GUIDELINES

Year : 2020  |  Volume : 5  |  Issue : 5  |  Page : 1-68

World NCD Federation guidelines for prevention, surveillance and management of noncommunicable diseases at primary and secondary health-care for low resource settings

JS Thakur¹, Kathirvel S¹, Ronika Paika¹, Nonita Dhirar¹, Ria Nangia¹, Kunjan Kunjan¹, Ajay Duseja², Ankur Gupta³, Arun Chockalingam⁴, Ashutosh N Aggarwal⁵, Dheeraj Khurana⁶, Dhirendra Sinha⁷, Gursimer Jeet¹, JP Narain⁸, KR Thankappan⁹, Manish Rathi¹⁰, Rajesh Vijayvergiya³, Rajveer Singh⁶, Rakesh Kapoor¹¹, Renu Madan¹¹, Sandeep Grover¹², Sanjay Jain¹³, Sanjay K Bhadada¹⁴, SK Jindal¹⁵, Sunil Taneja², Swapnajeet Sahoo¹², Vivek Kumar¹⁰, Vivekanand Jha^16
1 Department of Community Medicine and School of Public health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
² Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
³ Advanced Cardiac Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
⁴ Professor of Epidemiology, Medicine and Global Health, University of Toronto, Canada
⁵ Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
⁶ Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
⁷ School of Preventive Oncology, Patna, India
⁸ Former Director, Communicable Diseases WHO Regional Office for South-East Asia
⁹ Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
¹⁰ Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
¹¹ Department of Radiotherapy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
¹² Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
¹³ Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
¹⁴ Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
¹⁵ Emeritus-Professor, Post Graduate Institute of Medical Education and Research, Chandigarh, India and Medical Director, Jindal Clinics, India
¹⁶ Executive Director, The George Institute for Global Health, India

Correspondence Address:
J S Thakur
Department of Community Medicine and School of Public health, Post Graduate Institute of Medical Education and Research, Chandigarh
India

Source of Support: None, Conflict of Interest: None

Check

World NCD Federation guidelines for prevention, surveillance, and management of noncommunicable diseases at primary and secondary healthcare settings

Executive Summary

Introduction and process adopted for guideline development

Level of Evidence

• Level 1: Meta-analyses or systemic reviews of randomized controlled trials or good-quality randomized controlled trials
• Level 2: Systematic review of cohort studies or individual cohort studies or low-quality randomized controlled trials
• Level 3: Systematic review of case–control studies or individual case–control studies
• Level 4: Case series and poor-quality cohort and case–control studies
• Level 5: Expert opinion.

Guidelines for Prevention of Noncommunicable Diseases

Prevention of Noncommunicable Diseases in Primary and Secondary Healthcare Settings

Operational Definitions

Risk Factors

• Raise taxes on tobacco
• Ensure smoke-free environments in all indoor workplaces, especially schools, health facilities, public places, and public transport



• Institutional smoking bans.



• Ensure no forms of tobacco advertising, promotion, and sponsorship at the respective area
• Ensure that the size and shape of pictorial warning on tobacco products and different places
• Display warning messages with ill effects of tobacco
• Ban on sales of tobacco to minors.

[Table 1]: Interventions at primary and secondary healthcare setting for prevention and control of tobacco use Click here to view

• Level of evidence: Level 2
• Recommendation: Strong.

• Intake of >20 g/day or 140 g/week for men and >10 g/day or 70 g/week for women (approximately 30 ml of whiskey = 100 ml of wine = 240 ml of beer = 10 g of alcohol).

• Enforce restrictions on the physical availability of retailed alcohol (via reduced hours of sale)
• Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising (across multiple types of media)
• Increase excise taxes on alcoholic beverages
• Display warning messages with ill effects of harmful use of alcohol.

Table 2: Interventions at primary and secondary healthcare setting for prevention and control of harmful use of alcohol Click here to view

• Level of evidence: Level 2
• Recommendation: Strong.

• Reduce population salt/sodium consumption



• Food product reformulation; large-scale pricing strategies; food procurement policy in specific settings; restrictions on marketing to children; on-package nutrition information; levy higher tax on sugary drinks and processed food.



• Limit saturated fatty acids and virtually eliminate industrially-produced trans-fatty acids in the food supply
• Implement recommendations on marketing of foods and nonalcoholic sugary beverages such as colas to children
• Legislation/regulations for fully implementing the International Code of Marketing of Breast-milk Substitutes
• Nutritional labeling on food and drink products being retailed in market including menus in the restaurants



• Color-coded labeling and stop sign labeling of unhealthy foods
• Labeling should include:



• Total calories (energy value)
• Amounts of carbohydrate, sugars, fat, protein, sodium, dietary fiber
• Amount of trans-fat.
• Healthy eating policy at schools



• School curriculum that includes healthy eating
• Improvements in nutritional quality of the food supply in schools.
• Reduce SSBs and fat sugar and salt food
• Labeling and food claim rules; interventions changing the availability of different foods and beverages in public institutions and other settings; pricing interventions (including both fiscal and nonfiscal interventions altering the absolute and relative prices of SSB expand when used first or low-calorie alternatives to SSB); advertisement regulation especially on channels largely viewed by children or shows viewed by children in particular; discouraging endorsements by celebrities; bringing social media portals onboard for the advertisement ban on unhealthy foods; reformulation; changes to the beverage retail and foodservice environment; food system approaches (including health-in-all policies approaches in sectors such as agriculture and trade); gradual progression in the direction of total ban; set evidence-based regulatory limits by establishing monitoring systems which can assess the food and beverages periodically.
• Policy to reduce the portion, package, or tableware size of food.

Table 3: Multisectoral interventions applicable to primary and secondary healthcare setting for promotion of healthy diet Click here to view

• Level of evidence: Level 2 to Level 5
• Recommendation: Strong to moderate.

• Social marketing or mass media communication on improving physical activity
• Physical activity policy at school



• School curriculum includes physical activity and body image
• Increased sessions for physical activity and the development of fundamental movement skills throughout the school week.
• Enabling environment such as creation of playgrounds walking trails and infrastructure with legislative, fiscal, or policy requirements and planning for the broader population. Or the introduction of new environmental facilities including improvements of existing facilities (e.g., replacement of playgrounds in a park), improved access to facilities (e.g., improved opening hours, creation of new bridges), creation of new facilities (e.g., introduction of bicycle lanes or walking paths) or wider public transport initiatives (e.g., cycle hire schemes).

Table 4: Multisectoral interventions applicable to primary and secondary healthcare setting for promotion of physical activity Click here to view

• Level of evidence: Level 2 to Level 3
• Recommendation: Strong.

• Provide access to cleaner fuels-through subsidy
• Provide access to improved stoves-through subsidy.

Table 5: Multisectoral interventions applicable to primary and secondary healthcare setting for reducing indoor air pollution Click here to view

• Level of evidence: Level 3 to Level 5
• Recommendation: Strong.

