National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke: A Manual for Medical Officer

Objectives

The National Programme on Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke aims to reduce the growing burden of non-communicable diseases through prevention, early detection, risk reduction, treatment and strengthened health-system capacity.[1]It addresses lifestyle-related risks, especially unhealthy diet, physical inactivity and tobacco use, alongside diabetes, hypertension, dyslipidaemia, coronary disease and stroke.[2][1]

• Promote healthy lifestyles through health education, healthier diets, physical activity, weight control, tobacco cessation, avoidance of alcohol and supportive school and workplace environments.[1][3][4][5]
• Identify high-risk individuals through opportunistic screening, cardiovascular risk assessment and assessment of diabetes, hypertension, lipid disorders and end-organ damage.[1][6][7][8]
• Prevent cardiovascular events by lowering overall risk and prioritising primary and secondary prevention across the life course.[9]
• Provide early diagnosis, treatment and continuing care for type 2 diabetes, hypertension, dyslipidaemia, coronary artery disease, acute coronary syndrome and stroke.[10][11][12][13][14]
• Prevent diabetes complications through patient and family education, glycaemic control, blood-pressure and lipid management, foot care, retinal assessment, preconception counselling and timely referral.[15][16][17]
• Strengthen care quality through health-system development, treatment of sleep disorders and expansion of dialysis facilities.[1]

The clinical guidance uses risk-based prevention to target intensive lifestyle intervention and appropriate medicine to people with established cardiovascular disease, very high individual risk factors or high predicted 10-year risk.[9][6]It supports dietary changes including more green leafy vegetables and fresh fruit and less salt, refined carbohydrates, fried foods and sugary drinks.[18][4]

For diabetes, the focus is prompt management following diagnosis, including for asymptomatic people, and prevention of cardiovascular and end-organ complications.[10]For hypertension, the intended outcomes are sustained healthy blood pressure and prevention or control of factors that cause hypertension or increase complications.[11]For stroke, priorities include prevention through risk-factor control, timely acute treatment, rehabilitation, functional recovery and eventual return to work.[14][19]

Implementation

The programme is designed for nationwide implementation through district structures and the existing primary and secondary healthcare system, combining community health promotion, opportunistic screening, clinical risk management, referral and follow-up.[1]It was implemented across 626 districts in all states and Union Territories through medical colleges, district hospitals, Community Health Centres, Primary Health Centres and sub-centres.[1]

• Establish district programme structures, medical-college focal centres, State and Union Territory non-communicable disease cells, a national cell, behaviour-change communication, capacity-building, research, inter-sectoral convergence, monitoring and evaluation.[1]
• Mobilise medical officers, paramedical workers, teachers, community volunteers, health workers, non-governmental organisations, private practitioners and other sectors to deliver prevention and control activities.[1][3]
• Develop health-promoting schools through safe physical and psychosocial environments, skills-based education, supportive policies, access to health services and participation by education officials, students, parents and community leaders.[3]
• Develop healthy workplaces by linking health promotion with occupational safety, organisational culture and action on lifestyle-related risks.[3]
• Use World Health Organization and International Society of Hypertension risk-prediction charts for people without established atherosclerotic disease, using cholesterol-inclusive charts where testing is available and alternative charts where it is not.[9][6]
• Refer people with acute cardiovascular events, uncontrolled or newly diagnosed diabetes, severe hypertension, specialist treatment needs or serious complications to appropriate higher-level facilities.[9][15][13][19]

Primary care delivers screening, risk assessment, health education, lifestyle counselling, medicine adherence support, follow-up and referral, while Community Health Centres and secondary facilities provide initial clinical assessment, pharmacotherapy, annual assessment and specialist-linked services.[17][20]Medical colleges and tertiary centres provide advanced investigations, angiography, revascularisation and specialist management for refractory coronary disease or complex acute conditions where facilities are available.[13][21]

Diabetes care combines therapeutic lifestyle management, education and dietary counselling with glucose-lowering medicines or insulin and management of co-morbidities.[22][23]Nurses and multipurpose health workers at Primary Health Centres are intended to provide diabetes education, supported by dieticians, counsellors and nurses at sub-district and district hospitals.[15]Continuing care includes regular glucose and blood-pressure review, foot examination, retinal assessment and annual checks for renal, lipid and other complications.[16][17]

Clinical monitoring includes defined reassessment intervals for cardiovascular risk, ranging from five years for low risk to every three to six months for very high risk.[18]Diabetes follow-up includes physical review every three to six months and annual assessment at Community Health Centre or secondary-care level.[16]Hypertension treatment should be rechecked after two weeks when initiated or adjusted, while stroke follow-up begins at two weeks and continues every three or six months according to need.[11][19]

