Risk factors in non communicable chronic diseases

Dr Puneet Kumar Misra

Abstract – The  homoeopathy consider the  “ obstacles of recovery “  in  organon of medicine , and obstacles means maybe presence  of risk factor in the healthy person before morbid state or at the time of treatment. The various obstacles or risk factor is responsible for the development of non –communicable chronic diseases that is  proved today.

Keywords- Obstacles, Risk Factor, Chronic diseases, Non –Communicable, Prevention.

Introduction 

Organon of medicine – Chronic miasms (204-209) in the Aphorism 208 stated that “the age of the patient, his mode of living and diet, his occupation, his domestic position, his social relations and so forth must next be taken into consideration, in order to ascertain whether these things have tended to increase his malady, or in how far they may favour or hinder the treatment. in like manner the state of his disposition and mind must be attended to, to learn whether that present any obstacle to the treatment ,or requires to be directed, encouraged or modified.

Case management (245-263) in the Aphorism 261 stated that” the most appropriate regimen during the employment of medicine in chronic diseases consists in the removal of such obstacles to recovery, and in supplying where necessary the reverse: innocent moral and intellectual recreation, active exercise in the open air in almost all kinds of weather (daily walks, slight manual labor), suitable, nutritious, unmedicinal food and drink ,etc”.

Risk factors
The concept of multi factorial causation was revived by epidemiologists who have contributed significantly to our present-day understanding of multi factorial causation of disease and “risk-factors” in the aetiology of disease. For many chronic diseases, the disease “agent” is still unidentified and where the disease agent is not firmly established, the aetiology is generally discussed in terms of “risk factors”. The term “risk factor” is used by different authors with at least two meanings 

(A). an attribute or exposure that is significantly associated with the development of a disease 

(B) A determinant that can be modified by intervention, thereby reducing the possibility of occurrence of disease or other specified outcomes. 

The Risk factors are often suggestive, but absolute proof of cause and effect between a risk factor and disease is usually lacking. That is, the presence of a risk factor does not imply that the disease will occur, and in its absence, the disease will not occur. The important thing about risk factors is that they are observable or identifiable prior to the event they predict. It is also recognized that combination of risk factors in the same individual may be purely additive or synergistic (multiplicative).  Some risk factors can be modified; others cannot be modified.  They are amenable to intervention and are useful in the care of the individual. The unmodifiable or immutable risk factors are not subject to change. Risk factors may characterize the individual, the family, the group, the community or the environment.  Therefore it is stated that a risk factor is a proxy for need – indicating the need for promotive and preventive health services. The Contribution of epidemiology in the identification of risk factors has been highly significant. The detection of risk factors should be considered a prelude to prevention or intervention.  Most epidemiologists accept that a sets of “risk factors” are responsible for a major share of adult non communicable disease morbidity and premature mortality. Risk factors associated with some major  Non-communicable diseases (NCDs) include cardiovascular, renal, nervous and mental diseases, musculo-skeletal conditions such as arthritis and allied diseases, chronic non-specific respiratory diseases (e.g., chronic bronchitis, emphysema, asthma), permanent results of accidents, senility, blindness, cancer, diabetes, obesity and various other metabolic and degenerative diseases and chronic results of communicable diseases. Disorders of unknown cause and progressive course are often labeled “degenerative”. 

Global risk factor – Top 15 ranked causes 2015 (Rank in 1990 is shown in brackets)

1. High blood pressure (3)

2. Smoking/second-hand smoke exposure (5)

3. High fasting blood glucose (10)

4. High body mass index (13)

5. Childhood underweight (1)

6. Ambient particulate matter pollution (6)

7. High total cholesterol (12)

8. Household air pollution (4)

9. Alcohol use (11)

10. High sodium intake (14)

11. Low wholegrain intake (15)

12. Unsafe sex (20)

13. Low fruit intake (16)

14. Unsafe water (2)

15. Low glomerular filtration rate (21)

An offshoot of the screening is screening for “risk-factors” of disease and identification of “high-risk groups”. Since we do not have specific weapons against chronic diseases, screening and regular health-checkups have acquired an important place in the early detection of chronic disease and make the strategy for prevention of its. Three levels of prevention are now recognized: 

  1. primary, intended to prevent disease among healthy people; 
  2. secondary, directed towards those in whom the disease has already developed; 
  3. tertiary, to reduce the prevalence of chronic disability consequent to disease.

A large percentage of NCDs are preventable through the changes in these factors. The commonest risk factor which contribute in the   NCD their details  given below .

Cardiovascular disease -Cardiovascular diseases (CVD) comprise of a group of diseases of the heart and the vascular system. The major conditions are ischemic heart disease (IHD), hypertension, cerebrovascular disease (stroke) and congenital heart disease. Rheumatic heart disease (RHD) continues to be an important health problem in many developing countries. The present mortality rates are the consequence of previous exposure to behavioral risk factors such as inappropriate nutrition, insufficient physical activity and increased tobacco consumption. It is called the “lag-time” effect of risk factors for CVD. Overweight, central obesity, high blood pressure, dyslipidaemia, diabetes and low cardio-respiratory fitness are among the biological factors contributing principally to increased risk.  

