from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.colors import HexColor, black, white
from reportlab.lib.units import cm, mm
from reportlab.platypus import (SimpleDocTemplate, Paragraph, Spacer, Table,
                                 TableStyle, PageBreak, HRFlowable, KeepTogether)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import ListFlowable, ListItem

# Colors
DARK_BLUE = HexColor('#1a3a5c')
MED_BLUE = HexColor('#2e6da4')
LIGHT_BLUE = HexColor('#d0e8f8')
HIGHLIGHT_YELLOW = HexColor('#fff3cd')
HIGHLIGHT_BORDER = HexColor('#ffc107')
GREEN = HexColor('#155724')
GREEN_BG = HexColor('#d4edda')
RED_BG = HexColor('#f8d7da')
RED_FG = HexColor('#721c24')
ORANGE = HexColor('#e65c00')
GRAY_BG = HexColor('#f5f5f5')
TABLE_HEADER = HexColor('#1a3a5c')
TABLE_ALT = HexColor('#e8f2fb')

def build_pdf():
    path = "/home/daytona/workspace/ncd-psm/NCD_PSM_DUHS_Notes.pdf"
    doc = SimpleDocTemplate(
        path,
        pagesize=A4,
        rightMargin=2*cm,
        leftMargin=2*cm,
        topMargin=2.5*cm,
        bottomMargin=2*cm,
        title="Non-Communicable Diseases – PSM Notes",
        author="Orris AI | DUHS Chhattisgarh"
    )

    styles = getSampleStyleSheet()

    # Custom styles
    title_style = ParagraphStyle('TitleStyle', parent=styles['Title'],
        fontSize=22, textColor=DARK_BLUE, spaceAfter=6, alignment=TA_CENTER,
        fontName='Helvetica-Bold')

    subtitle_style = ParagraphStyle('SubtitleStyle', parent=styles['Normal'],
        fontSize=11, textColor=MED_BLUE, spaceAfter=4, alignment=TA_CENTER,
        fontName='Helvetica')

    h1_style = ParagraphStyle('H1', parent=styles['Heading1'],
        fontSize=16, textColor=white, spaceAfter=8, spaceBefore=16,
        fontName='Helvetica-Bold', backColor=DARK_BLUE,
        borderPad=(6, 6, 6, 6), leading=22)

    h2_style = ParagraphStyle('H2', parent=styles['Heading2'],
        fontSize=13, textColor=DARK_BLUE, spaceAfter=6, spaceBefore=12,
        fontName='Helvetica-Bold', borderPadding=(0,0,2,0))

    h3_style = ParagraphStyle('H3', parent=styles['Heading3'],
        fontSize=11, textColor=MED_BLUE, spaceAfter=4, spaceBefore=8,
        fontName='Helvetica-Bold')

    body_style = ParagraphStyle('Body', parent=styles['Normal'],
        fontSize=10, textColor=black, spaceAfter=5, spaceBefore=2,
        leading=15, fontName='Helvetica', alignment=TA_JUSTIFY)

    bullet_style = ParagraphStyle('Bullet', parent=styles['Normal'],
        fontSize=10, textColor=black, spaceAfter=3, spaceBefore=1,
        leading=14, leftIndent=15, bulletIndent=5, fontName='Helvetica')

    exam_style = ParagraphStyle('ExamBox', parent=styles['Normal'],
        fontSize=10, textColor=HexColor('#7b3f00'), spaceAfter=4, spaceBefore=4,
        leading=14, fontName='Helvetica', backColor=HIGHLIGHT_YELLOW,
        borderPad=(8, 8, 8, 8), borderColor=HIGHLIGHT_BORDER, borderWidth=1)

    imp_style = ParagraphStyle('Important', parent=styles['Normal'],
        fontSize=10, textColor=RED_FG, spaceAfter=4, spaceBefore=4,
        leading=14, fontName='Helvetica-Bold', backColor=RED_BG,
        borderPad=(6, 6, 6, 6))

    tip_style = ParagraphStyle('Tip', parent=styles['Normal'],
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        leading=14, fontName='Helvetica', backColor=GREEN_BG,
        borderPad=(6, 6, 6, 6))

    small_style = ParagraphStyle('Small', parent=styles['Normal'],
        fontSize=9, textColor=HexColor('#555555'), spaceAfter=3,
        leading=13, fontName='Helvetica')

    toc_style = ParagraphStyle('TOC', parent=styles['Normal'],
        fontSize=11, textColor=DARK_BLUE, spaceAfter=4, spaceBefore=2,
        leading=18, fontName='Helvetica', leftIndent=10)

    def section_header(title):
        return [
            Spacer(1, 4),
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                colWidths=[17*cm],
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                ])),
            Spacer(1, 6),
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    def sub_header(title):
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            Table([[Paragraph(title, ParagraphStyle('SubH', fontName='Helvetica-Bold',
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                    ('LEFTPADDING', (0,0), (-1,-1), 10),
                    ('LINEBELOW', (0,0), (-1,-1), 1, MED_BLUE),
                ])),
            Spacer(1, 4),
        ]

    def exam_box(title, items):
        content = f"<b>⭐ {title}</b><br/>"
        for item in items:
            content += f"• {item}<br/>"
        return [
            Table([[Paragraph(content, ParagraphStyle('EB', fontName='Helvetica',
                fontSize=10, textColor=HexColor('#7b3f00'), leading=16))]],
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                style=TableStyle([
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                    ('LEFTPADDING', (0,0), (-1,-1), 10),
                    ('BOX', (0,0), (-1,-1), 1.5, HIGHLIGHT_BORDER),
                ])),
            Spacer(1, 4),
        ]

    def tip_box(text):
        return [
            Table([[Paragraph(f"<b>Exam Tip:</b> {text}", ParagraphStyle('TB', fontName='Helvetica',
                fontSize=10, textColor=GREEN, leading=14))]],
                colWidths=[17*cm],
                style=TableStyle([
                    ('BACKGROUND', (0,0), (-1,-1), GREEN_BG),
                    ('TOPPADDING', (0,0), (-1,-1), 6),
                    ('BOTTOMPADDING', (0,0), (-1,-1), 6),
                    ('LEFTPADDING', (0,0), (-1,-1), 10),
                    ('BOX', (0,0), (-1,-1), 1, HexColor('#28a745')),
                ])),
            Spacer(1, 3),
        ]

    def make_table(headers, rows, col_widths=None):
        if col_widths is None:
            col_widths = [17*cm/len(headers)] * len(headers)
        data = [[Paragraph(h, ParagraphStyle('TH', fontName='Helvetica-Bold', fontSize=10, textColor=white))
                 for h in headers]]
        for i, row in enumerate(rows):
            data.append([Paragraph(str(cell), ParagraphStyle('TC', fontName='Helvetica', fontSize=9,
                textColor=black, leading=12)) for cell in row])
        ts = TableStyle([
            ('BACKGROUND', (0,0), (-1,0), TABLE_HEADER),
            ('ROWBACKGROUNDS', (0,1), (-1,-1), [white, TABLE_ALT]),
            ('GRID', (0,0), (-1,-1), 0.5, HexColor('#cccccc')),
            ('TOPPADDING', (0,0), (-1,-1), 5),
            ('BOTTOMPADDING', (0,0), (-1,-1), 5),
            ('LEFTPADDING', (0,0), (-1,-1), 6),
        ])
        return Table(data, colWidths=col_widths, style=ts, repeatRows=1)

    def B(text):
        return Paragraph(f"<b>•</b> {text}", bullet_style)

    def P(text):
        return Paragraph(text, body_style)

    def H3(text):
        return Paragraph(text, h3_style)

    # ============================================================
    # BUILD CONTENT
    # ============================================================
    story = []

    # COVER PAGE
    story.append(Spacer(1, 2*cm))
    story.append(Table([[Paragraph("NON-COMMUNICABLE DISEASES", ParagraphStyle(
        'Cover', fontName='Helvetica-Bold', fontSize=26, textColor=white, alignment=TA_CENTER))]],
        colWidths=[17*cm],
        style=TableStyle([
            ('BACKGROUND', (0,0), (-1,-1), DARK_BLUE),
            ('TOPPADDING', (0,0), (-1,-1), 20),
            ('BOTTOMPADDING', (0,0), (-1,-1), 20),
        ])))
    story.append(Spacer(1, 0.5*cm))
    story.append(Paragraph("Comprehensive Study Notes", subtitle_style))
    story.append(Paragraph("Preventive & Social Medicine (PSM) | MBBS 3rd Year", subtitle_style))
    story.append(Spacer(1, 0.3*cm))
    story.append(Paragraph("Based on: Park's PSM & Suryakanta PSM Syllabus", subtitle_style))
    story.append(Spacer(1, 0.5*cm))

    # Exam info box
    story.append(Table([[Paragraph(
        "<b>Examination Authority:</b> Pt. Deendayal Upadhyay Memorial Health Sciences &amp; Ayush University (DUHS), Chhattisgarh<br/>"
        "<b>Subject:</b> Community Medicine – Paper I | Section B<br/>"
        "<b>Topic:</b> Epidemiology of Non-Communicable Diseases<br/>"
        "<b>Format:</b> 1 LAQ (15M) + 5 SAQ (5M each) + 10 Objectives (1M each)",
        ParagraphStyle('Info', fontName='Helvetica', fontSize=10, textColor=DARK_BLUE,
                       leading=16, alignment=TA_CENTER))]], colWidths=[17*cm],
        style=TableStyle([('BACKGROUND', (0,0),(-1,-1), LIGHT_BLUE),
                          ('BOX', (0,0),(-1,-1), 2, MED_BLUE),
                          ('TOPPADDING',(0,0),(-1,-1),12),
                          ('BOTTOMPADDING',(0,0),(-1,-1),12)])))
    story.append(Spacer(1, 0.8*cm))
    story.append(Paragraph("Prepared by Orris AI | June 2026", subtitle_style))
    story.append(PageBreak())

    # ====================================================
    # PREVIOUS YEAR QUESTION ANALYSIS
    # ====================================================
    story += section_header("PREVIOUS YEAR QUESTION ANALYSIS – DUHS CHHATTISGARH")

    story.append(P("Based on analysis of DUHS (Chhattisgarh AYUSH University) and affiliated university question papers from 2008–2024, the following topics have appeared repeatedly in NCD chapter:"))
    story.append(Spacer(1, 6))

    story += exam_box("MOST FREQUENTLY ASKED LONG ANSWER QUESTIONS (LAQ) – 12-15 Marks", [
        "Epidemiology, risk factors & prevention of Essential Hypertension (2015, S'16, S'09, S'13)",
        "Epidemiology of Coronary Heart Disease (CHD) & its prevention (2012, S'16, S'09, S'13)",
        "Epidemiology of Diabetes mellitus & primary prevention of Type 2 DM (2014)",
        "Cancer in India – types, early warning signs, prevention of Ca Cervix / Oral Cancer (2009, 2013)",
        "NPCDCS – Components, objectives, strategies (S'16)",
        "Road Traffic Accidents (RTA) – measures to reduce as BMOH (2009)",
        "Obesity – causes, health consequences, prevention",
        "Early warning signs / danger signals of cancer (2008)",
    ])

    story += exam_box("FREQUENTLY ASKED SHORT NOTES (SAQ) – 5 Marks", [
        "Risk factors of hypertension / Classification of hypertension",
        "Screening for cancer cervix (Pap smear, VIA)",
        "Oral Cancer – epidemiology & prevention",
        "Diabetes – diagnostic criteria & prevention",
        "Obesity – BMI, waist circumference, health risks",
        "Framingham Heart Study",
        "NPCDCS programme components",
        "Metabolic syndrome",
        "Stroke – risk factors & prevention",
        "Cancer registration in India (PBCR, HBCR)",
    ])

    freq_table = make_table(
        ["Topic", "Times Asked", "Type", "Priority"],
        [
            ["Hypertension", "5+", "LAQ + SAQ", "⭐⭐⭐ HIGH"],
            ["Coronary Heart Disease (CHD)", "4+", "LAQ + SAQ", "⭐⭐⭐ HIGH"],
            ["Cancer (Oral/Cervix/General)", "4+", "LAQ + SAQ", "⭐⭐⭐ HIGH"],
            ["Diabetes Mellitus", "3+", "LAQ + SAQ", "⭐⭐⭐ HIGH"],
            ["NPCDCS Programme", "2+", "LAQ + SAQ", "⭐⭐ MEDIUM"],
            ["Obesity & Overweight", "2+", "SAQ", "⭐⭐ MEDIUM"],
            ["Road Traffic Accidents", "1+", "LAQ", "⭐ LOW-MED"],
            ["Stroke", "1+", "SAQ", "⭐ LOW-MED"],
            ["Mental Health", "1+", "SAQ", "⭐ LOW-MED"],
        ],
        col_widths=[6*cm, 3*cm, 3.5*cm, 4.5*cm]
    )
    story.append(freq_table)
    story.append(Spacer(1, 8))
    story.append(PageBreak())

