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GROUP A - LONG ANSWER QUESTIONS (15 Marks Each)

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Q1. Latent Period | NCD Risk Factors | Prevention of One NCD (2+3+10) [JIMSH]

Part A: Latent Period (2 marks)

• Coronary artery disease: latent period of 20-30 years
• Cancer: latent period may be 10-40 years (e.g., radiation-induced cancers)
• This prolonged latent period provides an extended window for primary prevention - interventions can be applied long before clinical disease manifests.

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Part B: Risk Factors of Non-Communicable Diseases (3 marks)

• Age (risk increases with age)
• Sex (gender differences in disease patterns)
• Genetic predisposition / family history
• Ethnicity / race

1. Tobacco use - smoking, smokeless tobacco
2. Harmful use of alcohol
3. Physical inactivity - sedentary lifestyle
4. Unhealthy diet - high salt, saturated fats, low fruits and vegetables

• Raised blood pressure (hypertension)
• Raised blood glucose / diabetes mellitus
• Raised blood lipids (dyslipidaemia)
• Overweight and obesity (BMI >25, waist-hip ratio)

• Air pollution (indoor and outdoor)
• Psychosocial stress
• Socio-economic deprivation

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Part C: Preventive & Control Methods for Hypertension (National Guidelines) (10 marks)

1. Primordial Prevention

• Prevent the emergence of risk factors themselves in the community
• Promote healthy lifestyle from childhood
• National policies on salt reduction in food industry, tobacco taxation, alcohol regulations

2. Primary Prevention

• Dietary modification: Reduce salt intake to <5 g/day; reduce saturated fat; avoid excess alcohol; adequate fruits and vegetables (≥400g/day)
• Weight control: Maintain BMI 18.5-22.9; waist circumference <90 cm (men), <80 cm (women)
• Physical activity promotion: Minimum 150 minutes of moderate intensity aerobic activity per week
• Stress reduction: Yoga, meditation, behavioural change
• Cessation of tobacco use: Counselling, NRT programmes
• Health education: IEC activities through mass media, school health programmes
• Self-care: Teach community members to monitor their own BP

• Screening programmes to identify pre-hypertensives (BP 130-139/85-89 mm Hg)
• Intensive lifestyle counselling for high-risk persons (obese, diabetics, family history)
• Regular BP monitoring for those with high-normal BP

3. Secondary Prevention

• Early detection: Community-based screening camps; opportunistic screening at all health facilities (as per NPCDCS - every adult attending any OPD should have BP checked)
• Diagnosis: Average of two readings on two separate occasions; rule out white coat hypertension
• Treatment:
  • Step-1: Lifestyle modifications for 3-6 months for Grade 1 hypertension
  • Step-2: Pharmacotherapy as per national protocol:
    • First line: Amlodipine (CCB) or Telmisartan (ARB) or Hydrochlorothiazide
    • Combination therapy for Grade 2/3 hypertension
  • Adherence support: Fixed-dose combinations, once-daily dosing, pill boxes
• Referral system: PHC - CHC - District hospital as per NPCDCS guidelines

4. Tertiary Prevention

• Management of complications: stroke rehabilitation, renal dialysis support, cardiac care
• Prevention of further damage to target organs
• Complications to prevent: Stroke, coronary artery disease, heart failure, chronic kidney disease, retinopathy, peripheral vascular disease

• Launched in 2010
• Opportunistic screening for hypertension at all government health facilities
• Community health workers (ASHAs, ANMs) trained for BP measurement
• Free antihypertensive drugs under PMBJP (Jan Aushadhi)
• Dedicated NCD clinics at District Hospitals and CHCs
• Target: Reduce premature mortality from NCDs by 25% by 2025

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Q2. Clinical Case - Hypertension (1+2+4+6+2 = 15) [ICARE]

Provisional Diagnosis (1 mark)

Classification of Blood Pressure (2 marks)

Risk Factors of Hypertension (4 marks)

• Age 35 years (risk increases with age)
• Sex: Male (higher risk vs pre-menopausal females)

1. Obesity - most significant; central obesity increases risk via RAAS activation and insulin resistance; every 1% increase in body weight raises BP ~1-3 mm Hg
2. Sedentary lifestyle - physical inactivity causes weight gain, impairs baroreceptor sensitivity
3. Smoking - nicotine causes acute vasoconstriction; chronic smoking accelerates atherosclerosis
4. Salt intake - excess sodium causes fluid retention and increased cardiac output
5. Alcohol - raises systolic BP more than diastolic
6. Stress - increases sympathetic activity and catecholamines
7. Saturated fat intake - raises both BP and serum cholesterol
8. Low physical activity - directly related to higher mean BP

Levels of Prevention with Special Emphasis on Diet (6 marks)

• Policy-level: food labelling laws, salt reduction in processed foods, banning trans fats
• Community campaigns on healthy dietary patterns

• Salt restriction: Reduce to <5 g NaCl/day (current Indian average is 9-12 g/day)
• Fruits and vegetables: ≥5 servings (400 g) per day; rich in potassium which antagonizes sodium
• Whole grains: Replace refined carbohydrates; lowers glycaemic load
• Reduce saturated fat: <10% of total calories from saturated fat; avoid trans fats; use mono/polyunsaturated fats (olive oil, mustard oil)
• Increase dietary potassium: Bananas, green leafy vegetables, pulses, coconut water (target 90 mmol/day)
• Calcium and magnesium: Low-fat dairy, nuts, seeds
• Limit alcohol: Not more than 2 standard units/day for men; 1 unit for women
• Dietary fibre: ≥25 g/day; reduces both cholesterol and BP

• Calorie-restricted diet to achieve 5-10% weight loss (reduces BP by 5-20 mm Hg per 10 kg)
• Low sodium, low fat, high fibre diet
• Avoid packaged foods, salty snacks, pickles, papads
• 6 small meals instead of 3 large meals
• Increase water intake

• Intensive counselling: smoking cessation, exercise prescription
• Regular BP monitoring every 3 months
• Lipid profile, blood glucose, serum creatinine evaluation

• Pharmacotherapy: Consider after 3-6 months if lifestyle changes insufficient
• First line for young male: Amlodipine 5 mg OD or Telmisartan 40 mg OD
• Regular follow-up, adherence monitoring

• Prevention of end-organ damage
• Echocardiography, renal function tests, fundoscopy yearly

Tracking of Blood Pressure (2 marks)

• Observed from childhood to adult life
• A child in the upper percentile of BP distribution is likely to remain there in adulthood
• Provides the rationale for early screening of BP in children (school health programmes)
• Important concept in preventive cardiology - identifies future high-risk adults
• Tracking is stronger for systolic than diastolic BP
• Supports the concept of primordial prevention beginning in childhood

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Q3. Clinical Case - Hypertension (52-year-old male teacher) [DHGMCH]

Diagnosis and Criteria (2 marks)

• BP ≥140/90 mm Hg on average of two or more readings on two or more separate occasions
• Patient should not be on antihypertensives, not acutely ill
• Reading taken after 5 minutes rest, seated, arm at heart level
• Both arms checked; higher reading used
• Confirm with repeat measurement at 4-week interval for Grade 1

Modifiable and Non-Modifiable Risk Factors in This Patient (3 marks)

• Age: 52 years (age-related arteriosclerosis)
• Sex: Male
• Family history/Genetic: Father had hypertension and died of stroke (positive family history - 45% risk if both parents hypertensive)

• Obesity (mentioned as obese)
• Smoking - 10 cigarettes/day for 20 years (pack years = 10)
• Sedentary lifestyle - school teacher, limited physical activity
• High salt intake - frequent consumption of salty snacks (>5 g NaCl/day)
• Psychosocial stress - occupational stress

Classification of Hypertension - WHO/Indian Guidelines (2 marks)

Rule of Halves in Hypertension (1 mark)

• Of ALL hypertensives in the community:
  • Only half are detected/aware of their condition
  • Of those detected, only half receive treatment
  • Of those on treatment, only half have their BP adequately controlled
• Net result: Only 1/8 (12.5%) of all hypertensives in the community have their BP adequately controlled

Four Lifestyle Modification Measures (2 marks)

1. Dietary modification (DASH diet): Reduce salt to <5 g/day; increase fruits, vegetables; reduce saturated fat and salty snacks
2. Weight reduction: Target BMI <25 kg/m²; even 5-10% weight loss reduces BP by 5-20 mm Hg
3. Smoking cessation: Complete cessation; use nicotine replacement therapy or counselling if needed
4. Physical activity: Minimum 30 minutes of moderate aerobic exercise (brisk walking) on most days of the week (≥150 min/week)

Four Complications of Uncontrolled Hypertension (2 marks)

1. Cerebrovascular: Stroke (ischaemic or haemorrhagic) - like his father
2. Cardiovascular: Coronary artery disease, myocardial infarction, left ventricular hypertrophy, heart failure
3. Renal: Hypertensive nephrosclerosis, chronic kidney disease, proteinuria
4. Ophthalmic: Hypertensive retinopathy (AV nipping, haemorrhages, papilloedema in malignant HTN)
5. (Additional: Aortic aneurysm / dissection, peripheral vascular disease)

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Q4. Classification, Risk Factors, Complications, Prevention of Essential Hypertension (2+4+4+5) [CNMCH]

Classification (2 marks)

• By aetiology: Essential (primary) - 90-95% | Secondary - 5-10% (renal, endocrine, etc.)
• By clinical presentation: Benign/stable HTN | Malignant/accelerated HTN (rapidly progressive, papilloedema, diastolic >130)

Risk Factors of Essential Hypertension (4 marks)

• Age, Sex (male), Genetics/Family history (polygenic inheritance), Ethnicity (Black > Asian)

• Obesity (especially central obesity - waist-hip ratio)
• High sodium intake (>7-8 g/day)
• Sedentary lifestyle / physical inactivity
• Tobacco use (smoking, chewing tobacco)
• Excess alcohol consumption
• High saturated fat diet
• Environmental stress / psychosocial factors (catecholamine excess)
• Low potassium, calcium, magnesium intake
• Oral contraceptive pills (oestrogen component)
• Socio-economic factors (urbanisation, transitional populations)

Complications of Essential Hypertension (4 marks)

• Left ventricular hypertrophy (LVH)
• Hypertensive cardiomyopathy
• Coronary artery disease (angina, MI)
• Congestive cardiac failure

• Hypertensive encephalopathy
• Cerebral haemorrhage (haemorrhagic stroke) - Charcot-Bouchard aneurysm
• Ischaemic stroke (lacunar infarcts)
• Transient ischaemic attacks (TIA)

• Benign nephrosclerosis → proteinuria → CKD
• Malignant nephrosclerosis (fibrinoid necrosis of arterioles)
• Renal failure

• Hypertensive retinopathy: Grade 1 (arteriolar narrowing) → Grade 2 (AV nipping) → Grade 3 (haemorrhage, exudates) → Grade 4 (papilloedema - malignant HTN)

