Wednesday, February 8, 2012


by C. Maya

There is a push to adopt a holistic approach towards tackling lifestyle diseases, through early risk detection and prevention.
The healthiest State in India is on the fast track to becoming the ‘wealthiest,' in terms of the percentage of population who are obese and suffering from a multitude of risk factors, putting them at high risk of death due to cardiovascular diseases and stroke very early in life.
The late C. R. Soman, a renowned public health activist, had voiced his concern at least a decade or more ago about the rapid health transition that the State was undergoing.
He had pointed out that the achievements of the State in the past four decades — a dramatic decline in infant mortality and total fertility rate and rising life expectancy — were being eclipsed by a picture of increasing mortality in the middle age group, with nearly half the deaths a result of lifestyle diseases.
The population-based studies initiated by Health Action by People, an initiative that Dr. Soman was spearheading since 1998, gave the first ever indication about the State's future disease burden due to chronic non-communicable diseases (NCDs).
As on 2005, among the 35 years plus population in the State, the prevalence of diabetes ranged from 21 per cent in the rural areas to 28 per cent in the urban areas, while the prevalence of hypertension was 34 to 43 per cent in the same age group. About 38 to 54 per cent in the age group was overweight, while the average cholesterol levels in any segment of the State's population was 225 mg.
Five years later, the results of the community-based study of risk factors for NCDs, conducted jointly by Achutha Menon Centre for Health Science Studies, the public health wing of Sree Chitra Tirunal Institute for Medical Sciences and Technology and the Indian Council for Medical Research, published in January 2010, gives a similar picture.
Alarming figures
The study reported the prevalence of diabetes in the population to be 16.2 per cent; hypertension 32.7 per cent; 30.8 per cent were overweight, with abdominal obesity found in 39.4 per cent. 56.8 per cent of the population had cholesterol levels above 200 mg/dl.
“What was more alarming was the rural statistics. In the rural areas, diabetes was 20.6 per cent; hypertension 32.5 per cent; 21 per cent were overweight and those with high cholesterol, 56 per cent. All these figures for rural areas are almost on par with the figures for urban Delhi,” says K.R. Thankappan, professor and head of AMCHSS, who led the study.
The alarming proportion of the population who were either overweight or on their way to becoming obese because of a diet rich in saturated fats and an absolute lack of physical activity are the basic risk factors which seem to have ushered in diabetes and cardiovascular diseases.
Women at risk
Obesity among women is being directly linked to the increase in the incidence of cardiovascular events among women and its effects go beyond the current generation.
As per the data of the Acute Coronary Syndrome Registry in the State, the ratio of men and women admitted to the coronary ICUs in 1967 with heart attacks was 24:1. In 1990, this ratio came down to 9:1, and the current ratio is 4:1, which is alarmingly high.
The incidence of breast cancer has also gone up. In 1985, the incidence rate was eight per one lakh population. By 2010, the breast cancer incidence had reached a whopping 32 per one lakh population, with about 25 per cent women under the age of 35 yearsGestational diabetes among women (again, obesity being the underlying factor) has grown four fold in the past few years and there also seems to be an epidemic of PCOS and thyroid diseases among adolescent girls or the future mothers of the next generation
The greatest contributor to this state of affairs has to be the lack of physical activity, apart from a diet which is high in fat and very low in fibre. The consumption of fruits and vegetables is very poor among the adolescents as well as the adults, doctors point out.
An estimated 50 per cent girls/women between 15 to 35 years in the State have elevated lipid levels (cholesterol, triglycerides) and low HDL, which is another risk factor for heart diseases.
In 2010, a study conducted among 18,000 school children at the Amrita Institute of Medical Sciences, Kochi, had reported high blood pressure among girls just into puberty.
Prevention better than cure
The past five years have seen a slew of public education campaigns on prevention of lifestyle diseases through a healthy diet, adequate physical activity and early management of risk factors, though much of the initiatives have come from the private sector.
The downside of it was that diabetes management became a super specialty, mostly run by the private sector, with expensive new medicines and new generation insulins. Public health activists advocated a preventive public health approach, with common-sense management of the disease, the thrust being on increased physical activity and a sensible, low fat diet.
According to the Union Ministry of Health, “the projected number of deaths in India attributable to chronic diseases has risen from 3.78 million in 1990 (40.4 per cent of all deaths) to an expected 7.63 million in 2020 (66.7 per cent of all deaths).
The challenge posed by the burden of NCDs is not just limited to Kerala, though the State certainly seems to have some of the highest prevalence rates for diabetes and CVD.
In 2007, a National Programme on Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke (NPDCS) was launched on a pilot basis in 10 states, including Kerala.
The programme has now been re-launched as the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS).
In 2009, through the National Rural Health Mission, Kerala had launched its own initiative at tackling the NCD burden by launching a pilot project for early intervention in two districts, Thiruvananthapuram and Wayanad in 2009, covering 360 sub-centres in all. The accent of the programme was on early identification and treatment of pre-diabetic persons, case management at the PHC level, uninterrupted drug supply and regular follow-ups.
The working group on health for the 12th Plan points out that the public health system is not oriented to the prevention and management of lifestyle related diseases and that Kerala should aim at integrating community-based prevention into primary health care.
It mooted that the control and management of NCDs should adopt a holistic approach leading from preventive action for the healthy, screening for the high risk population with primary care for the affected.
The programme aims at public education and early identification of risk factors, with the initial screening at the population-level by health workers so that early diagnosis and cost-effective management can be facilitated right from the primary health centre to the tertiary level.
Accordingly, NRHM will now open lifestyle clinics across the State, which will conduct monthly screenings, with registers maintained at sub-centre levels of those above 30 years and their entire health records.