Multisectoral Action

Figure 1: Proposed multisectoral action framework for prevention of noncommunicable diseases Click here to view

Way Forward

Guidelines for Noncomunicable Disease Surveillance

Background

Figure 6: Screening, diagnosis, and management of cervical cancer at primary and secondary healthcare Click here to view

Expectations from Noncommunicable Diseases Surveillance Guidelines

Figure 2: Framework for noncommunicable diseases surveillance Click here to view

1. Monitoring exposures (risk factors)
2. Monitoring outcomes (morbidity and disease-specific mortality)
3. Assessing health system capacity and response.

Assumptions and Operational Definitions

Table 7: Diseases to be part of the noncommunicable disease surveillance system Click here to view

Table 8: Levels of healthcare system and surveillance systems Click here to view

Noncommunicable Disease Surveillance System for High-resource Setting

Figure 3: Operational framework for noncommunicable diseases surveillance in settings with better resources Click here to view

Prerequisites for Setting up a Noncommunicable Disease Surveillance System in High-resource Settings

• A program for addressing
• Functional hospital- and/or population-based registries
• Strengthened disease-wise facility-based reporting of NCDs
• Multisectoral participation and data sharing mechanisms
• Clinical tests and diagnostics of high-risk cases at primary and secondary care level as per treatment guidelines
• The role of CHWs is critical as they will be provided with the list of high-risk cases for clinical tests and diagnosis at primary healthcare level for follow-up
• Unique identification number for each patient should be generated with adequate information retained by the system to ensure quick search of patient history during visits
• At the primary healthcare level, clinical tests and diagnostics can be performed using point-of-care diagnostics and measuring devices.

Noncommunicable Disease Surveillance System for Low resource Setting

Figure 4: Operational framework for noncommunicable diseases surveillance in settings with low resources Click here to view

Table 9: Variables to be reported under the surveillance system Click here to view

Recommendations

1. A standard surveillance instrument and methodology should be adopted
2. NCD risk factor surveys should be implemented periodically at regular intervals
3. Survey methodology should be designed in line with sustainable goals
4. Data should represent administrative blocks as per the requirement of the country
5. Data should be disseminated optimally and the data collected should be kept in public domain
6. Policymakers at the central and subnational level should be motivated to use the existing data for targeted policy changes and people's education
7. Stakeholders at all levels may be involved so that utility of data can be maximized.

Management of Noncommunicable Diseases

Cancer

Figure 5: Screening, diagnosis, and management of oral cancer at primary and secondary healthcare Click here to view

Figure 7: Screening, diagnosis, and management of breast cancer at primary and secondary healthcare Click here to view

Figure 8: Screening, diagnosis, and management of lung cancer at primary and secondary healthcare Click here to view

Figure 9: Screening, diagnosis, and management of colorectal cancer at primary and secondary healthcare Click here to view

Figure 10: Screening, diagnosis, and management of liver cancer at primary and secondary healthcare Click here to view

Figure 11: Screening, diagnosis, and management of esophageal cancer at primary and secondary healthcare Click here to view

Diabetes Mellitus

Table 10: American Diabetes Association criteria for diagnosis of diabetes mellitus and gestational diabetes mellitus Click here to view

Table 11: High-risk individuals for diabetes mellitus Click here to view

Table 12: Preliminary physical examination and investigations for newly diagnosed cases of diabetes at primary and secondary healthcare facility Click here to view

Table 13: Diabetes education at diagnosis and follow-up visit Click here to view

Table 14: Summary of the available oral antidiabetic agents at primary healthcare and their practical utility Click here to view

• If initial RBG is ≤ 300 mg/dl, and/or if initial HbA1c is ≤9%, then monotherapy with metformin/sulfonylureas is advised
• If HbA1c is between 9% and 10%, dual OADs, i.e., metformin and sulfonylureas, should be started
• There is no preferred drug as add-on to metformin for dual therapy. Any of the classes of OADs or basal insulin can be considered, depending on availability and patient factors. Sulfonylureas and glitazones are low-cost options for add on therapy
• If HbA1c is ≥10% and/or RBG ≥300 mg/dl, insulin should be added along with OADs
• The insulin initiation requires proper counseling and shared decision making with the patient about its need, effects, administration and storage technique, advice for self-glucose monitoring, and associated risks of insulin therapy including hypoglycemia. A physician should start with basal insulin (insulin NPH or insulin glargine; depending on availability) at the dose of 0.2 IU/Kg/day at bedtime^{[41],[42],[43]}
• If basal insulin has been titrated to an acceptable fasting blood glucose level (between 80 to 130 mg/dl) or if the dose is 0.5 units/kg/day and HbA1c remains above target, then combination injectable therapy should be started^{[41],[42],[43]}
• When initiating combination injectable therapy, metformin therapy should be maintained while other oral agents may be discontinued
• The recommended starting dose of premeal insulin is 4 units, 0.1 units/kg, or 10% of the basal dose, which might be required to be given before one or two meals or before each meal, depending on glycemic control
• If basal insulin is not available, then premixed insulin (30:70) may be initiated divided into two doses at 0.2 IU/kg/day, with 70% of total dose administered before breakfast and rest 30% before dinner. Details of insulin therapy are given in [Table 15].
• Insulin storage and injection techniques should be taught to all patients. Insulin vials should be stored at 4°C and hence can be kept in the door of the refrigerator. They must never be kept in the freezer compartment
• Insulin injection technique should be demonstrated to the patient at time of initiation. Subcutaneous injection in the abdominal wall, thigh, and forearm, with frequent site rotation should be advocated. Patients should be taught to check for site hypertrophy.
• Self-monitoring of blood glucose at home should be encouraged. Fasting and premeal blood glucose targets of 80–130 and 2-h postmeal blood glucose targets of <180 mg/dl should be achieved
• If urine dipstick test is suggestive of proteinuria, then angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blockers should be started^{[44],[45],[46],[47]}
• For loss of sensation, patient education is a must. They should be encouraged to daily inspect the feet (along with sole) with a handheld mirror for any cracks, fissures, callus, or ulcers and to avoid exposing the feet and hands to extremes of temperature
• For painful diabetic neuropathy, drugs such as pregabalin/gabapentin or duloxetine should be started.