• Aortic dissection
• Peripheral vascular disease
• Renal artery stenosis (accelerating secondary HTN)

Preventive Measures of Essential Hypertension (5 marks)

• A - Alcohol restriction (<2 units/day)
• B - BMI reduction (target <25 kg/m²)
• C - Cessation of smoking
• D - Diet: DASH diet, salt <5 g/day, increase fruits/vegetables/potassium
• E - Exercise: 150 minutes moderate activity/week

• Mass screening: NPCDCS, community health workers (ASHA/ANM)
• Pharmacotherapy: Amlodipine/Telmisartan/Hydrochlorothiazide as first-line agents
• Adherence: Fixed dose combinations, patient education, self-monitoring
• Regular follow-up: BP, renal function, lipids, blood sugar

• Rehabilitation after stroke/MI
• Dialysis for renal failure
• Laser photocoagulation for retinopathy
• Secondary prevention: Statin, aspirin, ACE inhibitor post-MI

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Q5. Adolescent Obesity - Public Health Problem (2+2+2+6+2+1) [MCK]

Most Likely Public Health Problem (2 marks)

Behavioral Risk Factors (2 marks)

1. Sedentary behaviour / Screen-based activities (physical inactivity): Excessive screen time (TV, mobile, video games) >2 hours/day replaces physical activity, reduces energy expenditure, disrupts sleep and promotes snacking
2. Unhealthy dietary habits - Fast food consumption: High calorie-dense food, high in saturated fats, refined carbohydrates, added sugars, and salt; low in fibre and micronutrients; large portion sizes; frequent eating out

Two Health Consequences if Left Untreated (2 marks)

1. Metabolic syndrome / Type 2 Diabetes Mellitus: Adolescent obesity leads to insulin resistance; T2DM increasingly diagnosed in teenagers - previously a disease of adults only
2. Cardiovascular disease risk: Hypertension, dyslipidaemia (high LDL, low HDL), early atherosclerosis - tracking of these risk factors from adolescence to adulthood; also risk of psychological consequences (low self-esteem, depression, bullying)

Preventive Strategies at School Level (6 marks)

• Healthy canteen/tiffin policies: Restrict sale of junk food, sugary drinks, chips within school premises
• Nutritious mid-day meal: Provide balanced, calorie-appropriate school meals (PM Poshan Abhiyan/Mid-Day Meal Scheme)
• Fruit and vegetable promotion: Daily fruit portions, salad bars
• Safe drinking water: Replace sugar-sweetened beverages with water and low-fat milk

• Compulsory physical education: Minimum 60 minutes/day of moderate-to-vigorous physical activity (WHO recommendation for children/adolescents)
• Active play time: Structured recess periods with guided play
• Sports and games: Inter-class and inter-school competitions
• Reduce sedentary time: No screen time during school, active transport (cycling/walking to school)

• Nutrition education integrated into the curriculum
• Teaching students to read food labels
• Life skills training: healthy cooking, body image, media literacy against unhealthy food advertisements
• Peer-led health education programmes

• Regular anthropometric measurements (height, weight, BMI calculation) as part of school health programme
• Annual health check-ups by school medical officers
• Referral of obese students to NCD clinics

• Training teachers to integrate physical activity into classroom
• Parent-teacher meetings on healthy home food environment
• Homework involving physical activity

• Adequate playground space
• Promote staircase use over lifts
• Green school initiatives

Level of Prevention (2 marks)

• Primary Prevention - for healthy non-obese students: preventing obesity from occurring through healthy school environment and education
• Secondary Prevention - for this patient (already obese, BMI >95th percentile): early detection through BMI screening, referral, lifestyle intervention to prevent complications
• Tertiary Prevention - if complications (diabetes, HTN) have developed: treatment and rehabilitation

National Programme (1 mark)

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Q6. Tuberculosis - Clinical Case, NTEP, Diagnosis, Treatment, Prevention (1+1+4+4+5=15) [IQCITY]

Probable Diagnosis & National Programme (1+1 marks)

Diagnostic Algorithm per NTEP Guidelines (4 marks)

• Sputum sample collection: Two samples (spot + early morning, or two spot samples)
• CBNAAT/Xpert MTB/RIF (Cartridge-Based Nucleic Acid Amplification Test): FIRST-LINE diagnostic test as per NTEP 2022
  • Simultaneously detects M. tuberculosis AND rifampicin resistance
  • Result in 2 hours
  • Preferred over smear microscopy alone
• Sputum smear microscopy (ZN staining / Fluorescence): Still used where CBNAAT unavailable
  • ≥3+ AFB: smear-positive PTB
• Sputum culture (LJ medium / MGIT liquid culture): Gold standard, takes 2-8 weeks; used for drug susceptibility testing (DST)
• Line Probe Assay (LPA): For rapid detection of RIF + INH resistance (MTBDRplus)
• TrueNat: Newer point-of-care test; approved by NTEP

• Chest X-ray: upper lobe infiltrates, cavitation, hilar lymphadenopathy
• Supports diagnosis but not diagnostic alone

• Bacteriologically confirmed TB (CBNAAT/smear positive)
• Clinically diagnosed TB (smear negative, CXR consistent, not responding to antibiotics)

Treatment Regimen per NTEP (4 marks)

• Isoniazid 300 mg + Rifampicin 450 mg daily
• Total duration: 6 months

• Pyridoxine (Vitamin B6) 10-25 mg/day: To prevent isoniazid-induced peripheral neuropathy (esp. in malnourished patients, pregnant, elderly)
• Nutritional support under Ni-kshay Poshan Yojana: Rs. 500/month direct benefit transfer

• All TB cases MUST be notified on Ni-kshay portal (government mandate under Notification of TB Act)
• Unique Ni-kshay ID issued
• Treatment outcome recorded

• CBNAAT showing RIF resistance → DST for all first-line + second-line drugs
• MDR-TB: Longer regimen (BPaL or shorter MDR regimen with Bedaquiline, Linezolid, etc.)

• Sputum smear/CBNAAT at end of IP (2 months), 5 months, end of treatment (6 months)
• If smear positive at 2 months → Extend IP by 1 month → Culture + DST
• Liver function tests (LFT) - if hepatotoxicity suspected

Preventive Measures for the Family (5 marks)

• Husband (30 years) and son (6 years) are household contacts - highest risk
• Both should undergo immediate evaluation:
  • Symptom screening: cough, fever, weight loss, night sweats
  • Chest X-ray
  • CBNAAT if symptomatic

• If child (son, 6 years) is unvaccinated or vaccination status unknown - provide BCG
• BCG is 60-80% protective against severe forms (miliary TB, TB meningitis) in children
• Part of universal immunisation programme

• Son (6-year-old child): If asymptomatic and contact of infectious PTB case → Isoniazid 10 mg/kg/day (max 300 mg) for 6 months as per NTEP guidelines (TPT for paediatric contacts)
• Husband: Screen for LTBI; if HIV-positive or immunocompromised → TPT with 6H or 3HP regimen
• As per NTEP: All household contacts <5 years and HIV-positive contacts of bacteriologically confirmed TB cases should receive TPT

• Adequate ventilation: Open windows/doors to allow sunlight; UV kills M. tuberculosis
• Patient isolation: Patient (wife) should sleep in separate, well-ventilated room until declared non-infectious (sputum negative at 2 months)
• Respiratory hygiene: Cover mouth while coughing (cough etiquette), use separate handkerchief/tissue, proper disposal
• Avoid overcrowding; no spitting indoors

• Protein-rich, calorie-adequate diet for all family members to maintain immunity
• Patient enrolled under Ni-kshay Poshan Yojana for nutritional support
• Address underlying poverty/malnutrition

• Nature of disease: airborne spread, curability with complete treatment
• Importance of treatment adherence: completing all 6 months is mandatory - explain dangers of drug resistance
• Early reporting of symptoms in family members
• Dispel stigma and myths about TB
• Register as DOT provider: Husband can be trained as DOT observer to supervise wife's treatment

• Husband: Repeat screening if he develops symptoms
• Child: Regular follow-up during 6 months of IPT; watch for isoniazid side effects (rash, hepatitis)
• All contacts: Annual surveillance for 2 years post-exposure

• Both index patient and husband offered HIV counselling and testing - TB-HIV co-infection alters management significantly (start ART within 2-8 weeks of ATT)

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Quick Reference Summary

• Latent period = time between first exposure and first symptoms; very long in NCDs (years-decades)
• NCD risk factors: 4 WHO behavioural (tobacco, alcohol, inactivity, unhealthy diet) + metabolic (HTN, DM, obesity, dyslipidaemia)
• HTN prevention per NPCDCS: Primordial → Population strategy (DASH diet, weight, exercise) → High-risk strategy → Secondary (screening, treatment) → Tertiary (complication management)

• Diagnosis: Grade 2 Essential Hypertension (diastolic 100 mm Hg dominates)
• WHO classification table (Optimal → Normal → High Normal → Grade 1/2/3)
• Risk factors: obesity, smoking, sedentary, high salt/fat
• Levels of prevention with DASH diet emphasis (salt <5g/day, K-rich foods, fibre, low saturated fat)
• Tracking = BP percentile rank maintained from childhood to adulthood; rationale for early screening

• Grade 1 HTN (154/96); criteria = 2+ readings on 2+ occasions
• Modifiable: obesity, smoking, sedentary, salty snacks | Non-modifiable: age, sex, family history
• WHO classification (same table)
• Rule of Halves: only 1/8 all hypertensives are adequately controlled at community level
• 4 lifestyle modifications: diet, weight, smoking cessation, exercise
• 4 complications: stroke, CAD/LVH, CKD, hypertensive retinopathy

• Classification by grade + by aetiology (essential vs secondary) + malignant HTN
• Full list of modifiable and non-modifiable risk factors
• Complications by system: cardiac, cerebrovascular, renal, ocular, vascular
• Prevention: ABCDE approach + pharmacotherapy + NPCDCS screening + tertiary rehabilitation

• Public health problem: Childhood/Adolescent Obesity (BMI ≥95th percentile)
• Behavioural risks: screen time + fast food
• Consequences: T2DM + CVD risk (+ psychological)
• School strategies: healthy canteen, compulsory PE, nutrition education, screening, parent involvement, environment
• Level: Secondary prevention (for identified obese child), Primary (school population)
• Programme: NPCDCS + RKSK (Rashtriya Kishor Swasthya Karyakram) + RBSK

• Diagnosis: Pulmonary TB | Programme: NTEP (formerly RNTCP)
• Diagnostic algorithm: Presumptive TB → CBNAAT (first-line) → Smear microscopy → CXR → Classify
• Treatment: 2HRZE + 4HR (daily FDC under DOT); Pyridoxine; Ni-kshay notification + portal
• Family prevention: Contact tracing (husband + son), TPT/IPT for child (INH 6 months), BCG, ventilation, respiratory hygiene, HIV testing, health education, DOT support

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GROUP B - SHORT ANSWER QUESTIONS (10 Marks Each)

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Q1. NCD Risk Factors + WHO STEPwise Surveillance [JNM]

Common Behavioural and Metabolic Risk Factors of NCDs

1. Tobacco use - Smoking (cigarettes, bidi, hookah), smokeless tobacco (gutka, khaini), passive smoking. It is the single largest preventable cause of NCDs, responsible for 7 million deaths/year globally. Causes lung cancer, COPD, CVD, stroke, oral cancers, peripheral vascular disease.
2. Harmful use of alcohol - Regular heavy drinking and binge drinking. Causes liver cirrhosis, several cancers (oro-pharyngeal, oesophageal, hepatic), cardiomyopathy, and raises BP. The dose-response relationship is well established.
3. Physical inactivity (sedentary behaviour) - Less than 150 minutes of moderate activity per week. India's Global Burden of Disease data shows physical inactivity causes 6% of coronary heart disease burden. Contributes to obesity, T2DM, hypertension, colon cancer, osteoporosis.
4. Unhealthy diet - Excess salt (>5g/day), high saturated and trans fats, excess sugar/refined carbohydrates, insufficient fruits and vegetables (<400g/day), insufficient dietary fibre. The "nutrition transition" in India - shift from traditional diet to ultra-processed foods - is a major driver of the NCD epidemic.