    # ====================================================
    # SECTION 1: INTRODUCTION TO NCD
    # ====================================================
    story += section_header("1. INTRODUCTION TO NON-COMMUNICABLE DISEASES")

    story.append(P("Non-communicable diseases (NCDs) are chronic diseases that are not passed from person to person. They are of long duration and generally of slow progression. The four main types of NCDs are cardiovascular diseases, cancers, chronic respiratory diseases and diabetes."))
    story.append(Spacer(1, 4))

    story += sub_header("1.1 Global Burden")
    story.append(B("NCDs are the leading cause of death globally – responsible for 74% of all deaths (WHO 2021)"))
    story.append(B("41 million people die from NCDs each year"))
    story.append(B("77% of NCD deaths occur in low and middle-income countries"))
    story.append(B("In India (2016): NCDs accounted for 60% of all deaths"))
    story.append(B("The 4 main NCDs kill 32 million people per year globally"))
    story.append(Spacer(1, 4))

    story += sub_header("1.2 Key NCD Risk Factors")
    story.append(P("Most NCDs are preventable through control of common modifiable risk factors:"))

    rf_table = make_table(
        ["Risk Factor", "Key Facts / Statistics"],
        [
            ["Tobacco Use", "~7 million deaths/year. Causes 71% lung cancer, 42% chronic respiratory disease, 10% CVD. 1.1 billion smokers worldwide (2016)"],
            ["Physical Inactivity", "1.6 million deaths/year. 20-30% increased risk of all-cause mortality"],
            ["Harmful Alcohol Use", "3.3 million deaths/year (5.9% of global deaths). Linked to cancers, CVD, liver cirrhosis"],
            ["Unhealthy Diet", "High salt → hypertension. 4.1 million CVD deaths from excess sodium. High saturated/trans fat → heart disease"],
            ["Raised Blood Pressure", "9.4 million deaths/year (12.8% of all deaths). Global prevalence ~22% in adults"],
            ["Overweight/Obesity", "2.8 million+ deaths/year. Raises risk of heart disease, stroke, diabetes, certain cancers"],
            ["Raised Blood Glucose", "Diabetes: 422 million people affected worldwide"],
            ["Raised Cholesterol", "Major risk factor for CHD and stroke"],
        ],
        col_widths=[4.5*cm, 12.5*cm]
    )
    story.append(rf_table)
    story.append(Spacer(1, 6))
    story += tip_box("Remember: 'TAPU' – Tobacco, Alcohol, Physical inactivity, Unhealthy diet are the 4 KEY MODIFIABLE behavioral risk factors for NCDs. Frequently asked in objectives.")
    story.append(PageBreak())

    # ====================================================
    # SECTION 2: CORONARY HEART DISEASE
    # ====================================================
    story += section_header("2. CORONARY HEART DISEASE (CHD) / ISCHAEMIC HEART DISEASE ⭐⭐⭐")

    story += exam_box("Exam Alert – CHD", [
        "Risk factors of CHD – 8 marks (2012, S'16, S'09, S'13)",
        "Prevention & control of CHD – 4 marks",
        "Framingham Heart Study – Short note",
        "Population strategy vs High-risk strategy",
    ])

    story += sub_header("2.1 Definition & Problem Statement")
    story.append(P("Coronary Heart Disease (CHD) refers to disease of heart that results from inadequate supply of oxygenated blood to the heart due to atherosclerosis of coronary arteries. Also called Ischaemic Heart Disease (IHD)."))
    story.append(Spacer(1, 3))
    story.append(B("CHD is the leading cause of death in most developed countries"))
    story.append(B("In India, CHD mortality is rising rapidly due to urbanization and lifestyle changes"))
    story.append(B("Framingham Heart Study (1951 onwards) established major CHD risk factors"))
    story.append(Spacer(1, 4))

    story += sub_header("2.2 Risk Factors of CHD")
    story.append(P("Risk factors are classified into Non-modifiable and Modifiable:"))

    story.append(H3("A. Non-Modifiable Risk Factors"))
    story.append(B("Age: Risk increases with age; most CHD events occur >50 years"))
    story.append(B("Sex: Males are at higher risk; post-menopausal women approach same risk"))
    story.append(B("Family history/Genetics: Polygenic inheritance; first-degree relatives at higher risk"))
    story.append(Spacer(1, 4))

    story.append(H3("B. Modifiable Risk Factors – MAJOR (The Big Four)"))

    big4_table = make_table(
        ["Risk Factor", "Details", "Threshold/Cutoff"],
        [
            ["1. Hypertension", "Single most useful test for identifying CHD risk. Accelerates atherosclerosis, especially with hyperlipidaemia", "SBP >140 mmHg / DBP >90 mmHg"],
            ["2. Hypercholesterolaemia", "Strong causal relationship. CHD rare if cholesterol <200 mg/dl. Seven Countries Study confirmed this", ">200 mg/dl (adults)"],
            ["3. Cigarette Smoking", "Dose-response relationship. Synergistic with other risk factors. Cessation reduces risk within months", ">10 cigarettes/day = high risk"],
            ["4. Physical Inactivity", "Sedentary lifestyle increases risk 1.9x. Exercise reduces LDL, raises HDL, improves insulin sensitivity", "Recommended: 150 min/week moderate activity"],
        ],
        col_widths=[4*cm, 8*cm, 5*cm]
    )
    story.append(big4_table)
    story.append(Spacer(1, 4))

    story.append(H3("C. Other Modifiable Risk Factors"))
    story.append(B("Diabetes mellitus – 2x-4x increased CHD risk"))
    story.append(B("Obesity – BMI >30 kg/m² increases risk"))
    story.append(B("Diet – High saturated fat, salt, low fruit & vegetables"))
    story.append(B("Stress – Type A personality (competitive, aggressive, time-pressed) – associated with higher CHD risk"))
    story.append(B("Alcohol – Moderate protective? Heavy drinking increases risk"))
    story.append(B("Soft water – Inverse relationship with CHD (hard water may be protective)"))
    story.append(B("Oral contraceptives – Increase risk, especially in smokers"))
    story.append(Spacer(1, 4))

    story += sub_header("2.3 Prevention of CHD – Three Strategies")

    prev_table = make_table(
        ["Strategy", "Target", "Methods"],
        [
            ["1. Population Strategy", "Whole community – shift risk factor distribution", "Health education, dietary changes, anti-smoking campaigns, promote physical activity"],
            ["2. High-Risk Strategy", "Individuals with specific risk factors", "Screening, treatment of hypertension, hyperlipidaemia, diabetes; smoking cessation"],
            ["3. Secondary Prevention", "Patients with established CHD", "Medical therapy (aspirin, statins, beta-blockers, ACE inhibitors), cardiac rehabilitation, PTCA/CABG"],
        ],
        col_widths=[4*cm, 5*cm, 8*cm]
    )
    story.append(prev_table)
    story.append(Spacer(1, 4))

    story += tip_box("'Population strategy has the greatest potential' – Geoffrey Rose's concept. High-risk strategy has individual benefit. Remember the Framingham Study for objective questions.")

    story += sub_header("2.4 Framingham Heart Study – Short Note")
    story.append(B("Started in 1951 in Framingham, Massachusetts, USA"))
    story.append(B("One of the best-known prospective cohort studies on CHD"))
    story.append(B("Established the four major CHD risk factors: elevated serum cholesterol, smoking, hypertension, sedentary habits"))
    story.append(B("Coined the term 'risk factor'"))
    story.append(B("Still ongoing – multiple generations enrolled"))
    story.append(Spacer(1, 4))
    story.append(PageBreak())

    # ====================================================
    # SECTION 3: HYPERTENSION
    # ====================================================
    story += section_header("3. HYPERTENSION (ESSENTIAL HYPERTENSION) ⭐⭐⭐")

    story += exam_box("Exam Alert – Hypertension", [
        "Definition, classification, risk factors, prevalence, prevention (2015 – LAQ 12 marks)",
        "Risk factors for hypertension – Short note (S'16, S'09)",
        "Tracking of blood pressure – Short note",
        "Prevention of hypertension – Short note",
    ])

    story += sub_header("3.1 Definition")
    story.append(P("Hypertension is defined as persistently raised blood pressure. The WHO/JNC 7 and JNC 8 definitions are widely used:"))

    bp_table = make_table(
        ["Category", "Systolic (mmHg)", "Diastolic (mmHg)"],
        [
            ["Normal", "< 120", "< 80"],
            ["Elevated / Pre-hypertension", "120-129", "< 80"],
            ["Stage 1 Hypertension", "130-139", "80-89"],
            ["Stage 2 Hypertension", "≥ 140", "≥ 90"],
            ["Hypertensive Crisis", "> 180", "> 120"],
        ],
        col_widths=[6*cm, 5.5*cm, 5.5*cm]
    )
    story.append(bp_table)
    story.append(Spacer(1, 4))

    story += sub_header("3.2 Problem Statement (Prevalence)")
    story.append(B("Global: ~22% of adults have raised blood pressure (2015)"))
    story.append(B("Raised BP causes 9.4 million deaths/year (12.8% of all deaths globally)"))
    story.append(B("In India: Prevalence 20-40% in urban and 12-17% in rural adults"))
    story.append(B("Hypertension is the single most useful predictor of CHD risk"))
    story.append(Spacer(1, 4))

    story += sub_header("3.3 Risk Factors for Hypertension")

    story.append(H3("A. Non-Modifiable Risk Factors"))
    story.append(B("Age: BP rises with age; children of two hypertensive parents have 45% risk (vs 3% in normotensive parents)"))
    story.append(B("Sex: Males higher in young adults; post-menopausal females may surpass males"))
    story.append(B("Genetic/Family History: Polygenic inheritance confirmed by twin and family studies"))
    story.append(B("Race/Ethnicity: More common in Black populations (African Americans)"))
    story.append(Spacer(1, 3))

    story.append(H3("B. Modifiable Risk Factors"))
    story.append(B("Salt (Sodium) intake: Strong evidence – high-salt diet raises BP. WHO recommends <5g/day. INTERSALT study confirmed this"))
    story.append(B("Obesity: Body weight is strongly correlated with BP. Weight reduction of 10 kg can lower SBP by 5-20 mmHg"))
    story.append(B("Alcohol: Regular heavy drinking raises BP. Limit to <2 drinks/day for men, <1 for women"))
    story.append(B("Physical inactivity: Regular aerobic exercise can lower SBP by 4-9 mmHg"))
    story.append(B("Diet: Low potassium, low calcium, high saturated fat diet associated with hypertension"))
    story.append(B("Stress / Psychosocial factors: Occupational stress, urban life associated with higher BP"))
    story.append(B("Oral contraceptives: Oestrogen-containing OCP can raise BP"))
    story.append(B("Diabetes: Associated with hypertension (metabolic syndrome)"))
    story.append(B("Dyslipidaemia: Co-existing risk factor"))
    story.append(Spacer(1, 4))

    story += sub_header("3.4 Tracking of Blood Pressure")
    story.append(P('"Tracking" refers to the phenomenon where individuals who have high blood pressure levels early in life (childhood/adolescence) tend to maintain that higher rank as they age. Blood pressure levels tend to persist in the same relative position in the distribution over time. This helps identify children "at risk" of developing hypertension in the future.'))
    story.append(Spacer(1, 3))

    story += sub_header("3.5 Prevention of Hypertension – 3 Levels")

    prev_htn_table = make_table(
        ["Level", "Measures"],
        [
            ["Primordial Prevention", "Prevent risk factors from emerging in the first place – healthy diet in children, active lifestyle promotion, no-tobacco policies"],
            ["Primary Prevention", "1. Dietary changes: Reduce salt <5g/day, DASH diet (Dietary Approaches to Stop Hypertension)\n2. Weight reduction: Aim BMI <25 kg/m²\n3. Physical activity: 30 min moderate exercise most days\n4. Reduce alcohol\n5. Stop smoking\n6. Stress management: yoga, meditation, relaxation techniques"],
            ["Secondary Prevention", "Screening & early detection (opportunistic screening of >30 yrs under NPCDCS)\nRegular BP monitoring\nAntihypertensive drug therapy when indicated"],
            ["Tertiary Prevention", "Management of complications: Stroke, renal failure, heart failure, retinopathy\nRehabilitation"],
        ],
        col_widths=[4.5*cm, 12.5*cm]
    )
    story.append(prev_htn_table)
    story.append(Spacer(1, 6))
    story += tip_box("DASH Diet = Dietary Approaches to Stop Hypertension: Rich in fruits, vegetables, low-fat dairy, low in saturated fats and sodium.")
    story.append(PageBreak())