Monitoring and evaluation, including a management information system, are programme components.[1]However, the source does not specify programme-wide indicators, reporting schedules, surveillance methods, evaluation designs, budgets, financing allocations or formal accountability arrangements.[1][3][9]

Monitoring & Evaluation

The programme combines system-level monitoring and evaluation with extensive clinical risk assessment and follow-up across non-communicable diseases, but does not establish a comprehensive indicator set, reporting architecture, surveillance system or formal accountability framework.[1][3][9]

• Establish monitoring, a management information system and evaluation as core components of the National Programme on Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke, alongside national, State and Union Territory, district and medical-college programme structures.[1]
• Assess cardiovascular risk using World Health Organization and International Society of Hypertension prediction charts for people without established cardiovascular disease, using diabetes status, sex, smoking, age, systolic blood pressure and cholesterol where available.[9][6]
• Classify cardiovascular risk as low below 10%, moderate from 10% to below 20%, high from 20% to below 30%, and very high above 30%; reassess respectively after five years, every two years, annually, and every three to six months.[18]
• Review people with isolated elevation of one risk factor after six months of lifestyle modification.[18][5]
• Use body mass index, waist circumference and waist-to-hip ratio to assess overweight, obesity and central obesity as part of lifestyle-risk management.[4]
• Monitor diabetes through blood glucose testing, cardiovascular-risk and end-organ-damage assessment, including lipid profiles, urine protein testing, electrocardiography and fundus examination.[10]
• Conduct annual diabetes assessment at community health centre or secondary-care level, covering blood glucose, urinary microalbuminuria, retinal or fundus examination, blood lipids, creatinine, foot examination and patient education.[16]
• Review diabetes patients physically every three to six months, including blood sugar, glycosylated haemoglobin where facilities are readily available, foot sensation and circulation, blood pressure, tobacco cessation and lifestyle measures.[16][17]
• Monitor blood glucose to titrate diabetes medicines, with metformin reviewed at two- to four-week intervals and glibenclamide at one- to two-week intervals; assess treatment response and secondary failure of oral treatment to determine whether insulin is needed.[22][23]
• Diagnose hypertension through consistently elevated readings on two or more properly measured sitting blood-pressure readings, and recheck blood pressure after two weeks when treatment is initiated or adjusted.[17][8][11]
• Provide hypertension follow-up and annual assessment across secondary care, community health centres and primary health centres.[20]
• Assess dyslipidaemia through cardiovascular disease history, diabetes status, other risk factors, blood glucose and lipid measurement where available, using a risk chart for patients with two or more risk factors.[24][12]
• Use electrocardiography and cardiac biomarkers for acute coronary syndrome assessment, including an electrocardiogram within 10 minutes of presentation and repeat testing every four to six hours where indicated.[25]
• Evaluate stroke follow-up after two weeks and then every three or six months according to individual needs, assessing functional recovery, blood pressure, blood glucose, rehabilitation adherence and anticoagulation where applicable.[19]
• Undertake yearly assessment of hypertension and diabetes risk factors for people with a positive family history of stroke.[26]

Programme-level indicators, routine reporting schedules, data-quality arrangements, population surveillance methods, independent evaluation designs, audit requirements and named accountability institutions are not specified beyond the monitoring and evaluation component and the clinical review activities described.[1][3][24][27]

Costing & Financing

The material identifies a major economic burden from non-communicable diseases but provides no programme costing, budget, financing allocation, funding source, resource-mobilisation plan, funding-gap estimate or economic model for implementation.[2][1]

• Recognise projected economic losses of 237 billion dollars by 2015 associated with premature mortality and disability from diabetes, hypertension and heart disease.[2]
• Recognise an estimated loss of 17.9 potentially productive years in India by 2030.[2]
• Use the cholesterol-free cardiovascular risk chart where cholesterol testing is unavailable because of resource limitations.[6]
• Consider affordability when tailoring hypertension treatment; hydrochlorothiazide, amlodipine and enalapril are identified as relatively cheap options in the Indian context.[11]
• Use low-molecular-weight heparin for stroke management only where it is available and affordable, without a stated price or financing estimate.[19]

No cost estimates are supplied for programme infrastructure, screening, diagnostics, medicines, specialist referral, rehabilitation, training, information systems, school or workplace interventions, dialysis expansion, or health-worker deployment.[1][3][25][14]