1. Raised blood pressure (hypertension) - BP ≥140/90 mm Hg; affects ~28% of Indian adults; the single biggest contributor to CVD mortality
2. Raised blood glucose (hyperglycaemia/diabetes) - Fasting glucose ≥7.0 mmol/L or OGTT 2h ≥11.1 mmol/L; India has 77 million diabetics (2nd globally)
3. Raised blood lipids (dyslipidaemia) - Elevated LDL, total cholesterol, triglycerides; low HDL; drives atherosclerosis
4. Overweight and obesity - BMI ≥25 (overweight) or ≥30 (obese); central obesity (waist ≥90 cm men, ≥80 cm women in Asians)

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WHO STEPwise Approach to NCD Surveillance (STEPS)

STEP 1 - Questionnaire (Behavioural/Self-Reported Data)

• Tobacco use: current smoker, ex-smoker, type, quantity, duration
• Alcohol consumption: frequency, amount, binge drinking
• Physical activity: occupation, leisure, travel (International Physical Activity Questionnaire - IPAQ)
• Dietary intake: fruit and vegetable servings, salt use, fat type
• History of raised BP, blood sugar, lipids: self-reported diagnosis
• Medication use: antihypertensives, hypoglycaemics, lipid-lowering drugs
• Family history of CVD, diabetes

STEP 2 - Physical Measurements (Anthropometric and BP Measurements)

• Height and Weight → BMI calculation
• Waist circumference (central obesity)
• Hip circumference → waist:hip ratio
• Blood pressure (two measurements, seated, with validated device)
• Heart rate

STEP 3 - Biochemical Measurements (Blood/Urine Samples)

• Fasting blood glucose (capillary or venous)
• Total blood cholesterol
• HDL cholesterol → derived LDL and total: HDL ratio
• Triglycerides
• HbA1c (in expanded version)
• Urinary sodium and creatinine (for population salt intake estimation)
• Serum creatinine (renal function)

• Modular design: Step 1 is mandatory; Steps 2 and 3 added as capacity allows
• Minimum sample size: 2,500-4,000 adults aged 15-69 years
• Cluster random sampling used
• Enables tracking of trends over time
• India conducted STEPS surveys (2017-18, published 2023) documenting national NCD risk factor prevalence

• Hypertension: 28.5% of adults
• Diabetes: 11.4% (FBG-based)
• Tobacco use: 28.6%
• Obesity (BMI ≥30): 11.4%
• Low fruit/vegetable intake: 98% adults did not meet WHO recommendations

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Q2. HTN Case - 40-year-old obese male, BP 146/100 mm Hg (2+8=10) [MMC]

Classification of Blood Pressure (2 marks)

• Systolic 146 → Grade 1 (140-159)
• Diastolic 100 → Grade 2 (100-109)
• Higher category applies → Grade 2 Hypertension

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Management with Special Emphasis on Lifestyle and Diet (8 marks)

• Repeat BP on 2 separate visits, 2 readings each
• Rule out white coat hypertension
• Assess target organ damage: ECG, fundoscopy, urine protein, creatinine, lipid profile, fasting glucose

1. Salt restriction:
   • Reduce to <5 g NaCl/day (WHO target) or <6 g/day (British HTN Society)
   • Avoid added salt at table; reduce salt in cooking
   • Avoid processed/packaged foods, salty snacks (crisps, namkeen), pickles, papads, instant noodles - all high in hidden sodium
   • Expected BP reduction: systolic 2-8 mm Hg per 6 g/day reduction
2. Reduce saturated and trans fats:
   • Limit red meat, full-fat dairy, ghee, butter, palm oil
   • Replace with mono/polyunsaturated fats: mustard oil, olive oil, groundnut oil (in moderation)
   • Avoid vanaspati (trans fat), deep-fried foods, bakery products
   • Total fat <30% of calories; saturated fat <10%
3. Increase fruits and vegetables:
   • ≥5 servings (400g) per day
   • Rich source of potassium (antagonises sodium): bananas, tomatoes, spinach, coconut water, lentils, sweet potatoes
   • Target potassium: 90 mmol/day (can reduce SBP by 2-3 mm Hg)
4. Increase dietary fibre:
   • ≥25 g/day: whole grains (brown rice, whole wheat chapati, oats), vegetables, pulses, fruits
   • Fibre reduces both cholesterol and BP, and aids weight reduction
5. Restrict alcohol:
   • Not more than 2 standard units/day for men (1 unit = 10 g alcohol)
   • Complete abstinence if possible; alcohol raises systolic BP
6. Increase low-fat dairy:
   • Calcium and magnesium have BP-lowering effects
   • Skimmed milk, low-fat yogurt preferred
7. Calorie restriction for weight loss:
   • This patient is obese - calorie-restricted diet is critical
   • 500-1000 kcal/day deficit to achieve 0.5-1 kg/week weight loss
   • Target BMI <25 kg/m²; even 5-10% weight loss reduces SBP 5-20 mm Hg per 10 kg

• 150 minutes/week of moderate-intensity aerobic exercise (brisk walking, cycling, swimming)
• Or 75 minutes/week of vigorous exercise
• Resistance/strength training 2 days/week
• Avoid prolonged sitting; break sedentary periods every 30 minutes
• Expected BP reduction: 4-9 mm Hg

• Complete and immediate cessation
• Counselling (5 A's: Ask, Advise, Assess, Assist, Arrange)
• Nicotine Replacement Therapy (NRT) patches, gum if needed
• Pharmacotherapy: Varenicline or Bupropion if counselling insufficient
• Note: Smoking does not cause sustained hypertension but dramatically multiplies CVD risk in a hypertensive patient - Framingham risk score doubles with smoking + HTN

• Yoga, pranayama, meditation: evidence for modest BP reduction
• Cognitive behavioural strategies; adequate sleep (7-8 hours)
• Reduce work-life stressors

• For Grade 2 HTN: initiate lifestyle modification AND drug therapy simultaneously (no waiting period unlike Grade 1)
• First-line agents (NPCDCS/JNC 8/WHO guidelines):
  • Amlodipine 5 mg OD (CCB - preferred for isolated systolic or obese patients)
  • Telmisartan 40-80 mg OD (ARB - good for obese/diabetics, renoprotective)
  • Hydrochlorothiazide 12.5-25 mg OD (thiazide diuretic)
  • Combination therapy preferred for Grade 2 (2 drugs from different classes)
• Target BP: <130/80 mm Hg (AHA 2017) or <140/90 mm Hg (JNC 8 / older guidelines)

• Review in 4 weeks: assess lifestyle changes, medication tolerance, BP response
• If BP not at target after 1 month: dose escalation or add 3rd drug
• Annual: ECG, urine albumin-creatinine ratio, eGFR, lipid profile, fasting glucose

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Q3. Classification of Obesity (WHO) | Epidemiological Determinants | Prevention (3+4+3) [MldMCH]

WHO Classification of Obesity (3 marks)

• Waist circumference: Men ≥90 cm; Women ≥80 cm
• Waist:Hip ratio: Men >0.90; Women >0.85

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Epidemiological Determinants of Obesity (4 marks)

• Age: Prevalence increases with age; adiposity increases with age even at stable weight (muscle loss, fat redistribution)
• Sex: Women generally have higher fat percentage; men accumulate central fat; post-menopausal women gain abdominal fat
• Genetic factors: Heritability of BMI is 40-70%; multiple gene variants (FTO gene, MC4R); single gene disorders (leptin deficiency, PCOS-linked genes) are rare
• Psychological factors: Emotional eating, binge eating disorder, depression, stress-induced cortisol elevation promotes adipogenesis
• Physiological: Hypothyroidism, Cushing's syndrome, PCOS, hypothalamic disorders (rare but important secondary causes)
• Hormonal: Leptin resistance, ghrelin dysregulation, insulin resistance

• Dietary patterns: High calorie-dense ultra-processed foods; increased portion sizes; sugar-sweetened beverages; eating out frequently
• Physical inactivity: Sedentary occupation and leisure; screen time; urban living with low walkability
• Sleep: Short sleep (<6 hours) increases ghrelin (appetite hormone) and decreases leptin; strong independent risk factor for obesity
• Socio-economic status: In LMICs like India, obesity is more common in urban higher-SES groups initially; shifts to lower-SES with economic development
• Urbanisation and nutrition transition: Shift from traditional high-fibre, plant-based diets to processed, calorie-dense Western-style foods

• Obesogenic environment: Built environment lacking parks, sidewalks, safe play areas; abundance of fast food outlets
• Marketing and advertising: Aggressive marketing of junk food, especially to children
• Cultural factors: Food preferences; body image perception (obesity seen as sign of prosperity in some communities)
• Medications: Corticosteroids, antipsychotics (olanzapine, clozapine), insulin, sulfonylureas, beta-blockers can cause weight gain

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Preventive Measures for Obesity (3 marks)

• National food policies: food labelling regulations (FSSAI nutrition labelling), front-of-pack labelling, sugar tax on SSBs, restrictions on junk food advertising to children
• Urban planning: parks, cycling infrastructure, walkable neighbourhoods

• Population strategy: Mass health education on healthy eating and physical activity through media (Eat Right India campaign, Fit India Movement)
• School health programmes: healthy tiffin policies, ban on junk food in school canteens, compulsory physical education, cooking and nutrition education
• High-risk strategy: Targeted interventions for children of obese parents, those with metabolic syndrome risk, women with PCOS
• Breastfeeding promotion (protective against childhood obesity)
• POSHAN Abhiyan: address nutrition in the first 1000 days

• Screening: Regular BMI measurement at health facilities (opportunistic screening under NPCDCS)
• Treatment of overweight before obesity develops:
  • Structured lifestyle intervention (diet + exercise + behaviour change)
  • Referral to dieticians and physical therapists
  • Pharmacotherapy (Orlistat): BMI ≥30 or ≥27 with comorbidities
• Very Low Calorie Diets (VLCDs) under medical supervision

• Bariatric surgery: BMI ≥40 or ≥35 with obesity-related comorbidities (T2DM, HTN, OSA)
• Management of obesity complications: DM, HTN, OSA (CPAP), joint disease (physiotherapy)
• Psychosocial support and rehabilitation

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Q4. Type 2 Diabetes Mellitus - Rising Trends (1+3+3+3) [SRIMS]

i. Two Epidemiological Determinants of Diabetes (1 mark)

1. Genetic susceptibility: Indians have a "diabetic genotype" - the "thrifty gene hypothesis" (Neel) suggests genes that were adaptive during feast-famine cycles become maladaptive when food is abundant. Family studies show 45% risk if both parents diabetic. Monozygotic twins have 70-90% concordance for T2DM.
2. Urbanisation and sedentary lifestyle: India's epidemiological transition has brought rapid urbanisation with calorie-dense diets, physical inactivity, and chronic stress - all precipitating T2DM in a genetically susceptible population. India has 77 million diabetics (2021), highest absolute numbers after China.