Table 15: The details of types, indication, and side effects of insulin therapy Click here to view

Figure 12: Pharmacological management of diabetes mellitus at primary and secondary healthcare setting. FBG- Fasting blood glucose; RBG- Random blood glucose; PPG- Postprandial glucose; SMBG-Self monitoring of blood glucose Click here to view

Table 16: Screening and follow.up of diabetes mellitus for end organ complications Click here to view

Cardiovascular Diseases

Table 17: The difference between chest pain of cardiac and noncardiac cause Click here to view

Table 18: Details of examination and investigations for diagnosis of cardiovascular diseases Click here to view

Figure 13: Algorithm for evaluation and management of patients with chest pain Click here to view

Table 19: Diagnosis, investigation, and management of chronic stable angina Click here to view

Figure 14: Spectrum of coronary artery diseases Click here to view

Table 20: Indications and contraindications for fibrinolysis among patients with ST elevation myocardial infarction Click here to view

Table 21: Common fibrinolytics used in myocardial infarction and its contraindication Click here to view

• Resolution of ST-segment elevation by ≥50%
• Resolution of ischemic discomfort or chest pain or hemodynamic instability.

Table 22: Medical management of acute coronary syndrome patient Click here to view

Table 23: Recommendation for the management of coronary artery disease at various levels in primary and secondary healthcare settings Click here to view

Cerebrovascular Disease or Stroke

• Stroke: A sudden focal or global neurologic deficit of vascular origin lasting >1 h; if the symptoms are fully reversible in <1 h, it should be labeled as a transient ischemic attack (TIA)
• TIA: “A transient episode of neurologic dysfunction caused by focal cerebral, spinal cord, or retinal ischemia, without acute infarction.”

Table 24: Details of the symptoms to recognize stroke Click here to view

Figure 15: Recommendations for initial assessment and management of stroke at primary and secondary healthcare Click here to view

Table 25: Recommendations for initial assessment and management of stroke with National Ambulance Service Click here to view

Figure 16: Recommendations for management of stroke at primary and secondary healthcare settings Click here to view

Table 26: Recommendations for secondary prevention following acute ischemic stroke and transient ischemic attack Click here to view

1. Large hemispheric infarct on CT/magnetic resonance imaging with impending herniation or malignant middle cerebral artery infarction
2. If a patient has comes within 4 h of an acute stroke, the patient should be immediately referred to a higher center with facilities for acute stroke thrombolysis if requisite facilities and expertise are not available at the district hospital
3. Patients with large vessel occlusion stroke should be referred if a tertiary care facility has endovascular treatment facility.

Figure 17: The assessment and management algorithm for stroke at primary and secondary healthcare setting. LVO - Large vessel occlusion Click here to view

Hypertension

Table 27: Operational definition of normal blood pressure and hypertension Click here to view

Figure 18: Diagnosis and management of hypertension at primary and secondary healthcare setting. ECG - Electrocardiogram, GFR - Glomerular filtration rate, CCB - Calcium channel blockers, ACEI - Angiotensin-converting enzyme inhibitor, ARB - Angiotensin receptor blockers, BB - Beta blocker Click here to view

• Four medication classes (calcium channel blockers [CCBs], ACEIs, angiotensin receptor blockers [ARBs], and diuretics) are effective drugs for the treatment of hypertension. Single drug or combination of drugs may be used for treatment^[63]
• Stage 1 hypertension: First assessment for atherosclerotic CVD (ASCVD) risk is done. If ASCVD risk is less than 10%, lifestyle changes are recommended, and reassessment is done in 3–6 months. BP-lowering medications are initiated in patients with clinical CVD or a 10-year risk of 10% or greater
• For stage 2 hypertension, Two BP-lowering medications (of different classes) are recommended in addition to lifestyle changes. Reassessment is done after 1 month. If treatment goal is met, reassessment is done after 3–6 months. If the goal is not met after 1 month, change of medication is done or titration of dose is done. Reassessment is done after every month till goal is reached
• Hypertensive urgency can be managed by intensification of therapy and treatment of anxiety as applicable.
• Hypertensive emergency requires admission of patient to an intensive care unit for monitoring of BP and parenteral administration of BP-lowering drugs.
• Lifestyle changes include DASH diet, weight reduction, physical activity (90–150 min of aerobic and/or dynamic resistance exercise per week and/or 3 sessions per week of isometric resistance exercises) and alcohol restriction (two or fewer drinks daily for men and not >1 drink daily for women)
• Goals of BP for pharmacological therapy: The treatment goal is to maintain the BP to <130/80 mmHg for all clinical conditions.
• If target BP is not reached, to reinforce lifestyle and adherence and/or titrate medications to maximum doses or consider adding another medication (ACEI, ARB, CCB, and thiazide)
• All patients with hypertension should be assessed through clinical examination and investigations at primary and secondary healthcare facilities [Figure 18]. Patients with hypertension and complications/comorbidities such as heart failure, CVDs, stroke, and CKD should be referred to secondary healthcare facilities for further evaluation and management. The antihypertensive drug of choice for specific conditions is given in [Table 28].^[64]

Table 28: Antihypertensive drugs used for co-existing morbidities or complications Click here to view

Table 29: Details of commonly used antihypertensive drugs at primary and secondary healthcare settings Click here to view

Chronic Respiratory Diseases

Table 30: Recommendation for the management of chronic respirtory diseases in primary and secondary healthcare settings Click here to view

Table 31: Differentiating between asthma and chronic obstructive airway disease (chronic obstructive pulmonary disease) Click here to view

Table 32: Severity classification for chronic obstructive airway disease Click here to view

Table 33: Level of current asthma control (over the preceding 4 weeks) Click here to view

Table 34: Preventive activities for patients and families Click here to view

Figure 19: Flow process for diagnosis and management of asthma and chronic obstructive airway disease at primary care level Click here to view

Figure 20: Initiation and modulation of asthma pharmacotherapy Click here to view

Figure 21: Initiation and modulation of chronic obstructive airway disease pharmacotherapy Click here to view

Table 35: Resources and medications required for management of asthma and chronic obstructive pulmonary disease at primary and secondary healthcare setting Click here to view

Chronic Kidney Diseases

Table 36: Suggestions for actions at primary and secondary levels of care (the listing is hierarchical with one level of care offering services over and above the ones offered at preceding level of care) Click here to view

Table 37: Recommended specific interventions Click here to view

Figure 22: Screening and management of chronic kidney disease at primary healthcare Click here to view

Figure 23: Screening and management algorithm at secondary healthcare level Click here to view

Nonalcoholic Fatty Liver Disease (NAFLD) and Alcoholic Liver Disease

Table 38: Difference between nonalcoholic fatty liver and nonalcoholic steatohepatitis Click here to view

Figure 24: Algorithmic approach for the evaluation of patients with nonalcoholic fatty liver disease. NAFLD: Nonalcoholic fatty liver disease; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; APRI: AST/Platelet ratio index; LSM: Liver stiffness measurement Click here to view

• Step 1 – History of alcohol intake


Significant alcohol intake as >20 g/day or >140 g/week for men and >10 g/day or >70 g/week for women (approximately 30 ml of whisky/spirit = 100 ml of wine = 240 ml of beer = 10 g of alcohol). Abstainer or insignificant intake will be categorized as nonalcoholic


• Step 2 – If nonalcoholic – assess for the presence or absence of metabolic syndrome


Metabolic syndrome is a clinical syndrome that is usually defined by the presence of at least 3 of the following 5 components as per the WHO criteria.


