TEN MAIN DISEASES IN

URBAN/RURAL AREA

Circulatory S

TBC

Digestive S

Neoplasma

Bron-Emp-Asthma Urban
Diarrhea Rural
Trauma- Accident

Other Inf

Respiratory Inf

Metabolic D

0 5 10 15 20 25
 10 jenis penyakit paling sering menjadi
penyebab kematian di Indonesia
1. STROKE
2. CARDIOVASCULAR
3. DIABETES MELLITUS.
4. LUNG TUBERKULOSIS
5. HIPERTENSION
6. COPD.
7. LIVER DISEASE.
8. ACCIDENT.
9. PNEUMONIA.
10. GASTROENTERITIS
 TEN MAIN DISEASES OF CAUSED OF
DEATH
Peny Sist Sirkulasi

TBC

Inf Sal Nafas

Diare

Peny Infeksi lain

Bronc-asma-emp

Trauma- Kerac-Kcl

Sist Pencernaan

Neoplasma

Malaria

0 5 10 15 20
 INTRODUCTION
NCDs, also known as chronic diseases, tend to be of
long duration and are the result of a combination of
genetic, physiological, environmental and behaviours
factors.
• The main types of NCDs are cardiovascular
diseases : stroke, heart attacks, cancers, COPD,
diabetes mellitus, hypertension etc.
Chronic Disease as comprising impairments or
deviations from normal, which have one or more of
the following characteristics. (permanent, leave residual
disability, caused by non-reversible pathological alteration,
require special training of the patient for rehabilitation, may be
expected to require a long period of supervision, observation or
care)
 Ketidaktahuan tentang Penelitian PENELITIAN
Besaran masalah, Masalah EPIDEMIOLOGI &
Distribusi dan biaya Kesehatan KESHT MASY
Ketidaktahuan tentang PENELITIAN
Penyebab biologis atau Penelitian DASAR
Proses patologis Etiologi KEDOKTERAN
Masalah Penyakit PENELITIAN
Tidak Menular Ketidaktahuan tentang
Intervensi-intervensi Penelitian KLINIS & KESH
efektif intervensi MASY
PENELITIAN
Ketidaktahuan tentang KESEHATAN
Penelitian
Pelayanan NASYARAKAT
operasional

1. Penyakit Kardiovaskuler : Penyakit jantung iskemik,hipertensi,stroke, penyakit jantung,rematik

2. Kanker : Payudara,leher rahim,paru,prostat,colo rectal,nasofaring,hati, pnkreas dll
3. Kecelakaan&kekerasan : Jalan raya,keracunan,kekerasan pada wanita dan anak-anak
4. Penyakit Endokrin : Diabetes Mellitus
5. Gangguan Kejiwaan : skizoprenia,demdensia,penyalahgunaan obat (termasuk merokok &
mental minor alkohol),depresi,neurosis dan gangguan
6. Penyakit syaraf : sakit kepala, epilepsi
7. Penyakit paru obstruktif Kronis : asma,bronkitis kronis,bronchiestasis & emfisema
8. Penyakit otot/tangka : rematik, lbp,osteoporosis,sakit pinggang bawah,osteoarthritis
9. Organ penginderaan : katarak, ketulian
10. Penyakit Gastrointestinal : radang lambung/gangguan pencernaan, sirisus hati
11. Penyakit saluran kemih : gagal ginjal kronis
RELATIONS AMONG DEMOGRAPIC, EPIDEMIOLOGY
AND HEALTH TRANSITIONS
HEALTH TRANSITIONS

DEMOGRAPHIC EPIDEMIOLOGIC
TRANSITION TRANSITION

-URBANIZATION INFECTIOUS FERTILITY POPULATION CHRONIC &

DISEASE DECLINES AGES NON COM-
- INDUSTRIALIZA MORTALITY MINICABLE
TION DECLINES DISEASE
- RISING INCOMES EMERGE
- EXPANSION OF
EDUCATION ECONOMIC PERSISTENCE
- IMPROVED MEDICAL RECESSION OR RE EMER-
& PUBLIC HEALTH AND IN GENCE OF COM
CREASING DISEASE