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ii. Risk Factors of Type 2 Diabetes (3 marks)

• Age ≥45 years (risk rises sharply; Indians develop T2DM a decade earlier than Caucasians)
• Family history (first-degree relative with DM)
• Ethnicity (South Asians, particularly Indians - higher visceral adiposity at lower BMI)
• Gestational diabetes history
• History of polycystic ovarian syndrome (PCOS)
• Low birth weight / intrauterine programming (Barker hypothesis)

• Obesity (especially central/abdominal obesity) - most important modifiable risk factor; visceral fat causes insulin resistance through adipokine dysregulation and ectopic fat deposition
• Physical inactivity - skeletal muscle is the primary site of glucose disposal; inactivity causes insulin resistance in muscle
• Unhealthy diet - high refined carbohydrates, saturated fats, low fibre; high glycaemic index foods
• Pre-diabetes / Impaired Fasting Glucose (IFG): FBG 100-125 mg/dL; converts to DM at 5-10%/year
• Impaired Glucose Tolerance (IGT): 2h OGTT 140-199 mg/dL
• Hypertension - shares pathophysiology via insulin resistance
• Dyslipidaemia - high triglycerides, low HDL
• Tobacco use - increases insulin resistance
• Psychosocial stress - cortisol excess impairs insulin sensitivity
• Sleep deprivation - increases ghrelin, cortisol, impairs glucose metabolism

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iii. BMI Classification - Asian Standard (3 marks)

• Higher percentage body fat at the same BMI vs Caucasians
• Greater central adiposity (visceral fat)
• Higher metabolic risk at lower BMI levels
• T2DM and CVD risk begins at BMI 23 in Asians (vs 25 in Caucasians)

• Men: ≥90 cm = abdominal obesity
• Women: ≥80 cm = abdominal obesity

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iv. Primordial Prevention vs Primary Prevention (3 marks)

• Defined by Strasser (1978) and Fuster (1994); later incorporated into Leavell and Clark's model
• Aims to prevent the emergence and establishment of risk factors themselves in the community before any individual develops them
• Acts on the social, economic, environmental and cultural conditions that give rise to risk factors
• Example for T2DM/NCDs:
  • National food policies reducing sugar in processed foods
  • Urban planning promoting physical activity (parks, cycling lanes)
  • Banning trans fats (as India did in 2022 via FSSAI)
  • Front-of-pack nutrition labelling
  • Restrictions on marketing junk food to children
  • Supporting breastfeeding policies (protects against childhood obesity)
• Target: Entire healthy population; changes the population distribution of risk factors

• Aims to prevent the occurrence of disease in individuals who are already exposed to or possess risk factors
• Intervenes after risk factors have developed, before disease onset
• Two approaches (Geoffrey Rose):
  • Population strategy: Reduce risk in everyone (e.g., national healthy eating campaigns, Fit India Movement, mid-day meal improvements)
  • High-risk strategy: Target those with pre-diabetes, family history, obesity (e.g., intensive lifestyle intervention reduces DM incidence by 58% - Diabetes Prevention Program; by 29% - Da Qing Study)
• Specific examples for T2DM: Weight reduction programmes, structured exercise prescription, dietary counselling for pre-diabetics, metformin for very high-risk pre-diabetics

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Q5. Rule of Halves + NP-NCD Screening and Interventions (4+6=10) [NRS]

Rule of Halves in Hypertension Epidemiology (4 marks)

ALL hypertensives in the community (100%)
        ↓ Only 50% are AWARE of their condition
50% detected / aware
        ↓ Only 50% of those detected RECEIVE TREATMENT
25% on treatment
        ↓ Only 50% of those on treatment are ADEQUATELY CONTROLLED
12.5% (≈ 1/8) with BP under control

• Despite hypertension being detectable and treatable, 87.5% of all hypertensives remain at continued cardiovascular risk
• This represents the iceberg phenomenon of hypertension - the majority of disease burden is invisible/unmanaged
• In India, the situation is even worse: STEPS 2017-18 data showed only 45% of hypertensives were aware, 41% of aware were treated, and only 15% of treated patients had controlled BP
• The rule highlights THREE distinct failure points:
  1. Awareness gap: Asymptomatic nature of HTN means detection requires active screening
  2. Treatment gap: Even when diagnosed, barriers to starting treatment (cost, access, denial)
  3. Control gap: Medication non-adherence, suboptimal dosing, lack of follow-up

• Strengthens the case for universal opportunistic screening
• Community-based HTN management programs (UDAY, Jan Aushadhi)
• Fixed-dose combinations improve adherence
• Task-shifting to community health workers (ASHAs) for BP measurement
• Telemedicine for follow-up in rural areas

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Screening Protocols and Key Interventions under NP-NCD (6 marks)

• All individuals ≥30 years attending any government health facility (PHC, CHC, DH) are to be screened for hypertension - "opportunistic screening"
• Community-level screening by ASHA workers and ANMs using validated semi-automated BP devices
• Annual screening in the general population ≥30 years
• More frequent (6-monthly) in high-risk groups: obese, diabetics, family history, previous high-normal BP

1. Patient seated, 5 minutes rest
2. Two BP readings taken with an interval of 1-2 minutes
3. Average of two readings recorded on CBAC form (Community Based Assessment Checklist)
4. Cut-offs: Systolic ≥140 OR Diastolic ≥90 → refer for confirmation

• Two elevated readings on two separate occasions (2 weeks apart)
• Exclude secondary causes: renal function, urine albumin, thyroid profile

• Community-Based Assessment Checklist completed by ASHAs for every household
• Risk scoring for NCDs (HTN, DM, CVD, cancer, COPD) during door-to-door visits
• High-risk individuals linked to NCD clinics

• Upgraded Sub-Centres and Primary Health Centres under Ayushman Bharat
• Provide NCD screening, early diagnosis, management and follow-up at primary level
• Population Health Management (12 services including HTN, DM, mental health, oral health, eye care)
• Telemedicine consultations available

• Dedicated NCD Clinics established at District Hospitals and CHCs
• Provide investigation (ECG, lipid profile, blood glucose, renal function), specialist consultation, medication
• Free essential drugs under PMBJP (Jan Aushadhi): Amlodipine, Atenolol, Enalapril, Losartan, HCTZ

• Step 1: Single drug (Amlodipine 5mg OD or Telmisartan 40mg OD)
• Step 2: Combination (Amlodipine + Telmisartan or + HCTZ)
• Step 3: Triple therapy with specialist referral
• Fixed-dose combinations to improve adherence

• Patients registered on Ni-kshay / NIKSHAY-like NCD portal
• Monthly follow-up for first 3 months; 3-monthly thereafter if controlled
• ASHA tracks defaulters; home visits

• World Hypertension Day (May 17), World Heart Day (September 29) campaigns
• Village Health and Nutrition Day (VHND) for awareness
• Mass media, social media campaigns on healthy diet, physical activity, tobacco cessation

• NPHCE (elderly care) - HTN is leading cause of disability in elderly
• NHM integration for drugs, diagnostics
• Tobacco control (COTPA enforcement, NTCP)
• Fit India Movement, Eat Right India campaign

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Q6. Danger Signals of Cancer | Breast Cancer Epidemiology | Levels of Prevention (4+3+3) [NBMCH]

Danger Signals of Cancer (4 marks) - "CAUTION US" Mnemonic

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Epidemiology of Breast Cancer (3 marks)

• Breast cancer surpassed lung cancer as the #1 cancer globally by incidence in 2020 (GLOBOCAN)
• 2.3 million new cases (2020); 11.7% of all cancers
• 685,000 deaths; 5th leading cause of cancer death worldwide
• Highest incidence in transitioned countries: Australia/NZ, Western Europe, North America (>80/100,000)
• Belgium has the world's highest incidence

• #1 cancer in Indian women - 178,361 new cases in 2020 (13.6% of all cancers)
• Incidence: 25.8 per 100,000 population
• Mortality: 13.3 per 100,000 population; 90,408 deaths in 2020
• Key feature: Occurs a decade earlier in Indian women (mean age 42 years) vs Western women (mean age 53 years)
• Survival is 2.7x lower when detected at Stage IV vs Stage I - underlining importance of early detection

• Age: Uncommon <35 years; rapid rise 35-50 years; bimodal distribution (dip at menopause, rise again >65)
• Family history: Especially first-degree relative with premenopausal breast cancer; BRCA1/BRCA2 mutations
• Reproductive factors: Early menarche (<12 years), late menopause (>55 years), nulliparity, late age at first full-term pregnancy (>30 years), no breastfeeding
• Hormonal factors: Exogenous oestrogen (HRT, OCP for >10 years); oestrogen drives proliferation
• Obesity: Post-menopausal obesity - adipose tissue as oestrogen source
• Lifestyle: Physical inactivity, alcohol consumption
• Prior breast biopsy showing atypical hyperplasia
• Radiation exposure (chest radiation, especially in adolescence - e.g., mantle field for Hodgkin's)
• Socio-economic status: Higher SES groups (related to reproductive patterns - later first birth)

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Modes of Intervention at Different Levels of Prevention (3 marks)

• Policies addressing obesity (sugar taxes, food labelling), physical inactivity, alcohol
• Cultural encouragement of early marriage and childbearing (where appropriate)
• Reduction of environmental carcinogens