• Central obesity



• Waist circumference ≥90 cm in males and ≥80 cm in females for Asians
• Population-specific cutoffs for other populations.



• Known DM or fasting plasma glucose of ≥100 mg/dl
• Hypertension (BP ≥130/85 mmHg)
• Low serum high-density lipoprotein (<40 mg/dl in males and <50 mg/dl in females)
• High serum triglycerides (≥150 mg/dl) or on treatment



• Step 3 – If metabolic syndrome or any of its components present [Figure 25]

Figure 25: Algorithmic approach for the treatment of patients with nonalcoholic fatty liver disease Click here to view




• Fatty liver likely to be NAFLD.



• Step 4 – If metabolic syndrome or any of its components absent



• As it is less likely to be NAFLD, search for other causes of hepatic steatosis such as intake of drugs, namely corticosteroids, methotrexate, tamoxifen, and amiodarone, and hepatitis C infection. Other secondary causes of fatty liver such as Wilson's disease, abetalipoproteinemia, lipodystrophy, and parenteral nutrition are uncommon and may require referral to a tertiary care center for further evaluation and confirmation.



• Step 5 – Assessment of liver function tests



• Serum bilirubin is usually normal unless the patient has progressed on to cirrhosis or hepatocellular carcinoma (HCC)
• ALT may be normal or elevated.
• Step 6 – Evaluate for other causes of raised transaminases if present



• All patients with raised ALT (>1.5 times the normal) should be tested for hepatitis B surface antigen (HBsAg) and antibodies to hepatitis C virus (anti-HCV). Refer to a tertiary care center for detailed work-up including autoimmune markers, celiac disease work-up, serum iron profile, and serum ceruloplasmin
• Raised ALT is insufficient to distinguish between NAFL and NASH.



• Step 7 – Noninvasive assessment for the severity of liver disease (irrespective of ALT level)



• AST/ALT ratio, AST to platelet ratio index (APRI), NAFLD fibrosis score (NFS) or by transient elastography (FibroScan) or other forms of hepatic elastography if available. Calculation of APRI and NFS is simple and can be done using free online calculators with age, BMI, diabetic status, and laboratory parameters such as AST, ALT, albumin, and platelets (https://www.hepatitisc.uw.edu/page/clinical-calculators/apri)
• Significant fibrosis: AST/ALT ratio >1, APRI >0.7, NFS >0.675, and liver stiffness measurement on ≥8 kPa on FibroScan (NAFLD Fibrosis Score: http://www.nafldscore.com/)
• Diagnosis of NASH-related cirrhosis liver and HCC may be suspected clinically or on imaging as per the clinical presentation of the patient.



• Step 8 – Manage at primary or secondary level healthcare if less likely to have severe liver disease/NASH/significant fibrosis/cirrhosis/HCC or Refer to tertiary care center otherwise.

• Step 1 – Control of metabolic risk factors.



• Control of overweight or obesity



• Regular exercise and weight reduction for overweight and obesity. Overweight and obesity need to create a negative balance by consuming fewer calories (30% reduction in calorie intake recommended by restricting both carbohydrates and fats) and burning more calories by regular exercise. Regular exercise improves insulin sensitivity and is the only treatment for lean NAFLD. Slow and sustained weight reduction of10% body weight for 6–8 months should be achieved. Severe hypocaloric diets are not recommended in NAFLD. Patients with NAFLD should avoid any amount of alcohol intake.



• Control of DM/hypertension/dyslipidemia



• There are no contraindications for the use of medications to control DM, hypertension, or dyslipidemia. Statins are also safe in patients with NAFLD having raised transaminases.



• Step 2 – Metabolic risk factors – absent



• Regular Exercise.



• Step 3 – Follow-up



• Six monthly follow-up for 1 year
• Observation if parameters improving
• Refer to tertiary care if not able to control the metabolic risk factors or continue to have raised transaminases.

Table 39: Spectrum of Alcoholic Liver Disease Click here to view

• Severe AH is identified by Maddrey's discriminant function score >32 (4.6 × prolonged prothrombin time + serum bilirubin)

• Compensated: Ultrasound or any other imaging or FibroScan evidence of cirrhosis with or without deranged liver function tests (LFTs) or coagulogram
• Decompensated: Clinical features of portal hypertension including ascites, bleeding from GI tract or development of altered sensorium with evidence of deranged LFTs, coagulogram, and ultrasound or other imaging evidence of cirrhosis.

Figure 26: Algorithmic approach for the evaluation and treatment of patients with alcoholic liver disease Click here to view

• Step 1 – History of alcohol intake



• Significant alcohol intake as >20 g/day or >140 g/week for men and >10 g/day or >70 g/week for women
• Heavy alcohol consumption: Consumption of >50 g/day of alcohol for a minimum of 6 months
• Binge drinking: >5 drinks in males and >4 drinks in females, consumed over 2 h period.


*(Approximately 30 ml of whiskey = 100 ml of wine = 240 ml of beer = 10 g of alcohol)

*(Approximate 1 unit of alcohol = one ounce of spirit = 12-ounce beer = 4-ounce of wine)


• Step 2 – If significant alcohol intake is present– Assess for the presence or absence of alcohol dependence or abuse by using the CAGE questionnaire [Figure 26]
• Step 3 – If significant alcohol intake is present look for symptoms and signs of ALD



• The initial symptoms are nonspecific and include pain abdomen, loss of appetite, fatigue, body aches, and sense of being unwell. Most patients do not develop symptoms until severe liver damage. The common symptoms are



• Yellowing of the skin and eyes (jaundice)
• Swelling of the legs (edema)
• Distension of the abdomen due to fluid (ascites)
• Bleeding in the gastrointestinal tract (blood in vomiting and or in stools)
• Weight loss and muscle wasting and change in sleep pattern in advanced liver disease.



• Step 4 – Assessment of severity of liver disease irrespective of symptoms and signs



• Serum bilirubin is usually normal unless a patient has progressed on to AH, cirrhosis, or HCC
• ALT and AST may be normal or elevated even in the early stage of ALD
• The platelet count is usually low in alcoholic cirrhosis, and coagulogram is deranged in advanced disease.



• Step 5 – Noninvasive assessment for the severity of liver disease in alcoholic steatosis (irrespective of elevation of transaminases)


Noninvasive assessment of hepatic fibrosis using AST/ALT ratio, APRI, or transient (FibroScan) or other forms of hepatic elastography in all alcoholic hepatic steatosis [See NAFLD section for details]. The liver stiffness can be fallaciously high in patients with active alcohol abuse and should be repeated once the patient is abstinent for 3 months.