PROTRACTED POLARIZED
EPIDEMIOLOGIC TRANSITION
 Transisi Epidemiologi
• Prevalensi communicable diseases (CDs)
<<, non communicable diseases (NCDs) >>
• Akibat perubahan life style, income percapita
>>, life ecpectancy >>, risiko penyakit
degeneratif >>, NCDs >>
• Morbiditas dan mortalitas NCDs >> (stroke,
CVD, DM, hipertensi).
• Transisi epidemiologi sudah terjadi tetapi
CDs belum sepenuhnya teratasi, NCDs
morbiditas dan mortalitas >>
 NON COMMUNICABLE
DISEASE (NCD)
• CHRONIC DISEASES ?
• NON-INFECTIOUS DISEASES
• NEW COMMUNICABLE DISEASES
• DEGENERATIVE DISEASES
 CHARACTERISTIC OF NCD

• INSIDIOUS TRANSMISION
• LONG INCUBATION TIME
• CHRONIC PROCESSING
• DIAGNOSIS IS DIFFICULT
• VARIATION OF SYMPTOM & SIGN
• HIGH COST FOR TREATMENT & PREVENTION
• MULTIFACTORIAL CAUSES
• DEVELOPED COUNTRY
• ICE BERG PHENOMENA
•TREND OF MORBIDITY & MORTALITY INCREASED
 CHRONICAL DISEASES

•PERMANENT CONDITION
• RECOVERY INCOMPLETE
• DISABILITY
• IRREVERSIBLE CHANGED
• NEED REHABILITATION
• LONGTERM PROCESSING
CROSS TABULATION OF ACUTE &
CHRONICAL DISEASES AND CD &NCD

COMM D NON CD
ACUTE D Infl, Morbili, Accident
Pnemonia Intoxication
Pertusis, Tetanus (food)

CHRONIC D Tuberculosis Diabetes mell

Leprosy Hypertension
Rheumatic Fever Coronary HD
 DIFFERENCIES OF CD & NCD

COMM D NON CD
Developing Countries Developed Countries
Transmission (+) Transmission (+/-)
Acute Process Chronic Process
Microorganism Causes Causes not clear
Single Causes Multiple Causes
Easy Diagnosis Difficult Diagnosis
Search of causes (+) Search of causes (-)
Cost not expensive Cost Expensive
In Community (+) In Community (+/-)
Trend of MM << Trend of MM >>
RISK FACTOR AND PREVENTION DISEASE
• Risk Factors are factors / condition which influence
of disease developed or health status disorders.
• Risk Factors are characteristics, sign, symptom in disease
free individual which are statisticaally associated with an
increased incidence of subsequent disease

• Two risk factors : Intrinsix and Extrinsix

• Intrinsix Risk Factor : Individual susceptibility for disease

(genetic, sex, age, anatomy and physiology condition,
nutrition etc.)

• Extrinsix Risk Factor : Environment Condition

(increased susceptibility and influenced of agent)
 RISK FACTORS

Risk factors are defined as “ an attribute

or exposure that is significantly
associated with the development of a
disease”

A determinant that can be modified by

intervention there by reducing the
possibility of occurrence of disease or
other specified outcomes
 CLASIFICATION OF RISK FACTORS

• Changeable : Unchangeble Risk Factors : age, genetic

Changeable Risk Factors : Lifestyle

• Role of Risk Factors : Suspected Risk Factors

Established Risk Factors

• Documented : Well Documented Risk Factors

Less Well Documented

• Main Risk Factors : Major Risk Factors / Strong

Minor Risk Factors / Weak
 Modifiable Risk Factor
• A behavioral risk factor that can be reduced or controlled by
intervention, thereby reducing the probability of disease.

• WHO has prioritized the following four:

– Physical inactivity,

– Tobacco use,

– Alcohol use, and

– Unhealthy diets (increased fat and sodium, with low fruit 1

and vegetable intake).

8
 Non-Modifiable Risk Factor
A risk factor that cannot be reduced or controlled by
intervention; for example :
•Age,

•Gender,

•Race, and

•Family history (genetics).

1
9
RISK FACTORS OF DEGENERATIVE DISEASE
Blood Pressure Heart disease
Tobacco Stroke
Dyslipidemia Hypertension
Improper food Dementia
Glucose Diabetes M
Personality / Stress CORE Cancer
Physical inactivity Osteoporosis
Alcohol Liver disease
Environment Renal Failure
Oral hygiene Respiratory disease

Figure : Risk Factors and Degenerative Disease.