• Breastfeeding promotion: Each year of breastfeeding reduces breast cancer risk by ~4.3% (IARC); also protects the breastfed child
• Healthy weight maintenance: Reduce post-menopausal obesity
• Limit alcohol consumption
• Regular physical activity: 150 min/week reduces risk by 10-20%
• Judicious use of HRT: Minimise duration; use lowest effective dose; avoid combined oestrogen-progesterone if possible
• Chemoprevention (high-risk women): Tamoxifen or Raloxifene for 5 years in women with high genetic/family risk (BRCA1/2 carriers); reduces risk by ~50%
• Prophylactic surgery: Bilateral mastectomy/oophorectomy for BRCA1/2 mutation carriers with very high lifetime risk

• Clinical breast examination (CBE): Most practical in low-resource settings; conducted by trained ASHA/ANM during home visits and camp screenings; recommended annually for women >30 years (NPCDCS)
• Breast self-examination (BSE): Monthly; 5-7 days after menstruation; empowers women, though insufficient alone as sole screening method
• Mammography: Gold standard screening tool; recommended every 2 years for women 50-69 years (WHO); every 1-2 years for 40-69 (ACS); sensitivity 70-90%; low availability in India
• Ultrasound: Used in younger women with dense breasts; not standalone population screening
• FNAC/biopsy for suspicious lesions (diagnosis, not screening)
• NPCDCS screening: Opportunistic CBE at all government health facilities for women ≥30 years

• Multidisciplinary cancer care: surgery (BCS/mastectomy), radiotherapy, chemotherapy, hormone therapy (tamoxifen, aromatase inhibitors), targeted therapy (trastuzumab for HER2+)
• Palliative care and pain management for advanced disease
• Psychosocial rehabilitation: support groups, counselling
• Breast reconstruction and prosthetics
• Lymphedema management post-axillary dissection

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Q7. T2DM Clinical Case - 58-year-old obese male (2+8+5) [JMNMCH]

a) Provisional Diagnosis and Justification (2 marks)

• Clinical triad of diabetes: Polydipsia (increased thirst) + Polyuria (frequent urination) + Weight loss - classic symptom triad
• Fasting blood glucose 160 mg/dL (8.9 mmol/L): Diagnostic criterion met - FBG ≥126 mg/dL (7.0 mmol/L) on two occasions = diabetes mellitus (WHO 2019 criteria)
• Type 2 (not Type 1): Age 58 years, obese, sedentary - typical Type 2 profile (insulin resistance predominates); Type 1 more common in younger lean individuals with acute onset, DKA
• Epidemiological context: Male, obese (highest risk), sedentary lifestyle, age >45 - all strong risk factors for T2DM

• FBG ≥126 mg/dL (7.0 mmol/L) on 2 occasions, OR
• 2-hour OGTT ≥200 mg/dL (11.1 mmol/L), OR
• Random blood glucose ≥200 mg/dL with symptoms, OR
• HbA1c ≥6.5% (48 mmol/mol)

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b) Levels of Prevention and Modes of Intervention (8 marks)

• Food industry regulations: reduce sugar content in processed foods; food labelling
• Urban design for active living; subsidy for healthy foods
• Anti-obesity mass media campaigns (Eat Right India, Fit India Movement)
• School health nutrition programmes

• Healthy eating campaigns (reduce refined carbs, sugar-sweetened beverages, saturated fats)
• Physical activity promotion (PMNRBM - physical activity for all)
• Weight reduction programmes at community level
• Tobacco cessation (smoking increases insulin resistance)

• Intensive lifestyle intervention: can prevent/delay T2DM by 58% (DPP trial, USA) and 31% (Da Qing study, China)
• Target 7% weight loss + 150 min/week exercise for pre-diabetics
• Metformin for high-risk pre-diabetics (IFG + IGT + BMI ≥35 + age <60)
• NDPP (National Diabetes Prevention Programme) - India's platform for this

• Opportunistic screening at all government facilities for ≥30-year-olds (NPCDCS)
• FBG, 2h OGTT, HbA1c; urine glucose (poor sensitivity)
• Screen family members (father/mother, siblings, children >10 years)

• Medical Nutrition Therapy (MNT):
  • Calorie-restricted diet: 1400-1600 kcal/day for obese male
  • Carbohydrate: 45-60% calories; prefer low GI foods (brown rice, whole wheat, oats, lentils)
  • Avoid sugar, sweets, white rice, maida products, fruit juices, SSBs
  • Protein: 15-20% calories; fibre ≥25g/day
  • 3 main meals + 2 small snacks; do not skip meals
  • Small frequent meals prevent postprandial spikes
• Physical Activity:
  • 30-45 min brisk walking daily (150-300 min/week)
  • Resistance training 2-3 days/week
  • Monitor blood glucose before/after exercise
  • Target: 5-10% weight loss (each kg lost reduces HbA1c by ~0.1%)
• Smoking cessation: Complete cessation; nicotine therapy if needed

• Metformin 500 mg OD with meals (first-line for T2DM; reduces hepatic glucose output; weight neutral; no hypoglycaemia)
• Titrate to 500 mg BD-TDS or 1g BD (max 2.5g/day) over 4-8 weeks
• Add Glipizide/Glimepiride (sulfonylurea) if glycaemia not controlled
• Or DPP-4 inhibitor (Teneligliptin, Sitagliptin) for older patients (less hypoglycaemia)
• SGLT2 inhibitor (Empagliflozin, Dapagliflozin) if CVD risk high - cardiorenal protective

• HbA1c every 3 months; target <7.0% (or <8.0% for elderly/comorbid)
• FBG target: 70-130 mg/dL; post-meal (2h) <180 mg/dL
• Annual: lipid profile, renal function (eGFR, urine ACR), fundoscopy, foot examination, BP
• Aspirin 75 mg/day if CVD risk high

• Cardiovascular: Statin therapy (Atorvastatin 20-40 mg); BP control (<130/80); aspirin
• Renal: ACE inhibitor/ARB for microalbuminuria (Enalapril/Telmisartan)
• Retinopathy: Annual fundoscopy; laser photocoagulation for proliferative retinopathy
• Neuropathy: Pregabalin, Gabapentin, Duloxetine for painful diabetic neuropathy; foot care
• Foot care: Daily inspection, proper footwear, podiatry referral for ulcers; prevent amputation
• Rehabilitation: Diabetic education programme; self-management support
• Palliative: End-stage renal disease (dialysis), advanced CVD (cardiac rehab)

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c) Screening Strategies for T2DM (5 marks)

• T2DM has a long asymptomatic phase (7-12 years on average from onset to diagnosis)
• Complications (retinopathy, nephropathy) may already be present at diagnosis if screening not done
• Cost-effective: identifying pre-diabetes and early DM allows intervention before complications

1. Age ≥45 years
2. BMI ≥23 kg/m² (Asian cut-off)
3. Sedentary lifestyle
4. Family history of diabetes (1st-degree relative)
5. Previous gestational diabetes or baby >4 kg birthweight
6. Women with PCOS
7. Hypertension (BP ≥140/90 mm Hg)
8. Dyslipidaemia (HDL <35 mg/dL or TG >250 mg/dL)
9. Pre-diabetes (IFG or IGT) on prior testing
10. Premature atherosclerosis / CVD history

• Normal result: Repeat every 3 years (low-risk); every year (high-risk/pre-diabetes)
• Pre-diabetes identified: Lifestyle intervention + repeat testing every 6-12 months

• CBAC (Community Based Assessment Checklist) filled by ASHA for all adults ≥30 years at household level
• High-risk individuals referred to nearest Health and Wellness Centre for FBG testing
• Positive cases linked to NCD clinic at PHC/CHC/District Hospital
• Free drugs (Metformin, Glipizide) under PMBJP Jan Aushadhi

• IFG (100-125 mg/dL) or IGT (2h OGTT 140-199 mg/dL) = Pre-diabetes
• Lifestyle intervention: 7% weight loss + 150 min/week physical activity → 58% reduction in progression to DM
• HbA1c 5.7-6.4% = Pre-diabetes (ADA); 6.0-6.4% (WHO)

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GROUP A – LAQ (15 Marks Each)

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Q1. Latent Period | NCD Risk Factors | Prevention of One NCD (2+3+10) [JIMSH]

Part A: Latent Period (2 marks)

• Also called "induction period" or "pre-clinical phase"
• Extremely long in NCDs - often 10-40 years (e.g., atherosclerosis begins in teens, manifests as MI in 40s-60s; radiation-induced cancers may appear 20-40 years after exposure)
• Contrast with communicable diseases where latent period is days to weeks
• The long latent period provides a prolonged window of opportunity for primary prevention
• During this phase, the "web of causation" (MacMahon & Pugh) is already active - risk factors are operating silently
• Example: Hypertension - risk factors (high salt, obesity, sedentary life) accumulate over years before BP becomes measurably elevated

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Part B: Risk Factors of NCDs (3 marks)

1. Age (risk increases with advancing age)
2. Sex/Gender (gender differences in disease pattern and timing)
3. Genetic predisposition / family history
4. Ethnicity / race (e.g., South Asians higher DM risk; Blacks higher HTN risk)

1. Tobacco use - smoking, bidi, hookah, smokeless tobacco (gutka, khaini)
2. Harmful use of alcohol
3. Physical inactivity - sedentary lifestyle, <150 min/week moderate activity
4. Unhealthy diet - excess salt, saturated and trans fats, low fruits and vegetables, excess sugar

1. Raised blood pressure (hypertension ≥140/90 mm Hg)
2. Raised blood glucose (hyperglycaemia / diabetes mellitus)
3. Raised blood lipids (dyslipidaemia - high LDL, low HDL, high TG)
4. Overweight and obesity (BMI ≥25; central obesity - waist ≥90 cm men, ≥80 cm women in Asians)

• Air pollution (indoor - biomass fuels; outdoor - PM2.5)
• Psychosocial stress (chronic stress, depression)
• Low socioeconomic status / poverty

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Part C: Preventive and Control Methods for Hypertension as per National Guidelines (10 marks)

Primordial Prevention

• National food policies: FSSAI regulations on salt reduction in processed foods; front-of-pack labelling; ban on trans fats (India 2022)
• Tobacco control: COTPA enforcement; pictorial warnings; taxation; smoke-free public places
• Urban planning: parks, cycling lanes, safe walking infrastructure
• School health nutrition programmes: remove junk food from school canteens
• Restrict junk food advertising targeting children