• Step 6 – Manage at primary or secondary level healthcare if alcoholic steatosis and mild alcoholic hepatitis present or refer to tertiary care center in case of severe liver disease/severe ASH/significant fibrosis/cirrhosis/HCC.

• Complete alcohol abstinence with use of pharmacological therapy and behavioral therapy with motivational interviewing techniques.
• 100 mg of thiamine daily and B complex vitamins should be given to all patients. Zinc and other trace elements may be replaced if available.
• Nutritional supplementation including high calorie (30–35 Kcal/kg/day) and high protein diet (1.2–1.5 g/kg/day) in mild AH
• Refer patients with advanced liver disease (severe AH and cirrhosis) to tertiary care facility for further management and follow-up.

Mental Disorders

Table 40: Classification of mental disorders Click here to view

Table 41: Scales/tools used by healthcare staffs to screen for various mental disorders Click here to view

Table 42: Signs and symptoms of stress Click here to view

Table 43: Strategies to prevent and manage stress Click here to view

Table 44: Presenting features of common mental disorders Click here to view

Table 45: Basic ingredients of psychoeducation Click here to view

Table 46: General simple psychosocial interventions Click here to view

Table 47: Simple psychosocial measures specific for patients with somatoform disorders/dissociative disorders/medically unexplained symptoms Click here to view

Table 48: Simple psychosocial measures specific for patients with dementia Click here to view

Table 49: Simple psychosocial measures specific for patients with alcohol and tobacco use Click here to view

Table 50: Commonly used psychotropic medications Click here to view

Figure 27: Assessment and management of depression at primary and secondary healthcare Click here to view

• Among the selective serotonin reuptake inhibitors (SSRIs), the first-line treatment for depression and anxiety disorders, escitalopram and sertraline are among the most commonly prescribed agents and can also be used in patients with^{[108],[109],[110],[111]} hypertension, CAD, DM,^[112] and various malignancies^[113]
• Tricyclic antidepressants such as amitriptyline and imipramine can be used if SSRIs are not available with the cost of more side effects and drug interactions^[114]
• Initiation of drugs: Start with lower doses; half recommended dose among patients with comorbid conditions and among elderly; one-fourth of the recommended dose for elderly with comorbid conditions.^[115]
• It usually takes 2–4 weeks to observe any significant beneficial effects with antidepressants. Patients with improved clinical outcome must be continued on the same medications in the same dose for at least 9–12 months after first episode of depression. After completion of this treatment duration, the doses of medications can be tapered off slowly, with close monitoring for side effects.
• The doses of antidepressants for anxiety disorders are also same, except for patients with obsessive–compulsive disorder, who require higher doses.
• Benzodiazepines may be used along with antidepressants during the initial phase of treatment for short duration and in minimal doses.

• Patients with somatoform disorders or those with medically unexplained symptoms can be managed with nonpharmacological measures such as psychosocial intervention [Table 47],^[104],[105] relaxation exercises, and activity scheduling.^[116] However, some of the patients may require the use of antidepressants which include amitriptyline and duloxetine
• Avoid use of opioid analgesics in patients with somatoform disorders. The summary is given in the [Figure 28].

Figure 28: Assessment and management of psychosis at primary and secondary healthcare Click here to view

• The most commonly used antipsychotics include risperidone and olanzapine^[117],[118]
• Other agents which are commonly used include haloperidol, trifluoperazine, and chlorpromazine
• The basic principle of start from lower doses and gradually increase the dose must be followed. In patients with comorbid medical illnesses, the starting doses and the maximum doses to be used are usually lower than those recommended for those without medical illnesses.

Table 51: Basic community based rehabilitation which can be done at primary care level Click here to view

Table 52: Things to do during the follow-up visits Click here to view

Table 53: Indications for referral to a psychiatrist Click here to view

Figure 29: Assessment and management of alcohol dependence at primary and secondary healthcare Click here to view

Conclusion

Monitoring and Implementation Framework of the Noncommunicable Diseases Guidelines

Table 54: Framework for implementation of guideline on “Prevention, surveillance, and management of noncommunicable diseases in primary and secondary healthcare settings” Click here to view

Table 55: Calculation for assessing the population/patients screened, managed, and followed up for NCDs at primary and secondary healthcare setting of a model district Click here to view

Table 56: The needed human resource and facilities for implementation of noncommunicable diseases guideline in a model district Click here to view

Table 57: Capacity-building budgetary guidelines for orienting/training the health human resource at public health facilities for implementation of guideline on Prevention, surveillance and management of NCDs Click here to view