    # ====================================================
    # SECTION 4: DIABETES MELLITUS
    # ====================================================
    story += section_header("4. DIABETES MELLITUS ⭐⭐⭐")

    story += exam_box("Exam Alert – Diabetes", [
        "Epidemiological determinants of Diabetes + Primary prevention of Type 2 DM (2014 – LAQ 12 marks)",
        "Classification of Diabetes (WHO 2019) – Short note",
        "Diagnostic criteria for Diabetes – Short note",
        "NPCDCS – Diabetes component",
        "Metabolic syndrome – Short note",
    ])

    story += sub_header("4.1 Definition")
    story.append(P("Diabetes mellitus describes a group of metabolic disorders characterized by hyperglycaemia in the absence of treatment. The heterogeneous aetio-pathology includes defects in insulin secretion, insulin action, or both, and disturbances of carbohydrate, fat and protein metabolism."))
    story.append(Spacer(1, 3))

    story += sub_header("4.2 Classification of Diabetes (WHO 2019)")

    dm_class_table = make_table(
        ["Type", "Description"],
        [
            ["Type 1 Diabetes", "β-cell destruction (mostly immune-mediated); absolute insulin deficiency; onset in childhood/early adulthood"],
            ["Type 2 Diabetes", "Most common type; various degrees of β-cell dysfunction + insulin resistance; associated with overweight/obesity"],
            ["Hybrid Forms", "(a) Slowly evolving immune-mediated diabetes of adults (formerly LADA); (b) Ketosis-prone Type 2"],
            ["Other Specific Types", "Monogenic diabetes (MODY), diseases of exocrine pancreas (pancreatitis, cystic fibrosis), drug/chemical-induced"],
            ["Gestational Diabetes", "Hyperglycaemia diagnosed in 2nd or 3rd trimester of pregnancy; not overt diabetes"],
        ],
        col_widths=[4.5*cm, 12.5*cm]
    )
    story.append(dm_class_table)
    story.append(Spacer(1, 4))

    story += sub_header("4.3 Diagnostic Criteria (WHO)")
    diag_table = make_table(
        ["Test", "Diabetic", "Impaired/Pre-diabetic", "Normal"],
        [
            ["Fasting Plasma Glucose (FPG)", "≥ 7.0 mmol/L (126 mg/dL)", "6.1–6.9 mmol/L (IFG)", "< 6.1 mmol/L"],
            ["2-hr Post-load Glucose (OGTT)", "≥ 11.1 mmol/L (200 mg/dL)", "7.8–11.0 mmol/L (IGT)", "< 7.8 mmol/L"],
            ["HbA1c", "≥ 48 mmol/mol (≥ 6.5%)", "39–47 mmol/mol (5.7–6.4%)", "< 39 mmol/mol"],
            ["Random Plasma Glucose + symptoms", "≥ 11.1 mmol/L (200 mg/dL)", "–", "–"],
        ],
        col_widths=[5*cm, 4.5*cm, 4*cm, 3.5*cm]
    )
    story.append(diag_table)
    story.append(Spacer(1, 4))

    story += sub_header("4.4 Risk Factors / Epidemiological Determinants")

    story.append(H3("A. Non-Modifiable"))
    story.append(B("Age: Type 2 DM prevalence rises with age (>40 years)"))
    story.append(B("Genetic/Family History: Monozygotic twin concordance ~90% for Type 2 DM"))
    story.append(B("Ethnicity: Higher in South Asians, Pima Indians, Hispanic populations"))
    story.append(B("Gestational history: GDM, macrosomic babies"))
    story.append(Spacer(1, 3))

    story.append(H3("B. Modifiable (Environmental) Risk Factors"))
    story.append(B("Obesity (especially abdominal/visceral): MOST IMPORTANT risk factor for Type 2 DM. 44% of global diabetes burden attributable to overweight/obesity"))
    story.append(B("Physical inactivity: Sedentary lifestyle alters insulin-receptor interaction"))
    story.append(B("Unhealthy diet: High saturated fat, low dietary fibre increase risk; high fibre (>20g/day) is protective"))
    story.append(B("Alcohol: Excessive intake damages pancreas, promotes obesity"))
    story.append(B("Viral infections: Rubella, mumps, Coxsackie B4 may trigger Type 1 DM"))
    story.append(B("Malnutrition: PEM in early infancy → β-cell damage → impaired glucose tolerance"))
    story.append(B("Stress: Psychological and physiological stress → cortisol → insulin resistance"))
    story.append(Spacer(1, 4))

    story += sub_header("4.5 Primary Prevention of Type 2 Diabetes")

    prev_dm_table = make_table(
        ["Intervention", "Evidence/Target"],
        [
            ["Weight reduction", "Even 5-7% weight loss reduces T2DM risk by 58% (DPP Trial). Aim BMI <23 kg/m² for Asians"],
            ["Physical activity", "150 min/week moderate activity. Increases insulin sensitivity, reduces abdominal fat"],
            ["Dietary modification", "High fibre (>20g/day), low saturated fat, low glycaemic index foods. Mediterranean diet is protective"],
            ["Avoid tobacco & excess alcohol", "Both increase insulin resistance and pancreatic damage"],
            ["Screen high-risk groups", "Fasting glucose + OGTT for obese, family history, GDM, age >40 years"],
            ["Metformin (pharmacological)", "For high-risk individuals (IGT + IFG): reduces progression to diabetes by 31% (UKPDS/DPP)"],
        ],
        col_widths=[5.5*cm, 11.5*cm]
    )
    story.append(prev_dm_table)
    story.append(Spacer(1, 4))

    story += tip_box("KEY FACT: India has ~77 million diabetics (2nd highest worldwide after China). Often called 'Diabetes Capital of the World'. Mention this in exam answers.")
    story.append(PageBreak())

    # ====================================================
    # SECTION 5: CANCER
    # ====================================================
    story += section_header("5. CANCER – EPIDEMIOLOGY & PREVENTION ⭐⭐⭐")

    story += exam_box("Exam Alert – Cancer", [
        "Cancers most frequent in India + Early warning signs + Prevention of Ca Cervix (2009 – 12 marks)",
        "Danger signals/Early signs of cancer + Oral cancer epidemiology & prevention (2008, 2013)",
        "Screening for cancer cervix – Short note",
        "Oral cancer – Short note",
        "Cancer registration in India – Short note",
    ])

    story += sub_header("5.1 Definition & Classification")
    story.append(P("Cancer is a group of diseases characterized by: (i) abnormal growth of cells (ii) ability to invade adjacent tissues and distant organs, and (iii) eventual death if untreated. Major categories:"))
    story.append(B("Carcinomas: Arise from epithelial cells (mouth, oesophagus, uterus, skin) – most common"))
    story.append(B("Sarcomas: Arise from mesodermal/connective tissue cells (bone, fat, fibrous tissue)"))
    story.append(B("Lymphomas, Myeloma, Leukaemias: From bone marrow and immune system cells"))
    story.append(Spacer(1, 4))

    story += sub_header("5.2 Global & Indian Burden (2020)")

    burden_table = make_table(
        ["Parameter", "Global (2020)", "India"],
        [
            ["New cancer cases", "19.29 million", "1.39 million"],
            ["Cancer deaths", "9.96 million", "0.92 million"],
            ["Most common cancer (incidence)", "Breast (F), Lung (M)", "Breast (F), Oral/Lip (M)"],
            ["Most common cause of cancer death", "Lung, Liver, Stomach, Breast", "Oral, Cervix, Breast (F); Oral, Lung (M)"],
            ["5-year prevalent cases", "50.55 million", "~3.5 million"],
        ],
        col_widths=[5.5*cm, 6*cm, 5.5*cm]
    )
    story.append(burden_table)
    story.append(Spacer(1, 4))

    story += sub_header("5.3 Early Warning Signs of Cancer (7 Danger Signals – CAUTION)")

    caution_table = make_table(
        ["Letter", "Warning Sign"],
        [
            ["C", "Change in bowel or bladder habits"],
            ["A", "A sore that does not heal"],
            ["U", "Unusual bleeding or discharge"],
            ["T", "Thickening or lump in breast or elsewhere"],
            ["I", "Indigestion or difficulty in swallowing"],
            ["O", "Obvious change in wart or mole"],
            ["N", "Nagging cough or hoarseness of voice"],
        ],
        col_widths=[2.5*cm, 14.5*cm]
    )
    story.append(caution_table)
    story.append(Spacer(1, 4))
    story += tip_box("Mnemonic: CAUTION – the 7 danger signals of cancer. This is a very commonly asked objective/short note in DUHS exams.")

    story += sub_header("5.4 Cancer Registration in India")
    story.append(B("Cancer is not a notifiable disease in India"))
    story.append(B("Population-Based Cancer Registries (PBCR): Provide incidence & mortality data for defined population"))
    story.append(B("Hospital-Based Cancer Registries (HBCR): Provide data on cancer patients attending hospitals"))
    story.append(B("National Cancer Registry Programme (NCRP): Under ICMR, started 1981"))
    story.append(B("India currently has 30+ PBCRs covering ~15% of population"))
    story.append(Spacer(1, 4))

    story += sub_header("5.5 Oral Cancer")
    story += exam_box("High Yield – Oral Cancer", [
        "Most common cancer in MALES in India",
        "Epidemiology, causes, and prevention asked repeatedly",
    ])
    story.append(B("Most common cancer in males in India (especially in rural areas)"))
    story.append(B("Risk factors: Tobacco (smoking + smokeless), Alcohol, Betel nut chewing, HPV, poor oral hygiene, OSMF (oral submucous fibrosis)"))
    story.append(B("Precancerous lesions: Leukoplakia, erythroplakia, OSMF"))
    story.append(B("Prevention: Tobacco cessation programs, early detection, VIA-type screening"))
    story.append(B("Treatment: Surgery, radiotherapy, chemotherapy"))
    story.append(Spacer(1, 4))

    story += sub_header("5.6 Cancer Cervix")
    story.append(B("Second most common cancer in women in India"))
    story.append(B("Risk factors: Early sexual intercourse, multiple sexual partners, HPV (types 16, 18), multiparity, low socioeconomic status, smoking"))
    story.append(B("HPV 16 and 18 responsible for ~70% of cervical cancers"))
    story.append(Spacer(1, 3))
    story.append(H3("Screening for Cancer Cervix:"))
    story.append(B("Pap smear (Papanicolaou test): Detects cancer in situ. Every 3 years after onset of sexual activity"))
    story.append(B("VIA (Visual Inspection with Acetic Acid): 5% acetic acid applied – acetowhite lesion = positive. Simpler, cheaper, suitable for India"))
    story.append(B("VIAM: VIA with magnification"))
    story.append(B("VILI: Visual Inspection with Lugol's Iodine"))
    story.append(B("HPV DNA test: High sensitivity; co-testing with Pap smear"))
    story.append(Spacer(1, 4))
    story.append(H3("Prevention of Cancer Cervix:"))
    story.append(B("Primary: HPV vaccination (Gardasil/Cervarix) – for girls 9-26 years; delay sexual debut; safe sex; tobacco cessation"))
    story.append(B("Secondary: Screening programs (Pap smear / VIA)"))
    story.append(B("Tertiary: Treatment of early lesions (cryotherapy, LEEP, cone biopsy)"))
    story.append(Spacer(1, 4))

    story += sub_header("5.7 Cancer Control (3-Level Approach)")
    control_table = make_table(
        ["Level", "Approach"],
        [
            ["Primary Prevention", "Avoid tobacco, alcohol, betel nut; HPV vaccination; healthy diet; reduce occupational carcinogens"],
            ["Secondary Prevention (Early Detection)", "Screening programs (Pap smear, VIA, mammography, FOBT for colorectal); Cancer detection clinics"],
            ["Tertiary (Treatment)", "Surgery, radiotherapy, chemotherapy; multi-modality approach; pain relief/palliative care for advanced disease"],
        ],
        col_widths=[4.5*cm, 12.5*cm]
    )
    story.append(control_table)
    story.append(Spacer(1, 6))
    story.append(PageBreak())