Primary Prevention

• Dietary/Nutritional interventions:
  • Reduce salt (NaCl) intake to <5 g/day (Indian average is 9-12 g/day)
  • Reduce saturated fat intake (<10% of calories); replace with unsaturated fats
  • Increase fruits and vegetables ≥400 g/day (5 servings)
  • Adequate dietary potassium (90 mmol/day): bananas, green leafy vegetables, pulses
  • Restrict alcohol consumption
  • Increase dietary fibre ≥25 g/day
• Weight control: Prevent and correct overweight/obesity (BMI >25); even 5-10% weight reduction reduces SBP by 5-20 mm Hg per 10 kg lost
• Physical activity promotion: ≥150 minutes/week moderate intensity aerobic exercise; reduces SBP by 4-9 mm Hg
• Behavioural changes: Smoking cessation; stress reduction (yoga, meditation); modify sedentary lifestyle
• Health education (IEC): Community mobilisation; mass media campaigns; public awareness on risk factors; World Hypertension Day (May 17) activities
• Self-care: Teach patients/community to measure their own BP; keep log-books; reduces burden on health system

• Screening of high-risk groups: obese individuals, diabetics, those with family history, smokers
• Intensive lifestyle counselling for those with high-normal BP (130-139/85-89 mm Hg)
• Regular BP monitoring every 6-12 months

Secondary Prevention

• Opportunistic screening: ALL individuals ≥30 years attending any government health facility (PHC, CHC, DH) to have BP measured - CBAC (Community Based Assessment Checklist)
• Community screening: ASHA workers and ANMs conduct door-to-door BP screening using validated semi-automated devices
• Refer if SBP ≥140 OR DBP ≥90 mm Hg on two readings

• Confirm on two separate occasions, two readings each
• Rule out white coat hypertension
• Assess target organ damage: ECG, fundoscopy, urine protein, serum creatinine, lipid profile

• Grade 1: 3-6 months lifestyle modification trial; then add drugs if uncontrolled
• Grade 2/3: Initiate lifestyle + pharmacotherapy simultaneously
• First-line drugs (free under PMBJP Jan Aushadhi):
  • Amlodipine (CCB) 5 mg OD
  • Telmisartan (ARB) 40-80 mg OD
  • Hydrochlorothiazide (thiazide) 12.5-25 mg OD
• Combination therapy for Grade 2 (2 drugs from different classes)
• Target BP: <140/90 mm Hg (or <130/80 mm Hg if DM/CKD)

• Health and Wellness Centres (HWCs): Upgraded PHCs/Sub-centres providing NCD screening, management, follow-up
• NCD Clinics at CHCs and District Hospitals: Investigations, specialist consultation, medication
• Ni-kshay-like NCD portal for patient registration and follow-up tracking
• Task-shifting to community health workers for BP measurement and adherence monitoring

Tertiary Prevention

• Cardiovascular: Statin therapy; aspirin for high CVD risk; management of LVH, heart failure
• Cerebrovascular: Stroke rehabilitation (physiotherapy, speech therapy, occupational therapy)
• Renal: ACE inhibitor/ARB for proteinuria; renal replacement therapy (dialysis) for end-stage renal disease
• Ocular: Laser photocoagulation for hypertensive retinopathy
• Multidisciplinary care; palliative care for end-stage complications

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Q2. Hypertension Case - 35-year-old sedentary obese male, smoker, BP 126/100 mm Hg (1+2+4+6+2=15) [ICARE]

Provisional Diagnosis (1 mark)

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Classification of Blood Pressure (2 marks)

• Systolic 126 → "Normal" (120-129)
• Diastolic 100 → "Grade 2" (100-109)
• Rule: When systolic and diastolic fall in different categories, the higher category is selected
• Classification: Grade 2 Hypertension

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Risk Factors of Hypertension (4 marks)

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Levels of Prevention with Special Emphasis on Diet (6 marks)

Primordial Prevention (community/policy level)

• National salt reduction policy in processed foods (FSSAI)
• Front-of-pack nutritional labelling
• Tobacco taxation and regulation (COTPA)
• Urban design promoting physical activity

Primary Prevention

1. Salt restriction - most important dietary intervention:
   • Reduce to <5 g NaCl/day (one level teaspoon)
   • Current Indian intake: 9-12 g/day
   • Expected BP reduction: 2-8 mm Hg systolic per 6g reduction
   • Practical advice: No added salt at table; reduce salt in cooking; avoid processed/packaged foods (biscuits, chips, instant noodles, canned foods - all contain hidden sodium); avoid pickles, papads, salty snacks
2. Increased fruits and vegetables:
   • ≥5 servings (400g) per day
   • Rich in potassium - antagonises sodium effects on BP
   • Sources: bananas, tomatoes, spinach, amla, citrus fruits, sweet potatoes, coconut water
   • Target: 90 mmol potassium/day (reduces SBP ~2-3 mm Hg)
3. Reduce saturated and trans fats:
   • Limit red meat, full-fat dairy, ghee, butter, palm oil, coconut oil (in excess)
   • Eliminate vanaspati (trans fat)
   • Avoid fried foods, bakery products, fast food
   • Replace with: mustard oil, groundnut oil, olive oil (unsaturated fats)
   • Total fat <30% of calories; saturated fat <10%
4. Increase dietary fibre:
   • ≥25 g/day
   • Sources: whole wheat chapati/bread, brown rice, oats, dalia (broken wheat), pulses (dal), vegetables, fruits
   • Reduces cholesterol absorption and BP
5. Alcohol restriction:
   • Not more than 2 standard units/day for men (1 unit = 10 g alcohol = 1 small peg whisky = 330 ml beer)
   • Complete abstinence preferred
   • Binge drinking especially harmful
6. Calorie restriction for this obese patient:
   • 500-1000 kcal/day deficit to achieve 0.5-1 kg/week weight loss
   • Target BMI <25 kg/m² (Asian cut-off: <23 kg/m²)
   • 5-10% weight loss reduces SBP by 5-20 mm Hg per 10 kg
   • Six small meals instead of three large meals
   • Avoid sugar-sweetened beverages, sweets, mithai, white rice excess
7. Increase calcium and magnesium:
   • Low-fat milk/curd (calcium); nuts, seeds, green vegetables (magnesium)
   • Both minerals have modest BP-lowering effects

• Physical activity: ≥150 min/week moderate exercise (brisk walking, cycling, swimming); reduces SBP 4-9 mm Hg
• Smoking cessation: Complete and immediate; 5As counselling (Ask, Advise, Assess, Assist, Arrange); NRT if needed
• Stress management: Yoga, pranayama, meditation; adequate sleep (7-8 hours)

Secondary Prevention (for this patient - Grade 2 HTN)

• Confirm diagnosis on two separate occasions
• Assess target organ damage and secondary causes
• For Grade 2: start lifestyle modifications AND pharmacotherapy simultaneously (no waiting period)
• Pharmacotherapy: Amlodipine 5 mg OD ± Telmisartan 40 mg OD (combination preferred for Grade 2)
• Follow-up every 4 weeks until BP controlled; 3-monthly thereafter

Tertiary Prevention

• Prevention of target organ damage: annual ECG, fundoscopy, urine albumin:creatinine ratio, eGFR
• Statin for CV risk reduction; aspirin if CVD risk >10% (Framingham)
• Rehabilitation after stroke/MI if complications develop

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Tracking of Blood Pressure (2 marks)

• Observed consistently in longitudinal studies from childhood through adolescence to adult life
• Tracking is stronger for systolic BP than diastolic BP
• A child in the top quintile of BP distribution at age 10 has a significantly higher probability of being hypertensive at age 40-50 than a child in the bottom quintile
• The phenomenon is independent of gender
• Provides the scientific rationale for:
  • Measuring BP in school health programmes and paediatric check-ups
  • Early identification of "pre-hypertensive children"
  • Primordial and primary prevention beginning in childhood - lifestyle habits established in childhood track into adulthood
• Supports the concept that hypertension prevention must start early in life
• Family studies show BP levels among first-degree relatives are significantly correlated - genetic + environmental tracking combined

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Q3. HTN Case - 52-year-old male school teacher, BP 154/96 mm Hg [DHGMCH]

Diagnosis and Criteria (2 marks)

• Systolic 154 mm Hg → falls in Grade 1 (140-159)
• Diastolic 96 mm Hg → falls in Grade 1 (90-99)
• Both fall in Grade 1 → Grade 1 Hypertension

• Blood pressure ≥140/90 mm Hg on the average of two or more readings taken on two or more separate occasions (minimum 2-week interval)
• Patient should not be on antihypertensive medications and not acutely ill
• Measurement technique: seated, 5 minutes rest, arm at heart level, validated device
• Both arms measured at first visit; higher reading used; subsequent readings from the higher arm
• Single elevated reading is NOT diagnostic - must be confirmed
• Exclude white coat hypertension (ambulatory BP monitoring if suspected)

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Modifiable and Non-Modifiable Risk Factors in This Patient (3 marks)

• Age: 52 years - risk increases progressively with age; arteriosclerosis and reduced vascular compliance
• Sex: Male - men have higher BP than pre-menopausal women of same age
• Genetic/Family history: Father had hypertension and died of stroke at 60 - strong positive family history; polygenic inheritance (45% risk if both parents hypertensive)

• Obesity - clearly stated; central obesity especially increases HTN risk via RAAS activation and insulin resistance
• Smoking: 10 cigarettes/day for 20 years (10 pack-years) - nicotine causes acute vasoconstriction; chronic smoking damages endothelium and accelerates atherosclerosis; massively increases CVD risk in hypertensive patient
• Sedentary lifestyle - school teacher (largely deskbound); physical inactivity contributes via weight gain, impaired baroreceptor sensitivity and insulin resistance
• High salt diet: frequent consumption of salty snacks - excess sodium intake drives fluid retention and BP elevation
• Psychosocial stress - occupational stress (teaching) acts through sympathetic overactivation

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Classification of Hypertension - WHO/Indian Guidelines (2 marks)

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Rule of Halves in Hypertension (1 mark)

• Only ½ (50%) are detected / aware of their condition (remaining 50% are undiagnosed - the "iceberg")
• Of those detected, only ½ (50%) are on treatment (25% of total)
• Of those on treatment, only ½ (50%) have adequately controlled BP (12.5% of total = 1/8)

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Four Lifestyle Modification Measures (2 marks)

1. Dietary modification (DASH diet): Reduce salt to <5 g/day; eliminate salty snacks (chips, namkeen, papads, pickles); increase fruits and vegetables; reduce saturated fats and total calories for weight loss
2. Weight reduction: Target BMI <25 kg/m²; even 5-10% body weight loss reduces SBP by 5-20 mm Hg; calorie-restricted diet with physical activity
3. Smoking cessation (most urgent for this patient): Complete and immediate cessation of all tobacco; 5As counselling (Ask, Advise, Assess, Assist, Arrange); NRT patches or gum if needed; smoking + HTN dramatically increases stroke risk (as seen in his father)
4. Regular physical activity: ≥150 minutes/week of moderate aerobic exercise (brisk walking, cycling, swimming); 30 min/day on 5 days/week; reduces SBP by 4-9 mm Hg and also aids weight loss

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Four Complications of Uncontrolled Hypertension (2 marks)

