
i. Public information and education.
ii. Legislative and restrictive measures
iii. Smoking cessation activities
iv. National and international coordination.
2- Secondary prevention.

Bwasiq 86 113