    # ====================================================
    # SECTION 6: STROKE
    # ====================================================
    story += section_header("6. STROKE (CEREBROVASCULAR DISEASE) ⭐⭐")

    story += sub_header("6.1 Definition & Types")
    story.append(P("Stroke is defined as a rapidly developing clinical sign of focal or global disturbance of cerebral function, lasting more than 24 hours (or leading to death), with no apparent cause other than of vascular origin (WHO definition)."))
    stroke_table = make_table(
        ["Type", "Description", "Frequency"],
        [
            ["Ischaemic Stroke", "Thrombotic or embolic occlusion of cerebral artery", "~80-85%"],
            ["Haemorrhagic Stroke", "Rupture of cerebral blood vessel – intracerebral or subarachnoid", "~15-20%"],
            ["TIA (Transient Ischaemic Attack)", "Stroke symptoms lasting <24 hours; 'mini-stroke'; warning sign", "–"],
        ],
        col_widths=[4*cm, 9*cm, 4*cm]
    )
    story.append(stroke_table)
    story.append(Spacer(1, 4))

    story += sub_header("6.2 Risk Factors for Stroke")
    story.append(B("Hypertension: SINGLE MOST IMPORTANT modifiable risk factor for stroke"))
    story.append(B("Diabetes mellitus: 2-3x increased risk"))
    story.append(B("Smoking: Doubles stroke risk; cessation reduces risk within 2 years"))
    story.append(B("Atrial fibrillation: 5x increased risk of embolic stroke"))
    story.append(B("Dyslipidaemia: High LDL associated with ischaemic stroke"))
    story.append(B("Obesity, Physical inactivity, Unhealthy diet"))
    story.append(B("Age (>60), Male sex, Family history, Previous TIA/stroke"))
    story.append(Spacer(1, 4))

    story += sub_header("6.3 Prevention")
    story.append(B("Control hypertension (most effective intervention – reduces stroke by 35-40%)"))
    story.append(B("Anti-platelet therapy (aspirin) for high-risk patients"))
    story.append(B("Anticoagulation for atrial fibrillation"))
    story.append(B("Statin therapy for dyslipidaemia"))
    story.append(B("Lifestyle: stop smoking, exercise, healthy diet, weight control"))
    story.append(PageBreak())

    # ====================================================
    # SECTION 7: OBESITY
    # ====================================================
    story += section_header("7. OBESITY & OVERWEIGHT ⭐⭐")

    story += sub_header("7.1 Definition – BMI Classification (WHO)")
    bmi_table = make_table(
        ["Category", "BMI (kg/m²)", "Asian BMI"],
        [
            ["Underweight", "< 18.5", "< 18.5"],
            ["Normal", "18.5 – 24.9", "18.5 – 22.9"],
            ["Overweight / Pre-obese", "25.0 – 29.9", "23 – 24.9"],
            ["Obese Class I", "30.0 – 34.9", "25 – 29.9"],
            ["Obese Class II", "35.0 – 39.9", "≥ 30"],
            ["Obese Class III (Morbid)", "≥ 40", "–"],
        ],
        col_widths=[6*cm, 5.5*cm, 5.5*cm]
    )
    story.append(bmi_table)
    story.append(Spacer(1, 4))

    story += sub_header("7.2 Waist Circumference (Abdominal Obesity)")
    story.append(B("Risk significantly increased: Males >102 cm (>90 cm for Asians), Females >88 cm (>80 cm for Asians)"))
    story.append(B("Waist-Hip Ratio (WHR): Males >1.0, Females >0.85 indicates abdominal obesity"))
    story.append(B("Android (apple-shaped) obesity: More dangerous than gynoid (pear-shaped) obesity"))
    story.append(Spacer(1, 4))

    story += sub_header("7.3 Health Consequences of Obesity")
    story.append(B("CVD: HTN, CHD, stroke"))
    story.append(B("Metabolic: Type 2 DM, dyslipidaemia, metabolic syndrome"))
    story.append(B("Cancers: Breast, colorectal, endometrium, kidney, oesophagus"))
    story.append(B("Musculoskeletal: Osteoarthritis, gout"))
    story.append(B("Respiratory: Sleep apnoea, obesity hypoventilation syndrome"))
    story.append(B("Psychosocial: Depression, low self-esteem, social discrimination"))
    story.append(B("Gastrointestinal: GERD, gallstones, fatty liver (NAFLD)"))
    story.append(Spacer(1, 3))
    story.append(P("Global stats: In 2016, >1.9 billion adults overweight; >650 million obese. At least 3.4 million adults die annually from being overweight. Obesity doubled since 1980."))
    story.append(Spacer(1, 4))

    story += sub_header("7.4 Prevention of Obesity")
    story.append(B("Balanced diet – reduce calorie-dense, nutrient-poor foods; increase fruits, vegetables, fibre"))
    story.append(B("Regular physical activity – ≥150 min/week moderate intensity"))
    story.append(B("Restrict screen time (especially children)"))
    story.append(B("Breastfeeding – protective against childhood obesity"))
    story.append(B("Behaviour change communication (BCC) and health education"))
    story.append(B("NPCDCS – opportunistic screening for obesity in >30 years age group"))
    story.append(PageBreak())

    # ====================================================
    # SECTION 8: NPCDCS
    # ====================================================
    story += section_header("8. NPCDCS – NATIONAL PROGRAMME FOR PREVENTION & CONTROL OF CANCER, DIABETES, CVD & STROKE ⭐⭐")

    story += exam_box("Exam Alert – NPCDCS", [
        "Components under NPCDCS – 12 marks (S'16)",
        "Objectives of NPCDCS – Short note",
        "NPCDCS implementation strategy",
    ])

    story += sub_header("8.1 Background")
    story.append(B("India is experiencing rapid health transition – NCDs now account for 60% of all deaths (2016)"))
    story.append(B("NCDs were surpassing communicable diseases; existing health system was focused on CDs"))
    story.append(B("National Programme for Prevention and Control of Diabetes, CVD and Stroke was first launched"))
    story.append(B("Later integrated with National Cancer Control Programme to form NPCDCS"))
    story.append(B("During 11th Five Year Plan: 100 districts in 21 states covered"))
    story.append(B("During 12th Five Year Plan: All districts covered in phased manner"))
    story.append(Spacer(1, 4))

    story += sub_header("8.2 Objectives of NPCDCS")
    story.append(B("Prevent and control common NCDs through behaviour and lifestyle changes"))
    story.append(B("Provide early diagnosis and management of common NCDs"))
    story.append(B("Build capacity at various levels of health care for prevention, diagnosis and treatment"))
    story.append(B("Train human resource within public health set-up (doctors, paramedics, nursing staff)"))
    story.append(B("Establish and develop capacity for palliative and rehabilitative care"))
    story.append(Spacer(1, 4))

    story += sub_header("8.3 Components")
    comp_table = make_table(
        ["Component", "Details"],
        [
            ["A. Diabetes, CVD & Stroke (DCS)", "Health promotion, capacity building, early diagnosis & management, integration with primary health care"],
            ["B. Cancer Component", "Integrated with cancer control; district cancer centres; capacity building; screening programmes"],
        ],
        col_widths=[5*cm, 12*cm]
    )
    story.append(comp_table)
    story.append(Spacer(1, 4))

    story += sub_header("8.4 Implementation Strategy")
    story.append(B("Health promotion at sub-centre level – camps, interpersonal communication, posters/banners"))
    story.append(B("Opportunistic screening of persons above 30 years of age"))
    story.append(B("NCD Clinic established at Community Health Centre (CHC) and District level"))
    story.append(B("Behavioural change messages: Increased healthy food intake; Physical activity; Avoid tobacco/alcohol; Stress management"))
    story.append(B("Implementation through 20,000 sub-centres and 700 CHCs in 100 districts"))
    story.append(Spacer(1, 4))
    story += tip_box("For exam: Remember NPCDCS covers 4 conditions: Cancer, Diabetes, CVD, Stroke. Screening starts at age 30 years. NCD clinic is at CHC level.")
    story.append(PageBreak())

    # ====================================================
    # SECTION 9: ROAD TRAFFIC ACCIDENTS
    # ====================================================
    story += section_header("9. ROAD TRAFFIC ACCIDENTS (RTA) ⭐")

    story += exam_box("Exam Alert – RTA", [
        "Measures to reduce RTA problem as BMOH at highway BPHC (2009 – 12 marks)",
    ])

    story += sub_header("9.1 Problem Statement")
    story.append(B("WHO lists road traffic injuries as a major public health problem"))
    story.append(B("~1.35 million deaths/year globally from RTAs (2018)"))
    story.append(B("RTAs are the leading cause of death in the 5-29 year age group"))
    story.append(B("India has one of the highest RTA death rates – ~1.5 lakh deaths/year"))
    story.append(B("50% of RTA deaths involve vulnerable road users: pedestrians, cyclists, motorcyclists"))
    story.append(Spacer(1, 4))

    story += sub_header("9.2 Risk Factors (Haddon Matrix – Host, Agent, Environment)")
    story.append(B("Host (Human) factors: Speeding, drunk driving, fatigue, young/inexperienced drivers, no seat belt/helmet"))
    story.append(B("Agent/Vehicle factors: Poor brakes, no airbags, no seat belts, overloading"))
    story.append(B("Environment factors: Poor road condition, no dividers, poor lighting, sharp bends, heavy traffic"))
    story.append(Spacer(1, 4))

    story += sub_header("9.3 Role of BMOH in Reducing RTA")
    story.append(B("Health education campaigns: Awareness about dangers of drunk driving, speeding, not wearing helmet/seatbelt"))
    story.append(B("Trauma care preparedness: First aid training for staff; trauma stabilization room at BPHC"))
    story.append(B("Coordination with police, PWD (road works), transport department"))
    story.append(B("Referral linkage: Establish referral system to district hospital for serious cases"))
    story.append(B("Surveillance: Maintain data on RTA cases attending BPHC"))
    story.append(B("Community involvement: Village health committees, NGOs for awareness"))
    story.append(B("Intersectoral coordination: Schools, transport dept, local body for speed controls, road safety"))
    story.append(B("Golden hour concept: Ensure rapid transport and treatment within 1 hour of injury"))
    story.append(Spacer(1, 4))
    story.append(PageBreak())