1. Cerebrovascular accidents (Stroke): Haemorrhagic stroke (rupture of Charcot-Bouchard microaneurysms) or ischaemic stroke/lacunar infarcts; most feared complication - as seen in patient's father; HTN is the single biggest risk factor for stroke
2. Cardiovascular complications: Left ventricular hypertrophy (LVH) → cardiomyopathy → heart failure; coronary artery disease (angina, myocardial infarction); sudden cardiac death
3. Chronic Kidney Disease (Hypertensive nephrosclerosis): Arteriolar damage to renal vasculature → proteinuria → reduced GFR → end-stage renal disease requiring dialysis; malignant HTN causes fibrinoid necrosis of renal arterioles (accelerated CKD)
4. Hypertensive Retinopathy: Grade 1 (arteriolar narrowing) → Grade 2 (AV nipping/crossing changes) → Grade 3 (flame haemorrhages, cotton wool spots/soft exudates) → Grade 4 (papilloedema - malignant hypertension); can cause visual loss

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Q4. Classify Hypertension | Risk Factors | Complications | Prevention (2+4+4+5) [CNMCH]

Classification of Hypertension (2 marks)

• Essential (Primary) Hypertension: 90-95% of cases; no identifiable single cause; multifactorial
• Secondary Hypertension: 5-10% of cases; identifiable cause:
  • Renal: chronic glomerulonephritis, renal artery stenosis, PKD
  • Endocrine: Cushing's syndrome, Conn's (primary hyperaldosteronism), phaeochromocytoma, hypothyroidism
  • Cardiovascular: coarctation of aorta
  • Drugs: OCP, NSAIDs, corticosteroids, sympathomimetics
  • Pregnancy-induced (pre-eclampsia)

• Benign (Stable) Hypertension: Slowly progressive; responds to treatment
• Malignant (Accelerated) Hypertension: Rapid-onset, very high BP (usually DBP >130 mm Hg); papilloedema; fibrinoid necrosis of arterioles; medical emergency

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Risk Factors of Essential Hypertension (4 marks)

• Age (progressive rise throughout life)
• Sex (male > female until menopause; reversal post-menopause)
• Genetic/Family history (polygenic; 45% risk if both parents hypertensive)
• Ethnicity (Black > South Asian > Caucasian for BP levels)

• Obesity, especially central obesity (waist:hip ratio)
• High sodium/salt intake (>7-8 g/day)
• Physical inactivity / sedentary lifestyle
• Tobacco use (smoking, smokeless)
• Excess alcohol (raises systolic BP more than diastolic)
• High saturated fat diet
• Low dietary potassium, calcium, magnesium
• Environmental/psychosocial stress (sympathetic overactivity, high catecholamines)
• Oral contraceptive pills (oestrogen component - commonest secondary cause)
• Socioeconomic status (inversely related in developed, directly in transitional societies)
• Noise, vibration (occupational)

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Complications of Essential Hypertension (4 marks)

• Left ventricular hypertrophy (LVH) - concentric initially, then eccentric
• Hypertensive cardiomyopathy → congestive cardiac failure
• Coronary artery disease: angina pectoris, myocardial infarction
• Sudden cardiac death (arrhythmias in LVH)
• Aortic dissection (type A - proximal; type B - distal)

• Hypertensive encephalopathy (acute)
• Intracerebral haemorrhage - Charcot-Bouchard microaneurysm rupture (mainly putamen, thalamus)
• Ischaemic stroke - lacunar infarcts (lenticulostriate territory), cortical strokes
• Transient ischaemic attacks (TIAs)
• Vascular dementia (multi-infarct)

• Benign nephrosclerosis: hyaline arteriolar sclerosis → proteinuria → progressive CKD
• Malignant nephrosclerosis: fibrinoid necrosis of arterioles (malignant HTN) → acute renal failure
• End-stage renal disease (ESRD)

• Hypertensive retinopathy:
  • Grade I: Arteriolar narrowing (silver-wire appearance)
  • Grade II: AV nipping/crossing changes (Gunn's sign)
  • Grade III: Haemorrhages (flame), cotton wool spots, hard exudates (macular star)
  • Grade IV: Papilloedema (malignant hypertension)
• Visual loss, retinal artery/vein occlusion

• Peripheral vascular disease (claudication, critical limb ischaemia)
• Renal artery stenosis (perpetuating cycle of worsening HTN)

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Preventive Measures of Essential Hypertension (5 marks)

• National policies: mandatory salt reduction in food industry; FSSAI regulations; trans fat ban; sugar tax
• Tobacco control legislation (COTPA); alcohol policy
• Urban planning for active communities (parks, cycling lanes, walkable cities)
• School programmes: nutrition education, banning junk food in school canteens

• (A)lchohol restriction: <2 units/day for men; complete abstinence preferred
• (B)MI/weight reduction: Prevent obesity; healthy BMI 18.5-22.9 (Asian); promote healthy weight from childhood
• (C)essation of smoking: Complete cessation; 5As counselling; NRT; NTCP national programme
• (D)iet (DASH diet):
  • Salt <5 g/day
  • Fruits and vegetables ≥400 g/day (K-rich)
  • Whole grains, pulses, fibre ≥25 g/day
  • Reduce saturated fat, trans fat
  • Restrict sugar-sweetened beverages
• (E)xercise: ≥150 min/week moderate aerobic activity; reduces SBP 4-9 mm Hg
• Stress management: Yoga, pranayama, meditation; regular leisure time; adequate sleep (7-8 h)
• Health education: IEC activities; World Hypertension Day campaigns; mass media

• Targeted counselling for obese, diabetics, pre-hypertensives, smokers, family history positive
• Regular BP monitoring every 6 months for high-normal BP

• Universal opportunistic screening at all government health facilities for ≥30 years (NPCDCS)
• Community-level screening by ASHA/ANM; CBAC tool
• Referral pathway: Sub-centre → PHC/HWC → CHC/NCD Clinic → District Hospital

• Lifestyle modification as above (mandatory for all grades)
• Pharmacotherapy:
  • Grade 1 with low CV risk: 3-6 months lifestyle trial first; then drugs
  • Grade 2/3 and high risk: drugs + lifestyle simultaneously
  • First-line (NPCDCS): Amlodipine 5 mg or Telmisartan 40 mg or HCTZ 12.5 mg
  • Combination therapy (2 drugs) for Grade 2 and uncontrolled Grade 1
• Free drugs under PMBJP (Jan Aushadhi scheme)
• Patient registration on NCD portal; follow-up schedule
• Adherence strategies: FDCs, pill boxes, ASHA-supervised adherence, telemedicine

• Annual ECG, fundoscopy, urine ACR, eGFR monitoring
• Statin for dyslipidaemia; aspirin for high CV risk
• Stroke rehabilitation: physiotherapy, occupational therapy, speech therapy
• Renal replacement therapy (dialysis, transplant) for ESRD
• Cardiac rehabilitation post-MI/CCF
• Psychosocial support and home-based care

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Q5. Adolescent Obesity - 15-year-old boy, BMI >95th percentile (2+2+2+6+2+1) [MCK]

Most Likely Public Health Problem (2 marks)

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Behavioural Risk Factors in This Case (2 marks)

1. Screen-based sedentary behaviour / Physical inactivity:
   • Boy "spends most of time on screen-based activities" - TV, mobile phones, video games, computers
   • Screen time >2 hours/day is an independent risk factor for obesity
   • Displaces active play and physical activity, reducing total energy expenditure
   • Screen time associated with increased snacking (viewing food advertisements, mindless eating)
   • Disrupts sleep patterns (blue light, late-night use) → impairs leptin/ghrelin balance → increased appetite
2. Regular consumption of fast food / unhealthy dietary habits:
   • Fast food is calorie-dense, high in saturated fats, trans fats, refined carbohydrates, added sugars, and salt
   • Low in fibre, vitamins, minerals, and satiety
   • Large portion sizes; energy density 3-4 times that of whole foods
   • Sugar-sweetened beverages (soft drinks, packaged juices) - high empty calories, do not trigger satiety signals
   • Frequent eating out, skipping traditional home-cooked meals
   • This pattern provides excess caloric intake beyond energy expenditure → positive energy balance → fat accumulation

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Two Health Consequences if Left Untreated (2 marks)

1. Type 2 Diabetes Mellitus (Metabolic syndrome / Insulin resistance):
   • Adolescent obesity leads to visceral fat accumulation → insulin resistance → progressive pancreatic beta-cell dysfunction
   • T2DM previously rare in adolescents is now being diagnosed with increasing frequency in India (particularly in urban areas)
   • Early-onset DM carries greater lifetime complications burden (30+ years of hyperglycaemia)
   • Associated with metabolic syndrome: HTN + dyslipidaemia + abdominal obesity + IFG/IGT
2. Cardiovascular disease risk - premature atherosclerosis:
   • Hypertension, dyslipidaemia (elevated LDL, triglycerides; low HDL) begin in obese adolescence
   • Tracking phenomenon: these risk factors track from adolescence to adulthood
   • Autoptic studies (Bogalusa Heart Study) show fatty streaks in coronary arteries of obese teenagers
   • Increased lifetime CVD risk (MI, stroke) decades earlier than non-obese peers
   Additional important consequences (for broader marks):
   • Obstructive sleep apnoea (daytime somnolence, poor school performance)
   • Orthopaedic: Slipped capital femoral epiphysis (SCFE), genu valgum, flat feet, back pain
   • Non-alcoholic fatty liver disease (NAFLD)
   • Psychological: Low self-esteem, depression, anxiety, social isolation, bullying victimisation
   • Polycystic ovarian syndrome in obese adolescent girls

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Preventive Strategies at School Level (6 marks)

• Healthy tiffin/canteen policy: Ban sale of junk food, chips, sugar-sweetened beverages, candy within school premises; replace with fruits, buttermilk, nuts, whole grain snacks
• Mid-day meal improvement: Nutritionally balanced, calorie-appropriate meals (PM Poshan Abhiyan); increase protein, fibre, micronutrient content; reduce refined carbohydrates
• Fruit and vegetable programme: Daily fruit/vegetable portions as part of school meals; school kitchen gardens where possible
• Safe drinking water access: Freely available clean water to replace SSBs; hydration stations
• Remove unhealthy food vending machines; restrict fast food vendors near school gates

• Compulsory, structured Physical Education (PE): Minimum 60 minutes/day of moderate-to-vigorous physical activity (MVPA) as per WHO child activity guidelines (≥60 min MVPA for 5-17 years)
• Qualified PE teachers; varied activities (team sports, gymnastics, dance, athletics)
• Active recess/breaks: Supervised outdoor play; structured games during lunch/breaks
• Inter-class and inter-school sports competitions: Cricket, football, kho-kho, kabaddi - promote active participation
• Active transport encouragement: Walking, cycling to school; reduce car/bus dependency for short distances
• Reduce sitting time: Movement breaks every 45-60 minutes in classroom (stretching, brief walks)