1)Hypertension – it   is a chronic condition of concern due to its role in the causation of coronary heart disease, stroke and other vascular complications. It is the commonest cardiovascular disorder, posing a major public . health challenge to population in socio-economic and epidemiological transition. It is one of the major risk factors for cardiovascular mortality, which accounts for 20-50 percent of all deaths. 

Risk factors for hypertension
Hypertension is not only one of the major risk factors for most forms of cardiovascular disease, but that it is a condition with its own risk factors. A WHO Scientific Group  has recently reviewed the risk factors for essential hypertension. These may be classified as:

1. Non-modifiable risk factors a) AGE b) SEX c) GENETIC FACTORS (d) ETHNICITY 

2. Modifiable risk factors. (a) OBESITY  (b) SALT INTAKE  (c) SATURATED FAT  (d) DIETARY FIBRE  (e) ALCOHOL (f) PHYSICAL ACTIVITY (h) ENVIRONMENTAL STRESS 

(i) SOCIO-ECONOMIC STATUS (j) OTHER FACTORS: The commonest present cause of secondary hypertension is oral contraception, because of the oestrogen component in combined preparations. Other factors such as noise, vibration, temperature and humidity require further investigation.

2) Diabetes –   Diabetes is an “iceberg” disease. Although increase in both the prevalence and incidence of type 2 diabetes have occurred gloablly, Once regarded as a single disease entity, diabetes is now seen as a heterogeneous group of diseases, characterized by a state of chronic hyperglycemia, resulting from a diversity  of a etiologies, environmental and genetic, acting jointly. The underlying cause of diabetes is the defective production or action of insulin, a hormone that controls glucose, fat and amino acid metabolism. Characteristically, diabetes is a long-term disease with variable clinical manifestations and progression. Chronic hyperglycaemia, from whatever cause, leads to a number of complications – cardiovascular, renal, neurological, ocular and others such as inter current infections. Unfavourable modification of lifestyle and dietary habits that are associated with urbanization are believed to be the most important factors for the development of diabetes but other many factor are also increase the risk of diabetes these may be classified as:

HOST FACTORS (a) age (b) Sex(c) genetic factors (d) genetic markers (e) immune mechanisms (f) obesity (g) maternal diabetes 

ENVIRONMENTAL RISK FACTORS Susceptibility to diabetes appears to be unmasked by a number of environmental factors acting on genetically susceptible individuals. They include : (a) SEDENTARY LIFESTYLE  (b) DIET :(c) DIETARY FIBRE (d) MALNUTRITION(e) ALCOHOL (f) VIRAL INFECTIONS (g) CHEMICAL AGENTS: A number of chemical agents are known to be toxic to beta cells,(h) STRESS : Surgery, trauma, and stress of situations, internal or external, (i) OTHER FACTORS : High and low rates of diabetes have been linked to a number of social factors such as occupation, marital status, religion, economic status, education, urbanization and changes in life style which are elements of what is broadly known as social class. One of the most important epidemiological features of diabetes is that it is now common in the lower social class rapid change in lifestyle.

3) obesity  – it may be defined as an abnormal growth of the adipose tissue due to an enlargement of fat cell size (hypertrophic obesity) or an increase in fat cell number ( hyperplastic obesity) or a combination of both. Obesity is often expressed in terms of body mass index (BMI) . Overweight is usually due to obesity but can arise from other causes such as abnormal muscle development or fluid retention (2). However, obese individuals differ not only in the amount of excess fat that they store, but also in the regional distribution of the fat within the body. The distribution of fat induced by the weight gain affects the risk associated with obesity, and the kind of disease that results. It is useful therefore, to be able to distinguish between those at increased risk as a result of “abdominal fat distribution” or “android obesity” from those with the less serious “gynoid” fat distribution, in which fat is more evenly and peripherally distributed around the body. .The aetiology of obesity is complex, and is one of multiple causation these may be classified as: (a) AGE: Obesity can occur at any age, and generally increases with age. Infants with excessive weight gain have an increased incidence of obesity in later life. (b) SEX: Women generally have higher rate of obesity than men, although men may have higher rates of overweight. (c) GENETIC FACTORS: There is a genetic component in the aetiology of obesity.  (d) PHYSICAL INACTNITY: There is convincing ob evidence that regular physical activity is protective against unhealthy weight gain. Whereas sedentary lifestyle particularly sedentary occupation promote it. (e) SOCIO-ECONOMIC STATUS: The relationship of obesity to social class has been studied in some detail.  (f) EATING HABITS: Eating habits and its composition of the diet, the periodicity with which it is eaten and the amount of energy derived from it are all relevant to the a etiology of obesity.  (g) PSYCHOSOCIAL FACTORS: Psychosocial factors (e.g., emotional disturbances) are deeply involved in the aetiology of obesity.  (h) FAMILIAL TENDENCY: Obesity frequently runs in families (obese parents frequently having obese children), but this is not necessarily explained solely by the influence of genes. (i) ENDOCRINE FACTORS: These may be involved in occasional cases, e.g., Cushing’s syndrome, growth hormone deficiency. (j) ALCOHOL: A recent review of studies concluded that the relationship between alcohol consumption and adiposity was generally positive for men and negative for women. (k) EDUCATION (I) SMOKING (m) ETHNICITY:  Evidence suggests that this may be due to a genetic predisposition to obesity that only become apparent when such groups are exposed to a more affluent lifestyle. (n) DRUGS: Use of certain drugs can promote weight gain. 