CLASIFICATION OF CARDIOVASCULAR
DISEASE
(1) ACUTE RHEUMATIC FEVER
(2) CHRONIC RHEUMATIC HEART DISEASE
(3) HYPERTENSIVE HEART DISEASE
(4) ISCHAEMIC HEART DISEASE (AMI, CHD)
(5) DISEASE OF PULMONARY CIRCULATION (ACUTE / CHRONIC OF
PULMONARY DISEASE)
(6) OTHER FORM OF HD (PERICARDITIS, MYOCARDITIS, HF)
(7) CEREBROVASCULAR DISEASE
(8) DISEASE OF ARTERIAE, ARTERIOLAE, CAPILLAIR
(9) DISEASE OF VEIN & LYMPHATIC SYSTEM
(10) OTHERS (ANEMIA HEART DISEASE, HYPERTHYROID HD ETC)
 MORBIDITY DATA (%) OF CVD IN INDONES.
COMMUNITY
==============================================
Group CHD RHD HHD PHD CoHD
-----------------------------------------------------------------
Geriatric 58 ? 34 7,5 ?
Survey-1 46 18 14 7,1 10,7
Survey-2 23 12 6 12 3,5
Coastal A 24 10 31 5 14
==============================================
 RISK FACTORS OF CHD
Major risk factors : (1) Hypertension (2)
Hyperlipidemia (3) Smoking (4) Obesity.
Minor risk factors : (1) Diabetes mellitus (2)
Emotional stres (3) Sports (-) (4) Family history (5)
Older age (>60 years) (6) Sexs (male), female post
menopause (7) Alcohol comsumption (8) South >>
(9) cardiac arrytmia (10) Type A personality (11)
Hyperuricemia.
PENCEGAHAN & PENGENDALIAN PENYAKIT

Disability Limitation and

Rehabilitation
Early Diagnostic and
Prompt Treatment
Health Promotion and Specific

25
 Recommendation of Life Style Change of
coronary heart disease patients

1. Low salt diet, low calorie dan high fiber

2. Normalize of Body Weight
3. Sodium Consumption < 2,4 gram/day
4. Physical activity (sport 30 minute/ day, 3 -
4 time a week)
5. No smoking
 RISK FACTORS OF HYPERTENSION
NONMODIFIABLE RISK FACTORS :
1. Aged
2. Sex (Male)
3. Family History

MODIFIABLE RISK FACTORS :

1.Dislipidemia (LDL level >>, HDL level << , Trigleserid >>)
2.Smoking habit
3.Alcohol consumpsion
4.High of south consumpsion
5. Low of fiber intake
6.Obesity
7.Low of physical activity
 STROKE – PENYAKIT PDO
• Stroke  masalah kesehatan masyarakat penting
• Stroke  penyebab kematian keempat dan penyebab
utama kecacatan di Amerika tahun 2012. Sekitar
795.000 kasus tiap tahun
Prevalensi diprediksi meningkat (2,8 % - tahun 2012
 3,88% - tahun 2030). Stroke: 1 dari 19 kematian
• Stroke di Asia, contoh di China, Jepang.
• Indonesia : stroke  penyebab kematian utama usia >
5 tahun (15,4%, Riskesdas 2007). Prevalensi
meningkat (8,3/1.000 penduduk  12,1/1.000
penduduk). Prevalensi stroke di Jawa Tengah hampir
sama dengan nasional yaitu sebesar 12,3‰.
 STROKE – PENYAKIT PDO
• Prevalensi stroke di Kota Semarang fluktuasi dari
tahun ke tahun. Kejadian stroke iskemik sekitar 3-4
kali lebih banyak dari stroke hemoragik. Angka
kematian untuk stroke mengalami fluktuasi dari
tahun ke tahun yaitu 24/100.000 penduduk (tahun
2008), 23/100.000 penduduk (tahun 2009, 2010,
2011), 33/100.000 penduduk (tahun 2012)  terus
>>
• Studi di Indonesia menunjukkan sekitar 67% pasien
stroke mengalami keterlambatan admisi (waktu
admisi > 6 jam onset) dan sebagian besar
keterlambatan admisi disebabkan oleh kurangnya
awareness bahwa pasien mengalami stroke.
 RISK FACTORS OF STROKE
• Strong risk factors are : Hypertension, TIA,
DM, Cholesterol >>, stroke history, and
smoking.
• Other risk factors are : age, ethnic B>W, sex
(M>W); prior cardiac disorder, atrium
fibrilation; obesity, genetic, life style (stroke
profile /stroke prone person).
 MORTALITY OF STROKE
Fatality rate 36%; In developed countries,
mortality number 3, circulation system (1) and
cancer (2).
In US mortality is 20.000 /year (cause of death
number 5).
In Europe 100/100.000 pop. (63.9/Sweden and
128,7/100.000 Scotland; CFR 10-12%, 88% (> 65
years old).
 MICRONUTRIENT
DEFICIENCY PROBLEM