• Curriculum integration: Life skills, home science, biology classes to teach food groups, balanced diet, reading food labels, understanding calorie content of fast foods
• Media literacy education: Train students to critically evaluate food advertisements; understand marketing techniques targeting children
• Cooking skills: Practical sessions on preparing healthy snacks; involve students in food preparation
• Peer-led health education: Train health "ambassadors" among students for peer influence

• Regular anthropometric monitoring (height, weight, BMI calculation) and BMI-for-age plotting by school medical officer/nurse - ideally every 6 months
• Identifying overweight (85th-94th percentile) and obese (≥95th percentile) students early
• Referral of identified obese students to paediatric NCD clinics for comprehensive assessment
• Vision, dental, and general health check-ups integrated

• School policy: No mobile phones during school hours
• Homework that involves physical activity or outdoor exploration
• After-school clubs: sports, dance, yoga, nature clubs as alternatives to screen time

• Teacher training: Incorporate movement into classroom teaching; role-model healthy behaviours
• Parent-Teacher meetings: Educate parents on healthy home food environment; healthy tiffin preparation; limiting screen time at home; encouraging outdoor play
• Community engagement: Involve local health workers (ASHA, ANM) in school health days
• Policy advocacy: School management committees to adopt and enforce healthy canteen policies

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Level of Prevention Applicable (2 marks)

• Secondary Prevention - Disease (obesity) has already developed; screening has identified it; now intervene to prevent complications (DM, HTN, CVD)
• Early detection + lifestyle intervention = halting disease progression before complications

• Primary Prevention - Preventing obesity from occurring in those currently normal/overweight through school-level interventions

• Primordial Prevention - Policy-level actions (healthy canteen policies, physical activity infrastructure) prevent the emergence of risk factors (physical inactivity, unhealthy diet) that lead to obesity

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National Programme Related (1 mark)

• RKSK - Rashtriya Kishor Swasthya Karyakram (National Adolescent Health Programme): addresses nutrition, physical activity, and NCD risk factors in 10-19 year age group
• RBSK - Rashtriya Bal Swasthya Karyakram: school health screening including anthropometry
• Fit India Movement (2019): national initiative to promote physical fitness and activity
• PM Poshan Abhiyan (formerly Mid-Day Meal Scheme): improving nutritional status of school children

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Q6. Tuberculosis - 27-year-old female, cough + fever + weight loss + night sweats (1+1+4+4+5=15) [IQCITY]

Probable Diagnosis and National Programme (1+1 marks)

• Chronic productive cough ≥2 weeks (3 weeks here)
• Constitutional symptoms: fever, significant weight loss, night sweats (drenching sweats - classic for TB)
• Young adult in a high TB burden country

• Vision: TB-Free India by 2025 (5 years ahead of global End TB target of 2030)
• Pillars: Detect-Treat-Prevent-Build (DTPB)
• Part of Ministry of Health & Family Welfare, Government of India

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Diagnostic Algorithm and Treatment Regimen per NTEP (4+4 marks)

Diagnostic Algorithm (4 marks)

• Any person with:
  • Cough ≥2 weeks, OR
  • Fever ≥2 weeks, OR
  • Significant unexplained weight loss, OR
  • Night sweats ≥2 weeks
• This patient fulfils ALL four → Presumptive TB case → initiate diagnostic work-up immediately

• FIRST-LINE diagnostic test per NTEP 2022 for all presumptive TB cases
• Detects M. tuberculosis AND rifampicin resistance simultaneously
• Result available in 2 hours
• Sputum sample: spot sample (2-4 mL sputum); if unable to produce, induced sputum
• Sensitivity: ~88% (pulmonary); Specificity: ~99%

• Used where CBNAAT unavailable or for follow-up monitoring
• Two sputum samples: spot + early morning (or two spot samples)
• Grade 1+, 2+, 3+ AFB positivity

• Point-of-care molecular test approved by NTEP
• Available at peripheral/sub-district level
• Detects MTB and RIF resistance

• Gold standard for TB diagnosis and Drug Susceptibility Testing (DST)
• LJ: 6-8 weeks; MGIT: 10-14 days
• Mandatory for: smear-negative cases, treatment failures, drug-resistance workup
• DST: First-line (Isoniazid, Rifampicin, Ethambutol, Pyrazinamide) and second-line (Fluoroquinolones, Aminoglycosides)

• Rapid molecular test for simultaneous detection of RIF + INH resistance (1st-line LPA)
• Used when CBNAAT shows RIF resistance → confirm MDR-TB; then 2nd-line LPA for XDR-TB

• Typical findings: Upper lobe infiltrates (apical/posterior segments of upper lobes or superior segment of lower lobe), cavitation, hilar lymphadenopathy, miliary pattern
• Supports diagnosis but CXR alone is NOT diagnostic
• Mandatory for: smear-negative cases, extrapulmonary TB evaluation

• Bacteriologically confirmed PTB: CBNAAT/smear/culture positive
• Clinically diagnosed PTB: All tests negative/inconclusive but CXR consistent + clinical judgment; NOT responding to broad-spectrum antibiotics
• Drug-sensitive (DS-TB): Sensitive to rifampicin on CBNAAT
• Rifampicin-resistant (RR-TB)/MDR-TB: Resistant to rifampicin on CBNAAT → confirmed MDR if also INH resistant on DST

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Treatment Regimen per NTEP (4 marks)

• Daily dosing (replaced thrice-weekly DOTS in 2016)
• Fixed-Dose Combination tablets (not individual drugs) - improve adherence, prevent single-drug default
• Direct Observation of Treatment (DOT): DOT provider (ASHA, family member, community volunteer) directly observes drug ingestion - especially during intensive phase
• Drugs taken on empty stomach (30 min before or 2 hours after meals) for better rifampicin absorption

• Pyridoxine (Vitamin B6) 10-25 mg/day throughout treatment: prevents isoniazid-induced peripheral neuropathy (especially in malnourished, elderly, pregnant, HIV+, alcoholics)
• Nutritional support under Ni-kshay Poshan Yojana: Rs. 500/month Direct Benefit Transfer to patient's bank account throughout treatment

• All TB cases must be notified within 24 hours on Ni-kshay portal (India's mandatory TB notification system since 2012; strengthened 2018)
• Unique Ni-kshay ID issued; all treatment outcomes recorded
• Nikshay Mitra scheme: corporate/individual sponsors provide nutritional/diagnostic/vocational support

• Sputum smear/CBNAAT: End of Intensive Phase (2 months), Month 5, End of Treatment (Month 6)
• If smear positive at 2 months: Extend intensive phase by 1 more month; send culture + DST
• If culture positive at month 2-3 or smear positive at month 5 → suspect treatment failure → DST urgently
• Liver function tests (baseline, then if symptomatic): Rifampicin + Isoniazid + Pyrazinamide all potentially hepatotoxic - monitor for hepatitis (nausea, vomiting, jaundice, RUQ pain → STOP all ATT, reintroduce sequentially)

• MDR-TB/RR-TB: Longer regimen (18-20 months)
• Newer shorter regimens: BPaL (Bedaquiline + Pretomanid + Linezolid) - 6-9 months
• Pre-XDR/XDR-TB: Individualised regimen based on DST
• Referred to district/state DR-TB centre

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Preventive Measures for the Family (5 marks)

• Both husband and son must be evaluated immediately
• Symptom screening: cough, fever, weight loss, night sweats
• Chest X-ray for both
• If symptomatic → CBNAAT sputum test
• If negative X-ray and asymptomatic → initiate TB Preventive Treatment (TPT)

• Per NTEP guidelines: All household contacts aged <5 years AND 5-14 years of bacteriologically confirmed PTB cases to receive TPT
• Regimen: Isoniazid (H) 10 mg/kg/day (maximum 300 mg/day) for 6 months = 6H regimen
• Rule out active TB before starting (CXR, symptom screen)
• Monitor for INH side effects: hepatitis (rare in children), peripheral neuropathy (give pyridoxine)

• If HIV-negative and asymptomatic with normal CXR: TPT may be offered; discuss with district TB officer
• If HIV-positive (all contacts should be offered HIV testing): 6H or 3HP (3 months Isoniazid + Rifapentine weekly) regimen mandatory for PLHIV contacts

• Check son's vaccination status; if unvaccinated → BCG vaccine (0.1 mL intradermal, left shoulder)
• BCG provides 60-80% protection against severe forms of TB in children (miliary TB, TB meningitis)
• Part of Universal Immunisation Programme (at birth / within 1 year)

• Adequate natural ventilation: Open windows and doors in all rooms to allow fresh air circulation; sunlight (UV) kills M. tuberculosis within 2 hours of exposure
• Patient respiratory hygiene:
  • Cover mouth and nose when coughing or sneezing (cough etiquette)
  • Use disposable tissues or cloth handkerchief; dispose of properly
  • Do not spit indoors or in public places
• Patient separation: Until declared non-infectious (sputum negative at 2 months), patient should sleep in a separate, well-ventilated room if feasible; avoid crowded poorly ventilated spaces
• Reduce overcrowding: Arrange sleeping spaces to minimise close contact
• Sunning of bedding and clothing: Regular exposure to sunlight

• Protein-rich, calorie-adequate diet for all family members to maintain cellular immunity
• Address underlying malnutrition if present
• Patient enrolled under Ni-kshay Poshan Yojana (Rs. 500/month)
• ICDS (Integrated Child Development Services) support for the 6-year-old son

• Nature of disease and transmission: TB spreads through air (droplet nuclei); NOT by sharing food, utensils, clothes, or touch - correct misconceptions
• Curability: Emphasise that TB is completely curable with full treatment adherence
• Treatment adherence is mandatory: Explain dangers of irregular treatment or early discontinuation (drug resistance development - MDR-TB)
• Duration of infectiousness: Patient becomes non-infectious after approximately 2 weeks of effective treatment; isolation not needed for full treatment duration
• Dispel stigma: TB is not a result of lifestyle or immorality; it is an infectious disease like any other; discourage social isolation/discrimination
• Train husband as DOT provider: Husband can be trained to supervise wife's daily drug intake; this also helps with early detection of side effects

• Both patient and husband should be offered HIV counselling and voluntary testing (VCT)
• TB-HIV co-infection is common (8.2% of all TB cases are PLHIV globally)
• If HIV-positive: Start Antiretroviral Therapy (ART) - initiate within 2 weeks of starting ATT if CD4 <50 cells/µL; within 8 weeks for other PLHIV
• Cotrimoxazole Prophylaxis for HIV+ TB patients

• Husband and son: repeat screening at 3 months and 6 months post-exposure
• If any contact develops symptoms during the 2-year observation period → immediate evaluation
• After 2 years with no disease development: surveillance can be discontinued

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