Cancer – it  may be regarded as a group of diseases characterized by an (i) abnormal growth of cells (ii) ability to invade adjacent tissues and even distant organs, and (iii) the eventual death of the affected patient if the tumour has progressed beyond that stage when it can be successfully removed. Cancer has multifactorial aetiology these may be classified as.   

(A)ENVIRONMENTAL FACTORS Environmental factors are generally held responsible for 80 to 90 per cent of all human cancers. The major environmental factors identified so far include (a) TOBACCO: Tobacco in various forms of its usage (e.g., smoking, chewing) (b) ALCOHOL: Excessive intake of alcoholic beverages is associated. (c) DIETARY FACTORS: Dietary factors are also related to cancer. (d) OCCUPATIONAL EXPOSURES: Occupational exposures of chemical are usually reported to account for 1 to 5 per cent of all human cancers (e) VIRUSES: An intensive search for a viral origin of human cancers revealed. PARASITES: Parasitic infections may also increase the risk of cancer. CUSTOMS, HABITS AND LIFE STYLES: To the above causes must be added customs, habits and lifestyles of people which may be associated with an increased risk for certain cancers.(h) OTHERS : There are numerous other environmental factors such as sunlight, radiation, air and water pollution, medications and pesticides which are related to cancer. (B)GENETIC FACTORS: genetic influences have long been suspected

Discussion
 1) when we see the   Top 15 ranked risk factors then we found that top four   ranks are occupied by the High blood pressure (hypertension), Smoking/second-hand smoke exposure, High fasting blood glucose (diabetes) , High body mass index (obesity) and out of four the only Smoking/second-hand smoke exposure is the self or environmental  risk factor while rest three  are the chronic disordered state of body itself.

2) The Smoking/second-hand smoke exposure particularly of tobacco product shows major effect on the cardiovascular disease and respiratory diseases including Cancer and both system disorder reduce the quality of life of patient as well as neighbor persons. 

3)  The age, sex, genetic factors and ethnicity are the non preventive risk factors but they help the individual, the family, the group or the community to takes the earlier measures for forthcoming unwanted health event.

4) The risk factors are origin due to dietary habit, working pattern and social atmosphere are the preventive for the diseases, if the health education are given by the clinician in the proper way and observe  it , as per indicated  in the Aphorism 208 and 261.  

5) The diabetes, hypertension,  and obesity are directly influence by the dietary habit, working pattern and social atmosphere. 

6)  When an asymptomatic individual assess underneath all risk factors then clinician can predict the disease incidence in  an individual  with its   unique features (e.g., risk factors) .  Currently, there are many types of data are available predict the disease incidence in asymptomatic individual i.e. physiologic (e.g., blood pressure, growth curves), biochemical (e.g., cholesterol, glucose), 

7) The materia medica also mentions the various risk factors in the descriptions of different section of remedy in the form of constitution, desire, aversion, amelioration and aggravation.

8) The rubric of the different section in repertories is also indicated about the risk factor. 

Conclusion – This is the major responsibility of the health care provider  and health care system that they recognized the risk factors in  the symptomatic as well as asymptomatic individual and starts essential measure i.e. 1) modification(primary prevention)  in risk factor to maintain individual healthy,2) Diseased person is directed towards the process of modification in risk factor & treatment of it (secondary prevention)  to minimize the disease within the normal limits and prevent  the occurrence  of disability 3)   The diseased person already effected by the diseases development then takes all measures includes  modification in risk factor ,treatment & rehabilitation ( tertiary prevention)  to improve the quality of life.

Bibliography

  • Davidson Sir Stanley. Davidson Principal & Practice of medicine. 23nd Edition. Elsevier Ltd; 2018. Page 93
  • Harrison T. R. Harrison’s Principles of Internal Medicine. 19 Editions.  By McGraw-Hill Education; 2015. page 26-27
  • Dr Dudgeon R E & Dr Boericke W. Organon of Medicine by Samuel Hahnemann combined 5th & 6th editions.36th impression.B. Jain Publishers (p) Ltd; 2018.Page193-194, 230
  • Park  K. Park`s textbook of preventive and social medicine. 24th edition. M/s Banarsidas Bhanot Jabalpur ; Jan2017. page 380,81,83,91,93,94,400,403,410,412,413,415,417,
  • Suryakantha AH.Community Medicine with Recent Advances.4th edition. Jaypee Brothers Medical Publishers (P)Ltd;2017.Page 565,570-573,578-579,

Dr Puneet Kumar Misra B.Sc, BHMS
Lecturer (Practice of Medicine)
Govt Pt J LN H M C Kanpur

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