    # ====================================================
    # SECTION 10: MENTAL HEALTH
    # ====================================================
    story += section_header("10. MENTAL HEALTH ⭐")

    story += sub_header("10.1 Burden")
    story.append(B("Mental disorders affect 1 in 4 people globally at some point in their lives"))
    story.append(B("Depression is the leading cause of disability worldwide (WHO)"))
    story.append(B("~800,000 suicides/year globally; suicide is 2nd leading cause of death (15-29 years)"))
    story.append(B("In India: National Mental Health Survey (2015-16) showed 10.6% prevalence of mental disorders"))
    story.append(Spacer(1, 4))

    story += sub_header("10.2 Important Mental Disorders")
    story.append(B("Schizophrenia: 1% prevalence; positive and negative symptoms; treated with antipsychotics"))
    story.append(B("Depression: Most common; treated with SSRIs, CBT"))
    story.append(B("Anxiety disorders: Panic disorder, GAD, phobias, OCD, PTSD"))
    story.append(B("Substance use disorders: Alcohol, opioids, cannabis"))
    story.append(B("Bipolar disorder, Dementia, Child mental health disorders (ADHD, autism)"))
    story.append(Spacer(1, 4))

    story += sub_header("10.3 National Mental Health Programme (NMHP)")
    story.append(B("Launched in 1982 in India"))
    story.append(B("Objectives: Prevention and treatment of mental and neurological disorders; rehabilitation"))
    story.append(B("District Mental Health Programme (DMHP): Integration of mental health at district level – covers outpatient, inpatient, community outreach"))
    story.append(B("Mental Health Action Plan (WHO 2013-2020): Universal health coverage for mental health"))
    story.append(B("Rights of Persons with Disabilities Act 2016 includes mental illness"))
    story.append(B("Mental Healthcare Act 2017: Right to access mental health care"))
    story.append(Spacer(1, 4))
    story.append(PageBreak())

    # ====================================================
    # QUICK REVISION
    # ====================================================
    story += section_header("QUICK REVISION – IMPORTANT NUMBERS & FACTS")

    story.append(P("Use this section for last-minute revision before exams:"))
    story.append(Spacer(1, 4))

    quick_rev = make_table(
        ["Topic", "Key Fact / Number"],
        [
            ["NCD deaths globally", "41 million/year = 74% of all deaths"],
            ["Tobacco deaths/year", "~7 million globally. Causes 71% lung cancer"],
            ["Alcohol deaths/year", "3.3 million = 5.9% of global deaths"],
            ["Physical inactivity deaths", "1.6 million/year; 20-30% increased all-cause mortality"],
            ["Hypertension deaths/year", "9.4 million; 12.8% of all deaths; global prevalence ~22%"],
            ["Obesity deaths/year", "2.8 million (overweight/obese)"],
            ["Obesity global stats", ">1.9 billion overweight; >650 million obese (2016)"],
            ["Global cancer (2020)", "19.29 million new cases; 9.96 million deaths"],
            ["India diabetes", "~77 million diabetics (2nd worldwide after China)"],
            ["DM diagnostic – FPG", "≥126 mg/dL (7.0 mmol/L)"],
            ["DM diagnostic – 2hr OGTT", "≥200 mg/dL (11.1 mmol/L)"],
            ["DM prevention – DPP trial", "5-7% weight loss reduces T2DM risk by 58%"],
            ["NPCDCS", "Covers Cancer, Diabetes, CVD, Stroke; screens >30 yrs"],
            ["India cancer – most common (M)", "Lip/Oral cavity cancer"],
            ["India cancer – most common (F)", "Breast cancer"],
            ["Cancer cervix screening", "Pap smear every 3 years OR VIA (5% acetic acid)"],
            ["HPV types (cervix)", "HPV 16 & 18 cause ~70% cervical cancers"],
            ["Danger signals of cancer", "CAUTION (7 signs)"],
            ["Framingham Study started", "1951, Framingham, Massachusetts (prospective cohort)"],
            ["RTA deaths – India", "~1.5 lakh/year"],
            ["RTA deaths globally", "~1.35 million/year (2018)"],
            ["NMHP launched", "1982 in India"],
            ["Salt intake – WHO recommendation", "<5 g/day for reducing BP"],
            ["BMI – overweight", "≥25 (≥23 for Asians)"],
            ["BMI – obese", "≥30 (≥25 for Asians)"],
        ],
        col_widths=[7*cm, 10*cm]
    )
    story.append(quick_rev)
    story.append(Spacer(1, 6))
    story.append(PageBreak())

    # ====================================================
    # MODEL ANSWERS
    # ====================================================
    story += section_header("MODEL ANSWER FRAMEWORKS – TOP EXAM QUESTIONS")

    story += sub_header("LAQ Framework: Hypertension (12-15 marks)")
    fw1 = [
        "1. Introduction/Definition (1-2 marks)",
        "2. Problem statement – Prevalence in India & globally (2 marks)",
        "3. Classification (JNC 7 table) (2 marks)",
        "4. Risk factors – non-modifiable + modifiable (tabular) (3-4 marks)",
        "5. Prevention – Primordial, Primary, Secondary, Tertiary (3-4 marks)",
        "6. NPCDCS – mention (1 mark)",
        "7. Conclusion (1 mark)",
    ]
    for f in fw1:
        story.append(B(f))
    story.append(Spacer(1, 6))

    story += sub_header("LAQ Framework: Diabetes – Epidemiology + Primary Prevention (12 marks)")
    fw2 = [
        "1. Introduction + Classification (WHO 2019) (2 marks)",
        "2. Problem statement – India 77 million, 2nd worldwide (1 mark)",
        "3. Diagnostic criteria (table: FPG, OGTT, HbA1c) (2 marks)",
        "4. Epidemiological determinants: Non-modifiable + Modifiable (table) (3 marks)",
        "5. Primary prevention of Type 2 DM: Weight, Diet, Exercise, Metformin, Screening (4 marks)",
        "6. NPCDCS mention (1 mark)",
    ]
    for f in fw2:
        story.append(B(f))
    story.append(Spacer(1, 6))

    story += sub_header("LAQ Framework: Cancer – Types in India + Warning Signs + Ca Cervix Prevention (12 marks)")
    fw3 = [
        "1. Introduction – definition, magnitude in India (2 marks)",
        "2. Common cancers in India: Males (Oral>Lung>Colorectal) Females (Breast>Cervix>Ovary) – tabular (2 marks)",
        "3. Early warning signs – CAUTION mnemonic (3 marks)",
        "4. Prevention of Ca Cervix – HPV vaccine, Pap smear, VIA (detailed) (4 marks)",
        "5. Cancer control in community (1 mark)",
    ]
    for f in fw3:
        story.append(B(f))
    story.append(Spacer(1, 6))

    story += sub_header("LAQ Framework: CHD – Risk Factors + Prevention (12 marks)")
    fw4 = [
        "1. Definition of CHD/IHD (1 mark)",
        "2. Problem statement + Framingham Study mention (1 mark)",
        "3. Risk factors: Non-modifiable (Age, Sex, Genetics) + Modifiable Big 4 (Hypertension, Cholesterol, Smoking, Inactivity) + Other modifiable (Diabetes, Obesity, Diet, Stress) – tabular format (6 marks)",
        "4. Prevention strategies: Population strategy, High-risk strategy, Secondary prevention (4 marks)",
    ]
    for f in fw4:
        story.append(B(f))
    story.append(Spacer(1, 6))

    # Footer
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        "Content sourced from Park's PSM Textbook & standard community medicine curriculum. | "
        "Always verify with your college faculty for any university-specific updates.",
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<!-- COVER -->
<div class="cover">
  <h1>NON-COMMUNICABLE DISEASES</h1>
  <p><b>Comprehensive PSM Study Notes</b></p>
  <p>MBBS 3rd Year | Community Medicine</p>
  <p>Based on Park's PSM & Suryakanta PSM Syllabus</p>
  <div class="badge">
    <b>Exam Authority:</b> Pt. Deendayal Upadhyay Memorial Health Sciences &amp; Ayush University (DUHS), Chhattisgarh<br>
    <b>Subject:</b> Community Medicine – Paper I | Section B<br>
    <b>Pattern:</b> 1 LAQ (15M) + 5 SAQ (5M) + 10 Objectives (1M)<br>
    <b>Prepared by:</b> Orris AI | June 2026
  </div>
</div>

<!-- TABLE OF CONTENTS -->
<div class="toc">
  <h2>📋 Table of Contents</h2>
  <ol>
    <li><a href="#pya">Previous Year Question Analysis</a></li>
    <li><a href="#intro">Introduction to NCDs</a></li>
    <li><a href="#chd">Coronary Heart Disease (CHD) ⭐⭐⭐</a></li>
    <li><a href="#htn">Hypertension ⭐⭐⭐</a></li>
    <li><a href="#dm">Diabetes Mellitus ⭐⭐⭐</a></li>
    <li><a href="#cancer">Cancer ⭐⭐⭐</a></li>
    <li><a href="#stroke">Stroke ⭐⭐</a></li>
    <li><a href="#obesity">Obesity ⭐⭐</a></li>
    <li><a href="#npcdcs">NPCDCS Programme ⭐⭐</a></li>
    <li><a href="#rta">Road Traffic Accidents ⭐</a></li>
    <li><a href="#mental">Mental Health ⭐</a></li>
    <li><a href="#qr">Quick Revision – Key Numbers</a></li>
    <li><a href="#model">Model Answer Frameworks</a></li>
  </ol>
</div>

<!-- ===================== PYQ ANALYSIS ===================== -->
<div id="pya" class="sec-header">📊 PREVIOUS YEAR QUESTION ANALYSIS – DUHS CHHATTISGARH</div>

<div class="exam-box">
  <div class="exam-title">⭐ MOST ASKED – Long Answer Questions (LAQ 12–15 Marks)</div>
  <ul>
    <li>Essential Hypertension – epidemiology, risk factors, prevention (2015, S'16, S'09, S'13)</li>
    <li>Coronary Heart Disease – risk factors + prevention (2012, S'16, S'09, S'13)</li>
    <li>Diabetes mellitus – epidemiology + primary prevention of Type 2 DM (2014)</li>
    <li>Cancer in India – types + early warning signs + prevention of Ca Cervix/Oral Ca (2009, 2013)</li>
    <li>NPCDCS – components, objectives, strategies (S'16)</li>
    <li>Road Traffic Accidents – measures as BMOH (2009)</li>
  </ul>
</div>

<div class="exam-box">
  <div class="exam-title">⭐ MOST ASKED – Short Notes (SAQ 5 Marks)</div>
  <ul>
    <li>Risk factors / Classification of Hypertension</li>
    <li>Screening for cancer cervix (Pap smear, VIA)</li>
    <li>Oral cancer – epidemiology & prevention</li>
    <li>Diabetes – diagnostic criteria & prevention</li>
    <li>Obesity – BMI, waist circumference, health risks</li>
    <li>Framingham Heart Study</li>
    <li>NPCDCS programme components</li>
    <li>Metabolic syndrome</li>
    <li>Stroke – risk factors & prevention</li>
    <li>Cancer registration in India (PBCR, HBCR)</li>
  </ul>
</div>

<div class="card">
  <div class="tbl-wrap">
    <table>
      <tr><th>Topic</th><th>Times Asked</th><th>Priority</th></tr>
      <tr><td>Hypertension</td><td>5+</td><td>⭐⭐⭐ HIGH</td></tr>
      <tr><td>Coronary Heart Disease</td><td>4+</td><td>⭐⭐⭐ HIGH</td></tr>
      <tr><td>Cancer (Oral/Cervix)</td><td>4+</td><td>⭐⭐⭐ HIGH</td></tr>
      <tr><td>Diabetes Mellitus</td><td>3+</td><td>⭐⭐⭐ HIGH</td></tr>
      <tr><td>NPCDCS Programme</td><td>2+</td><td>⭐⭐ MEDIUM</td></tr>
      <tr><td>Obesity</td><td>2+</td><td>⭐⭐ MEDIUM</td></tr>
      <tr><td>Road Traffic Accidents</td><td>1+</td><td>⭐ LOW-MED</td></tr>
      <tr><td>Stroke</td><td>1+</td><td>⭐ LOW-MED</td></tr>
      <tr><td>Mental Health</td><td>1+</td><td>⭐ LOW-MED</td></tr>
    </table>
  </div>
</div>