Expert list

References

1.	World Health Organization. Assessment of National Capacity for Noncommunicable Disease Prevention and Control: The Report of a Global Survey. Geneva: World Health Organization; 2018.
2.	GBD 2016 Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: A systematic analysis for the global burden of disease study 2016. Lancet 2017;390:1151-210.
3.	World Health Organization. Global Status Report on Noncommunicable Diseases 2014. Geneva: World Health Organization; 2014.
4.	United Nations. Sustainable Development Knowledge Platform: United Nations; 2019. Available from: https://sustainabledevelopment.un.org/sdg3. [Last accessed on 2019 Sep 21].
5.	World Health Organization. Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020. Geneva: Word Health Organization; 2013.
6.	World Health Organization. Global Status Report on Noncommunicable Diseases 2010. Geneva: World Health Organization; 2010.
7.	World Health Organization. Primary Healthcare. Fact Sheet Geneva: World Health Organization; 2019. Available from: https://www.who.int/news-room/fact-sheets/detail/primary-health-care. [Last accessed on 2018 Sep 30].
8.	World Health Organization. Saving Lives, Spending Less: A Strategic Response to Noncommunicable Diseases. Geneva: World Health Organization; 2018. Available from: https://www.who.int/ncds/management/ncds-strategic-response/en/. [Last accessed on 2019 Sep 21].
9.	World Health Organization. Prevention and Control of Noncommunicable Diseases: Guidelines for Primary Healthcare in Low Resource Settings. Geneva: World Health Organization; 2012.
10.	Thakur J, Bhadada S. World NCD Federation guidelines for prevention, surveillance, and management of noncommunicable diseases at primary and secondary health-care settings. Int J Noncommun Dis 2018;3:43-4.
11.	World Health Organization. Noncommunicable Diseases Fact Sheet. World Health Organization; 2017. Available from: http://www.who.int/mediacentre/factsheets/fs355/en/. [Last accessed on 2018 Sep 30].
12.	World Health Organization. (2018). Global Health Estimates. Causes of death 2000-2015. [online]. Available from: https://www.who.int/healthinfo/global_burden_disease/en/. [Last accessed on2018 Jul 14].
13.	World Health Organization. Tobacco. Word Health Organization; 2019. Available from: https://www.who.int/news-room/fact-sheets/detail/tobacco. [Last accessed on 2018 Sep 30].
14.	World Health Organization. WHO Global Report: Morality Attributable to Tobacco. Geneva: Word Health Organization; 2012.
15.	World Health Organization. MPOWER in Action Defeating the Global Tobacco Epidemic. Geneva: Word Health Organization; 2013.
16.	World Health Organization. Unhealthy Diet. World Health Organization; 2015. Available from: http://www.who.int/gho/ncd/risk_factors/unhealthy_diet_text/en/. [Last accessed on 2018 Mar 04].
17.	World Health Organization. Noncommunicable Diseases. World Health Organization; 2017. Available from: http://www.who.int/mediacentre/factsheets/fs355/en/. [Last accessed on 2018 Sep 30].
18.	Word Health Organization. Global Recommendations on Physical Activity for Health. Geneva: Word Health Organization; 2010.
19.	World Health Organization. Household Air Pollution and Health. World Health Organization; 2018. Available from: https://www.who.int/en/news-room/fact-sheets/detail/household-air-pollution-and-health. [Last accessed on 2018 Sep 30].
20.	Centres for Disease Control and Prevention. Comprehensive Plan for Epidemiologic Surveillance. 1986. Atlanta: Centres for Disease Control and Prevention; 1986.
21.	Hall HI, Correa A, Yoon PW, Braden CR, Centers for Disease Control and Prevention. Lexicon, definitions, and conceptual framework for public health surveillance. MMWR Suppl 2012;61:10-4.
22.	Li Y, Jiang Y, Zhang M, Yin P, Wu F, Zhao W. Drinking behaviour among men and women in China: The 2007 China chronic disease and risk factor surveillance. Addiction 2011;106:1946-56.
23.	Schmidt MI, Duncan BB, Azevedo e Silva G, Menezes AM, Monteiro CA, Barreto SM, et al. Chronic non-communicable diseases in Brazil: Burden and current challenges. Lancet 2011;377:1949-61.
24.	Raban MZ, Dandona R, Dandona L. Availability of data for monitoring noncommunicable disease risk factors in India. Bull World Health Organ 2012;90:20-9.
25.	Alwan A, Maclean DR, Riley LM, d'Espaignet ET, Mathers CD, Stevens GA, et al. Monitoring and surveillance of chronic non-communicable diseases: Progress and capacity in high-burden countries. Lancet 2010;376:1861-8.
26.	Centres for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. Atlanta. Georgia: U.S. Department of Health and Services; 2014. Available from: https://www.cdc.gov/brfss/about/index.htm. [Last updated on 2014 May 16].
27.	World Health Organization. Global School-Based Student Health Survey. Geneva: World Health Organization; 2018. Available from: https://www.who.int/ncds/surveillance/gshs/en/. [Last accessed on 2018 Sep 30].
28.	World Health Organization. Surveillance and Monitoring. Tobacco Free Initiative. Geneva: World Health Organization; 2018. Available from: https://www.who.int/tobacco/surveillance/survey/en/. [Last accessed on 2018 Aug 10].
29.	World Health Organization. STEPwise Approach to Noncommunicable Disease Risk Factor Surveillance. Geneva: World Health Organization; 2018. Available from: https://www.who.int/ncds/surveillance/steps/riskfactor/en/. [Last accessed on 2018 Jul 08].
30.	Kann L, McManus T, Harris WA, Shanklin SL, Flint KH, Queen B, et al. Youth risk behavior surveillance – United States, 2017. MMWR Surveill Summ 2018;67:1-14.
31.	World Health Organization. WHO STEPS Surveillance Manual: The WHO STEPwise Approach to Chronic Disease Risk Factor Surveillance. Geneva: World Health Organization; 2005.
32.	Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136:E359-86.
33.	Denny L, Quinn M, Sankaranarayanan R. Chapter 8: Screening for cervical cancer in developing countries. Vaccine 2006;24 Suppl 3:S3/71-7.
34.	Wolf AM, Fontham ET, Church TR, Flowers CR, Guerra CE, LaMonte SJ, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin 2018;68:250-81.
35.	Cho NH, Shaw JE, Karuranga S, Huang Y, da Rocha Fernandes JD, et al. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract 2018;138:271-81.
36.	Dagenais GR, Gerstein HC, Zhang X, McQueen M, Lear S, Lopez-Jaramillo P, et al. Variations in diabetes prevalence in low-, middle-, and high-income countries: Results from the prospective urban and rural epidemiological study. Diabetes Care 2016;39:780-7.
37.	Anjana RM, Deepa M, Pradeepa R, Mahanta J, Narain K, Das HK, et al. Prevalence of diabetes and prediabetes in 15 states of India: Results from the ICMR-INDIAB population-based cross-sectional study. Lancet Diabetes Endocrinol 2017;5:585-96.
38.	Sacks DA, Hadden DR, Maresh M, Deerochanawong C, Dyer AR, Metzger BE, et al. Frequency of gestational diabetes mellitus at collaborating centers based on IADPSG consensus panel-recommended criteria: The hyperglycemia and adverse pregnancy outcome (HAPO) study. Diabetes Care 2012;35:526-8.
39.	Government of India. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) Approved. New Delhi: Press information Bureau; 2010. Available from: http://www.pib.nic.in/newsite/erelease.aspx?relid=63087. [Last accessed on 2018 Sep 30].