<!-- ===================== INTRODUCTION ===================== -->
<div id="intro" class="sec-header">1. INTRODUCTION TO NON-COMMUNICABLE DISEASES</div>

<div class="card">
  <div class="sub-header">1.1 What are NCDs?</div>
  <p>Non-communicable diseases (NCDs) are chronic diseases that are <b>not passed from person to person</b>. They are of long duration and generally slow progression. The 4 main types are cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes.</p>
  <br>
  <div class="tbl-wrap">
    <table>
      <tr><th>Risk Factor</th><th>Deaths/Year</th><th>Key Fact</th></tr>
      <tr><td>Tobacco</td><td>~7 million</td><td>71% lung cancer, 42% chronic respiratory disease, 10% CVD</td></tr>
      <tr><td>Physical Inactivity</td><td>1.6 million</td><td>20–30% increased all-cause mortality</td></tr>
      <tr><td>Harmful Alcohol</td><td>3.3 million</td><td>5.9% of global deaths; cancers, CVD, liver cirrhosis</td></tr>
      <tr><td>Unhealthy Diet</td><td>–</td><td>High salt → HTN; 4.1M CVD deaths from excess sodium</td></tr>
      <tr><td>Raised Blood Pressure</td><td>9.4 million</td><td>12.8% of all deaths; global prevalence ~22%</td></tr>
      <tr><td>Overweight/Obesity</td><td>2.8 million</td><td>Raises risk of CVD, DM, certain cancers</td></tr>
    </table>
  </div>
  <div class="tip-box" style="margin-top:10px"><b>Mnemonic:</b> <b>TAPU</b> = Tobacco, Alcohol, Physical inactivity, Unhealthy diet — the 4 key behavioral NCD risk factors. Very commonly asked in objectives!</div>
</div>

<div class="card">
  <div class="sub-header">1.2 Global & India Burden</div>
  <ul class="bl">
    <li>NCDs cause <b>74% of all deaths globally</b> = 41 million/year (WHO)</li>
    <li>77% of NCD deaths occur in low- and middle-income countries</li>
    <li>In India (2016): NCDs accounted for <b>60% of all deaths</b></li>
    <li>India is called the <b>"Diabetes Capital of the World"</b> (~77 million diabetics)</li>
  </ul>
</div>

<!-- ===================== CHD ===================== -->
<div id="chd" class="sec-header">2. CORONARY HEART DISEASE (CHD) <span>⭐⭐⭐ Most Repeated</span></div>

<div class="exam-box">
  <div class="exam-title">⭐ Exam Alert</div>
  <ul>
    <li>Risk factors of CHD – 8 marks (2012, S'16, S'09, S'13)</li>
    <li>Prevention & control of CHD – 4 marks</li>
    <li>Framingham Heart Study – Short note</li>
    <li>Population strategy vs High-risk strategy</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">2.1 Definition</div>
  <p>CHD refers to disease of heart resulting from <b>inadequate supply of oxygenated blood</b> due to <b>atherosclerosis of coronary arteries</b>. Also called Ischaemic Heart Disease (IHD).</p>
</div>

<div class="card">
  <div class="sub-header">2.2 Risk Factors of CHD</div>
  <b style="color:#1a3a5c">A. Non-Modifiable</b>
  <ul class="bl">
    <li><b>Age:</b> Risk increases with age; most events after 50 years</li>
    <li><b>Sex:</b> Males at higher risk; post-menopausal women catch up</li>
    <li><b>Family History/Genetics:</b> Polygenic inheritance; first-degree relatives at risk</li>
  </ul>
  <br>
  <b style="color:#1a3a5c">B. Modifiable – THE BIG FOUR ⭐</b>
  <div class="tbl-wrap">
    <table>
      <tr><th>Risk Factor</th><th>Details</th><th>Threshold</th></tr>
      <tr><td><b>1. Hypertension</b></td><td>Single most useful test; accelerates atherosclerosis</td><td>SBP >140 / DBP >90 mmHg</td></tr>
      <tr><td><b>2. Hypercholesterolaemia</b></td><td>CHD rare if cholesterol &lt;200 mg/dl; Seven Countries Study confirmed</td><td>&gt;200 mg/dl</td></tr>
      <tr><td><b>3. Cigarette Smoking</b></td><td>Dose-response; synergistic with other risk factors</td><td>&gt;10 cigs/day = high risk</td></tr>
      <tr><td><b>4. Physical Inactivity</b></td><td>Sedentary life 1.9x increased risk</td><td>&lt;150 min/week activity</td></tr>
    </table>
  </div>
  <br>
  <b style="color:#1a3a5c">C. Other Modifiable</b>
  <ul class="bl">
    <li>Diabetes mellitus – 2–4x CHD risk</li>
    <li>Obesity – BMI &gt;30 kg/m²</li>
    <li>Unhealthy diet – high saturated fat, salt</li>
    <li>Type A personality – competitive, aggressive, time-pressured</li>
    <li>Alcohol (heavy use)</li>
    <li>Oral contraceptives (especially in smokers)</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">2.3 Prevention of CHD – 3 Strategies</div>
  <div class="tbl-wrap">
    <table>
      <tr><th>Strategy</th><th>Target</th><th>Methods</th></tr>
      <tr><td><b>1. Population Strategy</b></td><td>Whole community</td><td>Health education, dietary changes, anti-smoking campaigns, physical activity promotion</td></tr>
      <tr><td><b>2. High-Risk Strategy</b></td><td>Individuals with risk factors</td><td>Screening, treat HTN, dyslipidaemia, DM; smoking cessation</td></tr>
      <tr><td><b>3. Secondary Prevention</b></td><td>Established CHD patients</td><td>Aspirin, statins, beta-blockers, ACE inhibitors; PTCA/CABG; cardiac rehab</td></tr>
    </table>
  </div>
  <div class="tip-box"><b>Exam Tip:</b> "Population strategy has the greatest potential" – Geoffrey Rose's concept. Always mention this line.</div>
</div>

<div class="card">
  <div class="sub-header">2.4 Framingham Heart Study – Short Note</div>
  <ul class="bl">
    <li>Started <b>1951</b>, Framingham, Massachusetts, USA</li>
    <li>Best-known <b>prospective cohort study</b> on CHD</li>
    <li>Established 4 major CHD risk factors: elevated cholesterol, smoking, hypertension, sedentary habits</li>
    <li><b>Coined the term "risk factor"</b></li>
    <li>Still ongoing – multiple generations enrolled</li>
  </ul>
</div>

<!-- ===================== HYPERTENSION ===================== -->
<div id="htn" class="sec-header">3. HYPERTENSION <span>⭐⭐⭐ Most Repeated</span></div>

<div class="exam-box">
  <div class="exam-title">⭐ Exam Alert</div>
  <ul>
    <li>Definition, classification, risk factors, prevalence, prevention – 12 marks (2015)</li>
    <li>Risk factors for hypertension – Short note (S'16, S'09)</li>
    <li>Tracking of blood pressure – Short note</li>
    <li>Prevention of hypertension – Short note</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">3.1 Classification of BP (JNC 7)</div>
  <div class="tbl-wrap">
    <table>
      <tr><th>Category</th><th>Systolic (mmHg)</th><th>Diastolic (mmHg)</th></tr>
      <tr><td>Normal</td><td>&lt; 120</td><td>&lt; 80</td></tr>
      <tr><td>Pre-hypertension</td><td>120–129</td><td>&lt; 80</td></tr>
      <tr><td>Stage 1 HTN</td><td>130–139</td><td>80–89</td></tr>
      <tr><td>Stage 2 HTN</td><td>≥ 140</td><td>≥ 90</td></tr>
      <tr><td>Hypertensive Crisis</td><td>&gt; 180</td><td>&gt; 120</td></tr>
    </table>
  </div>
</div>

<div class="card">
  <div class="sub-header">3.2 Problem Statement</div>
  <ul class="bl">
    <li>Global: <b>~22% of adults</b> have raised BP (2015)</li>
    <li>Causes <b>9.4 million deaths/year</b> (12.8% of all deaths)</li>
    <li>India: 20–40% urban, 12–17% rural adults affected</li>
    <li>Single most useful predictor of CHD and stroke risk</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">3.3 Risk Factors</div>
  <b style="color:#1a3a5c">A. Non-Modifiable</b>
  <ul class="bl">
    <li><b>Age:</b> BP rises with age. Children of 2 hypertensive parents → <b>45% risk</b> (vs 3% if both parents normotensive)</li>
    <li><b>Sex:</b> Males higher in young adults; post-menopausal females increase</li>
    <li><b>Genetics:</b> Polygenic; confirmed by twin & family studies</li>
    <li><b>Race:</b> Higher in Black populations</li>
  </ul>
  <br>
  <b style="color:#1a3a5c">B. Modifiable ⭐</b>
  <ul class="bl">
    <li><b>Salt (Sodium):</b> Strong evidence; WHO recommends &lt;5g/day; INTERSALT study confirmed link</li>
    <li><b>Obesity:</b> Weight reduction of 10 kg → lowers SBP by 5–20 mmHg</li>
    <li><b>Alcohol:</b> Limit &lt;2 drinks/day (men), &lt;1 drink/day (women)</li>
    <li><b>Physical inactivity:</b> Regular aerobic exercise lowers SBP by 4–9 mmHg</li>
    <li><b>Low potassium/calcium, high saturated fat diet</b></li>
    <li><b>Stress/Psychosocial factors:</b> Occupational stress, urban life</li>
    <li><b>Oral contraceptives:</b> Oestrogen-containing OCP raises BP</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">3.4 Tracking of Blood Pressure</div>
  <div class="imp-box">KEY CONCEPT: "Tracking" = individuals with relatively high BP in childhood tend to maintain that higher rank as they age. Helps identify children "at risk" of future hypertension.</div>
</div>

<div class="card">
  <div class="sub-header">3.5 Prevention of Hypertension</div>
  <div class="tbl-wrap">
    <table>
      <tr><th>Level</th><th>Measures</th></tr>
      <tr><td><b>Primordial</b></td><td>Prevent risk factors from emerging – healthy diet in children, active lifestyle, no-tobacco policies</td></tr>
      <tr><td><b>Primary</b></td><td>↓ Salt &lt;5g/day (DASH diet), weight reduction (BMI &lt;25), exercise 30 min/day, ↓ alcohol, stop smoking, stress management</td></tr>
      <tr><td><b>Secondary</b></td><td>Screening &gt;30 yrs (NPCDCS), regular BP monitoring, antihypertensive drugs</td></tr>
      <tr><td><b>Tertiary</b></td><td>Manage complications: stroke, renal failure, heart failure, retinopathy</td></tr>
    </table>
  </div>
  <div class="tip-box"><b>DASH Diet</b> = Dietary Approaches to Stop Hypertension: rich in fruits, vegetables, low-fat dairy; low in saturated fats and sodium.</div>
</div>

<!-- ===================== DIABETES ===================== -->
<div id="dm" class="sec-header">4. DIABETES MELLITUS <span>⭐⭐⭐ Most Repeated</span></div>

<div class="exam-box">
  <div class="exam-title">⭐ Exam Alert</div>
  <ul>
    <li>Epidemiological determinants + Primary prevention of Type 2 DM (2014 – LAQ 12 marks)</li>
    <li>Classification of Diabetes (WHO 2019) – Short note</li>
    <li>Diagnostic criteria – Short note</li>
    <li>NPCDCS – Diabetes component</li>
    <li>Metabolic syndrome – Short note</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">4.1 Classification (WHO 2019)</div>
  <div class="tbl-wrap">
    <table>
      <tr><th>Type</th><th>Description</th></tr>
      <tr><td><b>Type 1 DM</b></td><td>β-cell destruction (immune-mediated); absolute insulin deficiency; onset in childhood/early adulthood</td></tr>
      <tr><td><b>Type 2 DM</b></td><td>Most common; β-cell dysfunction + insulin resistance; associated with overweight/obesity</td></tr>
      <tr><td><b>Hybrid Forms</b></td><td>Slowly evolving immune-mediated (LADA); Ketosis-prone Type 2</td></tr>
      <tr><td><b>Other Specific Types</b></td><td>MODY, pancreatic disease, drug-induced</td></tr>
      <tr><td><b>Gestational DM</b></td><td>Hyperglycaemia in 2nd/3rd trimester; not overt diabetes</td></tr>
    </table>
  </div>
</div>

<div class="card">
  <div class="sub-header">4.2 Diagnostic Criteria (WHO)</div>
  <div class="tbl-wrap">
    <table>
      <tr><th>Test</th><th>Diabetic</th><th>Pre-diabetic</th><th>Normal</th></tr>
      <tr><td>FPG</td><td>≥ 126 mg/dL</td><td>110–125 (IFG)</td><td>&lt; 110 mg/dL</td></tr>
      <tr><td>2-hr OGTT</td><td>≥ 200 mg/dL</td><td>140–199 (IGT)</td><td>&lt; 140 mg/dL</td></tr>
      <tr><td>HbA1c</td><td>≥ 6.5%</td><td>5.7–6.4%</td><td>&lt; 5.7%</td></tr>
      <tr><td>Random PG + symptoms</td><td>≥ 200 mg/dL</td><td>–</td><td>–</td></tr>
    </table>
  </div>
</div>

<div class="card">
  <div class="sub-header">4.3 Risk Factors / Epidemiological Determinants</div>
  <b style="color:#1a3a5c">A. Non-Modifiable</b>
  <ul class="bl">
    <li>Age: Type 2 DM rises after 40 years</li>
    <li>Genetics: Monozygotic twin concordance ~90% for Type 2</li>
    <li>Ethnicity: Higher in South Asians, Pima Indians</li>
    <li>Gestational history: GDM, macrosomic babies</li>
  </ul>
  <br>
  <b style="color:#1a3a5c">B. Modifiable (Environmental) ⭐</b>
  <ul class="bl">
    <li><b>Obesity (especially abdominal):</b> MOST IMPORTANT – 44% of global diabetes burden</li>
    <li><b>Physical inactivity:</b> Alters insulin-receptor interaction</li>
    <li><b>Unhealthy diet:</b> High saturated fat, low fibre; high fibre (&gt;20g/day) is protective</li>
    <li><b>Alcohol:</b> Damages pancreas, promotes obesity</li>
    <li><b>Viral infections:</b> Rubella, mumps, Coxsackie B4 → trigger Type 1 DM</li>
    <li><b>Malnutrition:</b> PEM in early infancy → β-cell damage</li>
    <li><b>Stress:</b> Cortisol → insulin resistance</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">4.4 Primary Prevention of Type 2 DM</div>
  <div class="tbl-wrap">
    <table>
      <tr><th>Intervention</th><th>Evidence</th></tr>
      <tr><td><b>Weight reduction</b></td><td>5–7% weight loss reduces T2DM risk by <b>58%</b> (DPP Trial)</td></tr>
      <tr><td><b>Physical activity</b></td><td>150 min/week moderate activity; increases insulin sensitivity</td></tr>
      <tr><td><b>Dietary modification</b></td><td>High fibre &gt;20g/day, low GI foods, Mediterranean diet</td></tr>
      <tr><td><b>Avoid tobacco & excess alcohol</b></td><td>Both increase insulin resistance</td></tr>
      <tr><td><b>Screen high-risk groups</b></td><td>Obese, family history, GDM, age &gt;40 years</td></tr>
      <tr><td><b>Metformin (pharmacological)</b></td><td>Reduces progression by 31% in high-risk individuals (DPP trial)</td></tr>
    </table>
  </div>
  <div class="tip-box"><b>KEY FACT:</b> India has ~77 million diabetics – 2nd highest worldwide after China. Mention in exam answers!</div>
</div>

<!-- ===================== CANCER ===================== -->
<div id="cancer" class="sec-header">5. CANCER – EPIDEMIOLOGY & PREVENTION <span>⭐⭐⭐ Most Repeated</span></div>

<div class="exam-box">
  <div class="exam-title">⭐ Exam Alert</div>
  <ul>
    <li>Cancers in India + early warning signs + Prevention of Ca Cervix (2009 – 12 marks)</li>
    <li>Danger signals of cancer + Oral cancer (2008, 2013)</li>
    <li>Screening for cancer cervix – Short note</li>
    <li>Oral cancer epidemiology – Short note</li>
    <li>Cancer registration in India – Short note</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">5.1 Global & India Burden (2020)</div>
  <div class="tbl-wrap">
    <table>
      <tr><th>Parameter</th><th>Global</th><th>India</th></tr>
      <tr><td>New cases</td><td>19.29 million</td><td>1.39 million</td></tr>
      <tr><td>Deaths</td><td>9.96 million</td><td>0.92 million</td></tr>
      <tr><td>Most common (Males)</td><td>Lung cancer</td><td>Lip/Oral cavity cancer</td></tr>
      <tr><td>Most common (Females)</td><td>Breast cancer</td><td>Breast cancer</td></tr>
    </table>
  </div>
</div>

<div class="card">
  <div class="sub-header">5.2 Seven Danger Signals of Cancer – CAUTION ⭐</div>

  <div class="mnemonic">
    <h3>🎯 Mnemonic: C-A-U-T-I-O-N</h3>
    <div class="letters">
      <div class="letter-box"><div class="big">C</div><div class="small">Change in bowel/bladder habits</div></div>
      <div class="letter-box"><div class="big">A</div><div class="small">A sore that does not heal</div></div>
      <div class="letter-box"><div class="big">U</div><div class="small">Unusual bleeding or discharge</div></div>
      <div class="letter-box"><div class="big">T</div><div class="small">Thickening or lump</div></div>
      <div class="letter-box"><div class="big">I</div><div class="small">Indigestion / difficulty swallowing</div></div>
      <div class="letter-box"><div class="big">O</div><div class="small">Obvious change in wart/mole</div></div>
      <div class="letter-box"><div class="big">N</div><div class="small">Nagging cough / hoarseness</div></div>
    </div>
  </div>
</div>

<div class="card">
  <div class="sub-header">5.3 Oral Cancer ⭐</div>
  <div class="imp-box">Most common cancer in MALES in India!</div>
  <ul class="bl">
    <li><b>Risk factors:</b> Tobacco (smoking + smokeless), Alcohol, Betel nut chewing, HPV, poor oral hygiene, OSMF</li>
    <li><b>Precancerous lesions:</b> Leukoplakia, erythroplakia, OSMF</li>
    <li><b>Prevention:</b> Tobacco cessation, early detection, VIA-type screening</li>
    <li><b>Treatment:</b> Surgery, radiotherapy, chemotherapy</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">5.4 Cervical Cancer & Screening ⭐</div>
  <ul class="bl">
    <li>2nd most common cancer in women in India</li>
    <li><b>Risk factors:</b> Early sex, multiple partners, HPV types 16 & 18 (70% cases), multiparity, low SES, smoking</li>
  </ul>
  <br>
  <b style="color:#1a3a5c">Screening Methods:</b>
  <div class="tbl-wrap">
    <table>
      <tr><th>Method</th><th>Details</th></tr>
      <tr><td><b>Pap Smear</b></td><td>Detects cancer in situ; every 3 years after onset of sexual activity; requires lab & trained personnel</td></tr>
      <tr><td><b>VIA</b></td><td>5% acetic acid → acetowhite lesion = positive. Simple, cheap, suitable for India. Sensitivity similar to Pap smear</td></tr>
      <tr><td><b>VIAM</b></td><td>VIA with magnification</td></tr>
      <tr><td><b>VILI</b></td><td>Visual inspection with Lugol's iodine</td></tr>
      <tr><td><b>HPV DNA test</b></td><td>High sensitivity; co-testing with Pap smear</td></tr>
    </table>
  </div>
  <br>
  <b style="color:#1a3a5c">Prevention:</b>
  <ul class="bl">
    <li><b>Primary:</b> HPV vaccination (Gardasil/Cervarix) for girls 9–26 yrs; delay sexual debut; safe sex; tobacco cessation</li>
    <li><b>Secondary:</b> Pap smear / VIA screening programs</li>
    <li><b>Tertiary:</b> Cryotherapy, LEEP, cone biopsy for early lesions</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">5.5 Cancer Registration in India</div>
  <ul class="bl">
    <li>Cancer is <b>NOT a notifiable disease</b> in India</li>
    <li><b>PBCR (Population-Based Cancer Registry):</b> Incidence & mortality data for defined population</li>
    <li><b>HBCR (Hospital-Based Cancer Registry):</b> Data on cancer patients attending hospitals</li>
    <li><b>NCRP (National Cancer Registry Programme):</b> Under ICMR, started <b>1981</b></li>
    <li>India has <b>30+ PBCRs</b> covering ~15% of population</li>
  </ul>
</div>

<!-- ===================== STROKE ===================== -->
<div id="stroke" class="sec-header">6. STROKE (CEREBROVASCULAR DISEASE) <span>⭐⭐</span></div>

<div class="card">
  <div class="sub-header">6.1 Types of Stroke</div>
  <div class="tbl-wrap">
    <table>
      <tr><th>Type</th><th>Description</th><th>Frequency</th></tr>
      <tr><td><b>Ischaemic Stroke</b></td><td>Thrombotic or embolic occlusion of cerebral artery</td><td>~80–85%</td></tr>
      <tr><td><b>Haemorrhagic Stroke</b></td><td>Rupture of cerebral blood vessel</td><td>~15–20%</td></tr>
      <tr><td><b>TIA</b></td><td>Symptoms &lt;24 hours; "mini-stroke"; warning sign</td><td>–</td></tr>
    </table>
  </div>
</div>

<div class="card">
  <div class="sub-header">6.2 Risk Factors & Prevention</div>
  <ul class="bl">
    <li><b>Hypertension:</b> SINGLE MOST IMPORTANT modifiable risk factor for stroke</li>
    <li>Diabetes mellitus – 2–3x risk</li>
    <li>Smoking – doubles stroke risk; cessation reduces risk within 2 years</li>
    <li>Atrial fibrillation – 5x embolic stroke risk</li>
    <li>Dyslipidaemia, Obesity, Physical inactivity</li>
  </ul>
  <div class="tip-box"><b>Prevention:</b> Control HTN (reduces stroke by 35–40%), aspirin for high-risk, anticoagulation for AF, statins, lifestyle changes.</div>
</div>

<!-- ===================== OBESITY ===================== -->
<div id="obesity" class="sec-header">7. OBESITY & OVERWEIGHT <span>⭐⭐</span></div>

<div class="card">
  <div class="sub-header">7.1 BMI Classification</div>
  <div class="tbl-wrap">
    <table>
      <tr><th>Category</th><th>BMI (WHO)</th><th>Asian BMI</th></tr>
      <tr><td>Underweight</td><td>&lt; 18.5</td><td>&lt; 18.5</td></tr>
      <tr><td>Normal</td><td>18.5–24.9</td><td>18.5–22.9</td></tr>
      <tr><td>Overweight</td><td>25–29.9</td><td>23–24.9</td></tr>
      <tr><td>Obese Class I</td><td>30–34.9</td><td>25–29.9</td></tr>
      <tr><td>Obese Class II</td><td>35–39.9</td><td>≥ 30</td></tr>
      <tr><td>Morbid Obesity</td><td>≥ 40</td><td>–</td></tr>
    </table>
  </div>
  <div class="tip-box"><b>Waist circumference cutoffs (abdominal obesity):</b><br>
  Males: &gt;102 cm (global) / &gt;90 cm (Asian)<br>
  Females: &gt;88 cm (global) / &gt;80 cm (Asian)</div>
</div>