40.	Bennett WL, Maruthur NM, Singh S, Segal JB, Wilson LM, Chatterjee R, et al. Comparative effectiveness and safety of medications for type 2 diabetes: An update including new drugs and 2-drug combinations. Ann Intern Med 2011;154:602-13.
41.	Singh SR, Ahmad F, Lal A, Yu C, Bai Z, Bennett H. Efficacy and safety of insulin analogues for the management of diabetes mellitus: A meta-analysis. CMAJ 2009;180:385-97.
42.	Horvath K, Jeitler K, Berghold A, Ebrahim SH, Gratzer TW, Plank J, et al. Long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus. Cochrane Database Syst Rev 2007; CD005613.
43.	Monami M, Marchionni N, Mannucci E. Long-acting insulin analogues versus NPH human insulin in type 2 diabetes: A meta-analysis. Diabetes Res Clin Pract 2008;81:184-9.
44.	Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001;345:861-9.
45.	Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The collaborative study group. N Engl J Med 1993;329:1456-62.
46.	Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001;345:851-60.
47.	Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: Results of the HOPE study and MICRO-HOPE substudy. Heart outcomes prevention evaluation study investigators. Lancet 2000;355:253-9.
48.	Institute for Health Metrics and Evaluation. GBD Compare Data Visualisation. Seattle, WA: Institute for Health Metrics and Evaluation, University of Washington; 2016. Available from: https://vizhub.healthdata.org/gbd-compare/. [Last accessed on 2017 Dec 19].
49.	Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr., Ganiats TG, Holmes DR Jr., et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation 2014;130:e344-426.
50.	O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr., Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2013;61:e78-140.
51.	Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): A prospective analysis of registry data. Lancet 2008;371:1435-42.
52.	Prabhakaran D, Yusuf S, Mehta S, Pogue J, Avezum A, Budaj A, et al. Two-year outcomes in patients admitted with non-ST elevation acute coronary syndrome: Results of the OASIS registry 1 and 2. Indian Heart J 2005;57:217-25.
53.	Abarbanell NR. Is prehospital blood glucose measurement necessary in suspected cerebrovascular accident patients? Am J Emerg Med 2005;23:823-7.
54.	Rashid P, Leonardi-Bee J, Bath P. Blood pressure reduction and secondary prevention of stroke and other vascular events: A systematic review. Stroke 2003;34:2741-8.
55.	Kloska SP, Nabavi DG, Gaus C, Nam EM, Klotz E, Ringelstein EB, et al. Acute stroke assessment with CT: Do we need multimodal evaluation? Radiology 2004;233:79-86.
56.	Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:227-76.
57.	Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, et al. Primary prevention of ischemic stroke: A guideline from the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline. Stroke 2006;37:1583-633.
58.	Kwiatkowski TG, Libman RB, Frankel M, Tilley BC, Morgenstern LB, Lu M, et al. Effects of tissue plasminogen activator for acute ischemic stroke at one year. National institute of neurological disorders and stroke recombinant tissue plasminogen activator stroke study group. N Engl J Med 1999;340:1781-7.
59.	Lawes CM, Vander Hoorn S, Rodgers A; International Society of Hypertension. Global burden of blood-pressure-related disease, 2001. Lancet 2008;371:1513-8.
60.	Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G, et al. Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015. J Am Coll Cardiol 2017;70:1-25.
61.	Forouzanfar MH, Liu P, Roth GA, Ng M, Biryukov S, Marczak L, et al. Global burden of hypertension and systolic blood pressure of at least 110 to 115 mm hg, 1990-2015. JAMA 2017;317:165-82.
62.	Mills P, Joseph AE, Adam EJ. Total abdominal and pelvic ultrasound: Incidental findings and a comparison between outpatient and general practice referrals in 1000 cases. Br J Radiol 1989;62:974-6.
63.	Whelton PK, Carey RM, Aronow WS, Casey DE Jr., Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension 2018;71:1269-324.
64.	Armstrong C, Joint National Committee. JNC8 guidelines for the management of hypertension in adults. Am Fam Physician 2014;90:503-4.
65.	Mirza S, Clay RD, Koslow MA, Scanlon PD. COPD guidelines: A review of the 2018 GOLD report. Mayo Clin Proc 2018;93:1488-502.
66.	Global INitiative of Asthma GIfA. Global Strategy for Asthma Management and Prevention, 2018. Global INitiative of Asthma; 2018.
67.	World Health Organization. Management of Asthma. Geneva: World Health Organization; 2017.
68.	World Health Organization. Management of Chronic Obstructive Pulmonary Disease. Geneva: World Health Organization; 2014.
69.	Agarwal R, Dhooria S, Aggarwal AN, Maturu VN, Sehgal IS, Muthu V, et al. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations. Lung India 2015;32:S3-42.
70.	Gupta D, Agarwal R, Aggarwal AN, Maturu VN, Dhooria S, Prasad KT, et al. Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations. Lung India 2013;30:228-67.   [PUBMED]  [Full text]
71.	Jindal SK, Gupta D, Aggarwal AN; WHO-Government of India Biennium (2002-2003) Programme. Guidelines for management of chronic obstructive pulmonary disease (COPD) in India: A guide for physicians (2003). Indian J Chest Dis Allied Sci 2004;46:137-53.
72.	Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F, Casaburi R, et al. Interpretative strategies for lung function tests. Eur Respir J 2005;26:948-68.
73.	Ducharme FM, Ni Chroinin M, Greenstone I, Lasserson TJ. Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma. Cochrane Database Syst Rev 2010; CD005533.
74.	Greenstone IR, Ni Chroinin MN, Masse V, Danish A, Magdalinos H, Zhang X, et al. Combination of inhaled long-acting beta2-agonists and inhaled steroids versus higher dose of inhaled steroids in children and adults with persistent asthma. Cochrane Database Syst Rev 2005; CD005533.
75.	Agarwal R, Khan A, Aggarwal AN, Gupta D. Is the SMART approach better than other treatment approaches for prevention of asthma exacerbations? A meta-analysis. Monaldi Arch Chest Dis 2009;71:161-9.
76.	Global Action Plan for the Prevention and Control of NCDs 2013-2020. Geneva: World Health Organization; 2013. Available from: http://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236_eng.pdf; jsessionid=BBE9025A043AB9F53F095AAD72BA2DC8?sequence=1. [Last accessed on 2018 Sep 30].
77.	Bowe B, Xie Y, Li T, Mokdad AH, Xian H, Yan Y, et al. Changes in the US burden of chronic kidney disease from 2002 to 2016: An analysis of the global burden of disease study. JAMA Netw Open 2018;1:e184412.
78.	GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: A systematic analysis for the global burden of disease study 2015. Lancet 2016;388:1459-544.
79.	Garcia-Garcia G, Jha V. Chronic kidney disease in disadvantaged populations. Indian J Nephrol 2015;25:65-9. doi:10.4103/0971-4065.150078.   [PUBMED]  [Full text]
80.	Stanifer JW, Muiru A, Jafar TH, Patel UD. Chronic kidney disease in low – And middle-income countries. Nephrol Dial Transplant 2016;31:868-74.