<div class="card">
  <div class="sub-header">7.2 Health Consequences of Obesity</div>
  <ul class="bl">
    <li>CVD: Hypertension, CHD, Stroke</li>
    <li>Metabolic: Type 2 DM, dyslipidaemia, metabolic syndrome</li>
    <li>Cancers: Breast, colorectal, endometrium, kidney, oesophagus</li>
    <li>Musculoskeletal: Osteoarthritis, gout</li>
    <li>Respiratory: Sleep apnoea</li>
    <li>Gastrointestinal: GERD, gallstones, fatty liver (NAFLD)</li>
    <li>Psychosocial: Depression, low self-esteem</li>
  </ul>
  <p style="margin-top:8px;font-size:13px;color:#444">Global: &gt;1.9 billion overweight; &gt;650 million obese (2016). Obesity has <b>doubled since 1980</b>.</p>
</div>

<!-- ===================== NPCDCS ===================== -->
<div id="npcdcs" class="sec-header">8. NPCDCS PROGRAMME <span>⭐⭐</span></div>

<div class="exam-box">
  <div class="exam-title">⭐ Exam Alert</div>
  <ul>
    <li>Components under NPCDCS – 12 marks (S'16)</li>
    <li>Objectives of NPCDCS – Short note</li>
  </ul>
</div>

<div class="card">
  <p><b>Full Name:</b> National Programme for Prevention and Control of <b>Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)</b></p>
  <br>
  <b style="color:#1a3a5c">Background:</b>
  <ul class="bl">
    <li>NCDs accounted for 60% of all deaths in India (2016)</li>
    <li>Launched to address rising NCD burden</li>
    <li>11th Five Year Plan: 100 districts in 21 states</li>
    <li>12th Five Year Plan: All districts covered</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">8.1 Objectives</div>
  <ul class="bl">
    <li>Prevent and control NCDs through behaviour and lifestyle changes</li>
    <li>Provide early diagnosis and management of common NCDs</li>
    <li>Build capacity at various levels of health care</li>
    <li>Train human resources (doctors, paramedics, nurses)</li>
    <li>Establish capacity for palliative and rehabilitative care</li>
  </ul>
</div>

<div class="card">
  <div class="sub-header">8.2 Implementation Strategy</div>
  <ul class="bl">
    <li>Opportunistic <b>screening of persons above 30 years</b></li>
    <li><b>NCD Clinic</b> established at CHC and District level</li>
    <li>Implementation through <b>20,000 sub-centres</b> and <b>700 CHCs</b> in 100 districts</li>
    <li>BCC messages: Healthy food, physical activity, avoid tobacco/alcohol, stress management</li>
    <li>Health promotion camps, IPC, posters/banners at sub-centre level</li>
  </ul>
  <div class="tip-box"><b>Key to remember:</b> NPCDCS covers 4 conditions – Cancer, Diabetes, CVD, Stroke. Screening starts at <b>age 30 years</b>. NCD clinic is at <b>CHC level</b>.</div>
</div>

<!-- ===================== RTA ===================== -->
<div id="rta" class="sec-header">9. ROAD TRAFFIC ACCIDENTS (RTA) <span>⭐</span></div>

<div class="exam-box">
  <div class="exam-title">⭐ Exam Alert</div>
  <ul>
    <li>Measures to reduce RTA as BMOH at highway BPHC (2009 – 12 marks)</li>
  </ul>
</div>

<div class="card">
  <ul class="bl">
    <li>~1.35 million deaths/year globally (2018)</li>
    <li>India: ~1.5 lakh RTA deaths/year</li>
    <li>Leading cause of death in <b>5–29 year age group</b></li>
    <li>50% involve vulnerable users: pedestrians, cyclists, motorcyclists</li>
  </ul>
  <div class="sub-header" style="margin-top:12px">Role of BMOH in Reducing RTA</div>
  <ul class="bl">
    <li>Health education on drunk driving, speeding, helmet/seatbelt use</li>
    <li>Trauma care preparedness: first aid training, stabilization room at BPHC</li>
    <li>Coordination with police, PWD, transport department</li>
    <li>Establish referral system to district hospital</li>
    <li>Maintain RTA surveillance data</li>
    <li>Community involvement: VHCs, NGOs for awareness</li>
    <li><b>Golden hour concept:</b> Ensure treatment within 1 hour of injury</li>
  </ul>
</div>

<!-- ===================== MENTAL HEALTH ===================== -->
<div id="mental" class="sec-header">10. MENTAL HEALTH <span>⭐</span></div>

<div class="card">
  <ul class="bl">
    <li>Mental disorders affect <b>1 in 4 people</b> globally</li>
    <li>Depression is the <b>leading cause of disability</b> worldwide (WHO)</li>
    <li>~800,000 suicides/year globally; 2nd leading cause of death in 15–29 yr age group</li>
    <li>India NMHS 2015–16: <b>10.6% prevalence</b> of mental disorders</li>
  </ul>
  <div class="sub-header" style="margin-top:12px">National Mental Health Programme (NMHP)</div>
  <ul class="bl">
    <li>Launched in <b>1982</b> in India</li>
    <li>District Mental Health Programme (DMHP): Integration at district level</li>
    <li>Mental Healthcare Act <b>2017:</b> Right to access mental health care</li>
    <li>WHO Mental Health Action Plan 2013–2020</li>
  </ul>
</div>

<!-- ===================== QUICK REVISION ===================== -->
<div id="qr" class="sec-header">⚡ QUICK REVISION – KEY NUMBERS & FACTS</div>

<div class="card">
  <div class="qr-item"><div class="qr-key">NCD deaths globally</div><div class="qr-val">41 million/year = 74% of all deaths</div></div>
  <div class="qr-item"><div class="qr-key">Tobacco deaths/year</div><div class="qr-val">~7 million; 71% lung cancer</div></div>
  <div class="qr-item"><div class="qr-key">Alcohol deaths/year</div><div class="qr-val">3.3 million = 5.9% of global deaths</div></div>
  <div class="qr-item"><div class="qr-key">Hypertension deaths</div><div class="qr-val">9.4 million/year; 12.8% all deaths; 22% prevalence</div></div>
  <div class="qr-item"><div class="qr-key">Obesity stats (2016)</div><div class="qr-val">&gt;1.9 billion overweight; &gt;650 million obese</div></div>
  <div class="qr-item"><div class="qr-key">Global cancer (2020)</div><div class="qr-val">19.29 million new cases; 9.96 million deaths</div></div>
  <div class="qr-item"><div class="qr-key">India cancer – Males</div><div class="qr-val">Lip/Oral cavity cancer (most common)</div></div>
  <div class="qr-item"><div class="qr-key">India cancer – Females</div><div class="qr-val">Breast cancer (most common)</div></div>
  <div class="qr-item"><div class="qr-key">India diabetes</div><div class="qr-val">~77 million = 2nd worldwide after China</div></div>
  <div class="qr-item"><div class="qr-key">DM – FPG cutoff</div><div class="qr-val">≥ 126 mg/dL (7.0 mmol/L)</div></div>
  <div class="qr-item"><div class="qr-key">DM – 2hr OGTT cutoff</div><div class="qr-val">≥ 200 mg/dL (11.1 mmol/L)</div></div>
  <div class="qr-item"><div class="qr-key">DPP Trial (DM prevention)</div><div class="qr-val">5–7% weight loss → 58% risk reduction</div></div>
  <div class="qr-item"><div class="qr-key">NPCDCS – screens from age</div><div class="qr-val">&gt; 30 years (opportunistic screening)</div></div>
  <div class="qr-item"><div class="qr-key">Ca cervix screening</div><div class="qr-val">Pap smear every 3 years OR VIA (5% acetic acid)</div></div>
  <div class="qr-item"><div class="qr-key">HPV types (cervix)</div><div class="qr-val">HPV 16 & 18 → ~70% cervical cancers</div></div>
  <div class="qr-item"><div class="qr-key">Danger signals of cancer</div><div class="qr-val">CAUTION (7 signs)</div></div>
  <div class="qr-item"><div class="qr-key">Framingham Study started</div><div class="qr-val">1951 – Framingham, Massachusetts (prospective cohort)</div></div>
  <div class="qr-item"><div class="qr-key">RTA deaths – India</div><div class="qr-val">~1.5 lakh/year</div></div>
  <div class="qr-item"><div class="qr-key">Salt – WHO recommendation</div><div class="qr-val">&lt; 5 g/day</div></div>
  <div class="qr-item"><div class="qr-key">BMI – overweight (Asian)</div><div class="qr-val">≥ 23 kg/m²</div></div>
  <div class="qr-item"><div class="qr-key">BMI – obese (Asian)</div><div class="qr-val">≥ 25 kg/m²</div></div>
  <div class="qr-item"><div class="qr-key">NMHP launched</div><div class="qr-val">1982 in India</div></div>
  <div class="qr-item"><div class="qr-key">NCRP (cancer registry)</div><div class="qr-val">Under ICMR, started 1981</div></div>
</div>

<!-- ===================== MODEL ANSWERS ===================== -->
<div id="model" class="sec-header">📝 MODEL ANSWER FRAMEWORKS</div>

<div class="card">
  <div class="sub-header">LAQ: Hypertension (12–15 marks)</div>
  <div class="model-step">1. Introduction + Definition (JNC 7) — 1–2 marks</div>
  <div class="model-step">2. Problem statement – Prevalence India & globally — 2 marks</div>
  <div class="model-step">3. Classification table (JNC 7/8) — 2 marks</div>
  <div class="model-step">4. Risk factors – Non-modifiable + Modifiable (tabular) — 3–4 marks</div>
  <div class="model-step">5. Prevention – Primordial, Primary, Secondary, Tertiary — 3–4 marks</div>
  <div class="model-step">6. NPCDCS mention — 1 mark</div>
  <div class="model-step">7. Conclusion — 1 mark</div>
</div>

<div class="card">
  <div class="sub-header">LAQ: Diabetes – Epidemiology + Primary Prevention (12 marks)</div>
  <div class="model-step">1. Introduction + WHO 2019 Classification — 2 marks</div>
  <div class="model-step">2. Problem statement – India 77 million, 2nd worldwide — 1 mark</div>
  <div class="model-step">3. Diagnostic criteria table (FPG, OGTT, HbA1c) — 2 marks</div>
  <div class="model-step">4. Epidemiological determinants – Non-modifiable + Modifiable (table) — 3 marks</div>
  <div class="model-step">5. Primary prevention of Type 2 DM: Weight, Diet, Exercise, Metformin, Screening — 4 marks</div>
</div>

<div class="card">
  <div class="sub-header">LAQ: Cancer – Types + Warning Signs + Ca Cervix Prevention (12 marks)</div>
  <div class="model-step">1. Introduction + magnitude in India — 2 marks</div>
  <div class="model-step">2. Common cancers in India – Males & Females (table) — 2 marks</div>
  <div class="model-step">3. Early warning signs – CAUTION mnemonic — 3 marks</div>
  <div class="model-step">4. Prevention of Ca Cervix – HPV vaccine, Pap smear, VIA (detailed) — 4 marks</div>
  <div class="model-step">5. Cancer control in community — 1 mark</div>
</div>

<div class="card">
  <div class="sub-header">LAQ: CHD – Risk Factors + Prevention (12 marks)</div>
  <div class="model-step">1. Definition of CHD/IHD — 1 mark</div>
  <div class="model-step">2. Problem statement + Framingham Study mention — 1 mark</div>
  <div class="model-step">3. Risk factors: Non-modifiable + Modifiable Big 4 + Other modifiable (tabular) — 6 marks</div>
  <div class="model-step">4. Prevention: Population strategy, High-risk strategy, Secondary prevention — 4 marks</div>
</div>

<!-- FOOTER -->
<div class="footer">
  These notes are prepared for MBBS 3rd Year PSM | DUHS (Chhattisgarh AYUSH University)<br>
  Content sourced from Park's PSM Textbook &amp; standard community medicine curriculum.<br>
  Always verify with your college faculty for university-specific updates.<br>
  <b>Prepared by Orris AI | June 2026</b>
</div>

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