81.	Jessani S, Levey AS, Bux R, Inker LA, Islam M, Chaturvedi N, et al. Estimation of GFR in South Asians: A study from the general population in Pakistan. Am J Kidney Dis 2014;63:49-58.
82.	Kumar V, Yadav AK, Yasuda Y, Horio M, Kumar V, Sahni N, et al. Existing creatinine-based equations overestimate glomerular filtration rate in Indians. BMC Nephrol 2018;19:22.
83.	Grogan JR, Kochar MS. Alcohol and hypertension. Arch Fam Med 1994;3:150-4.
84.	Yohannes AM, Alexopoulos GS. Depression and anxiety in patients with COPD. Eur Respir Rev 2014;23:345-9.
85.	World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.
86.	Vahia VN. Diagnostic and statistical manual of mental disorders 5: A quick glance. Indian J Psychiatry 2013;55:220-3.   [PUBMED]  [Full text]
87.	Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
88.	Goldberg DP, Hillier VF. A scaled version of the general health questionnaire. Psychol Med 1979;9:139-45.
89.	Beusenberg M, Orley , John H. A User's Guide to the Self Reporting Questionnaire (SRQ). Geneva: World Health Organization; 1994.
90.	Kroenke K, Spitzer RL, Williams JB. The patient health questionnaire-2: Validity of a two-item depression screener. Med Care 2003;41:1284-92.
91.	Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.
92.	Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092-7.
93.	Kroenke K, Spitzer RL, Williams JB. The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;64:258-66.
94.	Gierk B, Kohlmann S, Kroenke K, Spangenberg L, Zenger M, Brähler E, et al. The somatic symptom scale-8 (SSS-8): A brief measure of somatic symptom burden. JAMA Intern Med 2014;174:399-407.
95.	Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.
96.	Eddy JR, Sriram S. Clock-drawing and telling time as diagnostic aids. Neurology 1977;27:595.
97.	World Health Organization. The ASSIST Project – Alcohol, Smoking and Substance Involvement Screening Test. World Health Organization; 2010.
98.	Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA 1984;252:1905-7.
99.	Malhotra S, Varma VK, Verma SK, Malhotra A. Childhood psychopathology measurement schedule: Development and standardization. Indian J Psychiatry 1988;30:325-31.   [PUBMED]  [Full text]
100.	Patel V, Weiss HA, Chowdhary N, Naik S, Pednekar S, Chatterjee S, et al. Lay health worker led intervention for depressive and anxiety disorders in India: Impact on clinical and disability outcomes over 12 months. Br J Psychiatry 2011;199:459-66.
101.	Shinde S, Andrew G, Bangash O, Cohen A, Kirkwood B, Patel V. The impact of a lay counselor led collaborative care intervention for common mental disorders in public and private primary care: A qualitative evaluation nested in the MANAS trial in Goa, India. Soc Sci Med 2013;88:48-55.
102.	Bäuml J, Froböse T, Kraemer S, Rentrop M, Pitschel-Walz G. Psychoeducation: A basic psychotherapeutic intervention for patients with schizophrenia and their families. Schizophr Bull 2006;32 Suppl 1:S1-9.
103.	Swartz HA, Swanson J. Psychotherapy for bipolar disorder in adults: A review of the evidence. Focus (Am Psychiatr Publ) 2014;12:251-66.
104.	Bower P, Knowles S, Coventry PA, Rowland N. Counselling for mental health and psychosocial problems in primary care. Cochrane Database Syst Rev 2011; CD001025.
105.	England MJ, Butler AS, Gonzalez ML; Committee on Developing Evidence-Based Standards for Psychosocial Interventions for Mental Disorders; Board on Health Sciences Policy; Institute of Medicine. Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards. Washington DC: National Academies Press (US); 2015.
106.	McDermott O, Charlesworth G, Hogervorst E, Stoner C, Moniz-Cook E, Spector A, et al. Psychosocial interventions for people with dementia: A synthesis of systematic reviews. Aging Ment Health 2019;23:393-403.
107.	Gamble C, Hart C. The use of psychosocial interventions. Nurs Times 2003;99:46-7.
108.	Tripathi A, Avasthi A, Desousa A, Bhagabati D, Shah N, Kallivayalil RA, et al. Prescription pattern of antidepressants in five tertiary care psychiatric centres of India. Indian J Med Res 2016;143:507-13.   [PUBMED]  [Full text]
109.	Grover S, Avasth A, Kalita K, Dalal PK, Rao GP, Chadda RK, et al. IPS multicentric study: Antidepressant prescription patterns. Indian J Psychiatry 2013;55:41-5.   [PUBMED]  [Full text]
110.	Grover S, Avasthi A, Sinha V, Lakdawala B, Bathla M, Sethi S, et al. Indian Psychiatric Society Multicentric Study: Prescription patterns of psychotropics in India. Indian J Psychiatry 2014;56:253-64.   [PUBMED]  [Full text]
111.	Grover S, Avasthi A, Sinha V, Lakdawala B, Bathla M, Sethi S, et al. Indian Psychiatric Society Multicentric Study: Correlates of prescription patterns of psychotropics in India. Indian J Psychiatry 2016;58:417-24.   [PUBMED]  [Full text]
112.	Grover S, Avasthi A, Tripathi A, Tanra AJ, Chee KY, He YL, et al. Antidepressant prescription pattern in the presence of medical co-morbidity: REAP-AD 2013 study. East Asian Arch Psychiatry 2015;25:99-107.
113.	Sanjida S, Janda M, Kissane D, Shaw J, Pearson SA, DiSipio T, et al. A systematic review and meta-analysis of prescribing practices of antidepressants in cancer patients. Psychooncology 2016;25:1002-16.
114.	Gautam S, Jain A, Gautam M, Vahia VN, Grover S. Clinical practice guidelines for the management of depression. Indian J Psychiatry 2017;59:S34-S50.
115.	Avasthi A, Grover S. Clinical practice guidelines for management of depression in elderly. Indian J Psychiatry 2018;60:S341-62.   [PUBMED]  [Full text]
116.	Kallivayalil RA, Punnoose VP. Understanding and managing somatoform disorders: Making sense of non-sense. Indian J Psychiatry 2010;52:S240-5.   [PUBMED]  [Full text]
117.	Choi HJ, Jung SH, Kang MH, Lee JS, Bae JN, Kim CE. Antipsychotics prescribing patterns of patients with schizophrenia admitted to Korean General Hospital Psychiatric Unit: 2001 to 2008. Clin Psychopharmacol Neurosci 2011;9:17-22.
118.	Ramadas S, Kuttichira P, Sumesh TP, Ummer SA. A study of an antipsychotic prescription pattern of patients with schizophrenia in a developing country. Indian J Psychol Med 2010;32:13-6.   [PUBMED]  [Full text]
119.	Schwarz S, Froelich L, Burns A. Pharmacological treatment of dementia. Curr Opin Psychiatry 2012;25:542-50.
120.	Dalal P, Basu B. Synopsis of the Clinical Practice Guidelines. Kolkata: Indian Psychiatric Society, India Substance Use Disorders; 2015.
121.	Grover S, Bhateja G, Basu D. Pharmacoprophylaxis of alcohol dependence: Review and Update Part I: Pharmacology. Indian J Psychiatry 2007;49:19-25.   [PUBMED]  [Full text]
122.	Verbiest M, Brakema E, van der Kleij R, Sheals K, Allistone G, Williams S, et al. National guidelines for smoking cessation in primary care: A literature review and evidence analysis. NPJ Prim Care Respir Med 2017;27:2.
123.	Gelder MG, Andreasen NC, Jr JJL-I, Geddes JR. New Oxford Textbook of Psychiatry. 2nd ed. Oxford, UK: Oxford University Press; 2012.
124.	Stahl SM. The Prescriber's Guide: Antidepressants: Stahl's Essential Psychopharmacology. New York: Cambridge Cambridge University Press; 2011.
125.	Stahl SM. Essential Psychopharmacology: The Prescriber's Guide. New York: Cambridge Cambridge University Press; 2006.