• VITAMIN A
• Fe (IRON)
• VITAMIN B 12
• ZINC (Zn)
• IODIUM (IDD / GAKI)
• OTHERS (FOLAT, SELENIUM)
 VITAMIN A DEFICIENCY
• Long known to be associated with blindness
and signs of “toad skin” (ophthalmologist
Sommers noted that in populations with eye
signs of VAD, the children had very high levels
of mortality and morbidity)
Eye signs were dryness, clouding, then rapid
corneal clouding, and liquifaction and extrusion
of lens.
Increased deaths from infection; especially
pneumonia, diarrhea, measles
Noted in VAD: body barriers to infection
damaged (i.e., skin, all mucous membranes, eye
covering); immune function impaired
Approaches:
•Nutrition education, cultivation of
vitamin A-rich fruits and vegetables
(sweet potato, carrots, tomatoes,
green leafy vegetables)
• Food fortification
• Pharmaceuticals: high-dose vitamin
A capsule distribution to children
under five years of age and nursing
mothers every six months, low
doses to pregnant women
 ANEMIA DEFISIENSI BESI GIZI
• Zat besi : salah satu mikronutrien yg penting pd tiap
sel, yg sebagian besar berada dalam darah (hemoglobin
65%), hati (30%), sel-2 otot (3,5%), bentuk enzim
(0,5%) dan tranferin (0,1%).
• Menurunnya kadar hemoglobin, hematokrit &
juml.SDM < normal, sebagai akibat dari defisiensi salah
satu atau beberapa makanan esensial (protein, besi,
asam folat dan B 12).
•Zat besi diperoleh dari diet dan suplemen  disimpan
di hati, dikirim ke SDM melalui sumsum tl.belakang;
dlm darah bertahan 3-4 bln, sebagian mati, daur ulang
utk dijadikan Hb.
 KRITERIA ANEMIA
Kriteria WHO :
1. Umur 6 bln – 5 tahun : < 11 gr%
2. Umur 6 – 14 tahun : < 12 gr%
3. Umur > 14 th (laki-laki) : < 13 gr%
4. Umur > 14 th (wanita) : < 12 gr%
5. Wanita hamil : < 11 gr%

Kriteria epidemiologik : (1) Severe (>40%); (2)

Moderate (10-39,9%) dan (3) Mild (<10%).
 PENYEBAB DEFISIENSI BESI
(1) Konsumsi diet kaya besi <
(2) Kebutuhan >> (hamil, peny. infeksi (malaria,
infeksi kronis), tumbuh-kembang,
(3) Kehilangan besi >> (perdarahan, infestasi
cacing) dll.
(4) Tak seimbang antara kebutuhan tubuh dan
penyerapan dari makanan.
(5) Wanita cenderung anemia : (i) konsum-si diet
kaya besi <, (ii) menstruasi (iii) diet pengurangan
berat badan ?)
 DAMPAK ANEMIA DEF.BESI
(1) Bumil :
(a) Pada ibu, (i) kebutuhan oksigen jaringan <,
jantung kerja berat  GJ ? (ii) kontraksi uterus
<  perdarahan, (iii) daya tahan tubuh < 
infeksi  AKI >.
(b) Pada janin  angka kematian >,
prematuritas (3 X), gawat janin > (2X), hipoksia
intrauterin  kematian perinatal >.
 DAMPAK ANEMIA DEF.BESI
(2) Bayi, mengakibatkan gangguan perkembang
motorik, koordinasi, kembang bahasa,
kemampuan belajar <, aktivitas fisik < dll.
(3) Anak < 2 tahun : akibat serius, ggn
perkembangan otak sbg dasar proses tumbuh-
kembang anak.
(4) Anak pra-sekolah & sekolah : risiko
perkembangan kognisi >.
 VITAMIN B12 DEFICIENCY

• Seen in vegetarians

• Key role in brain and CNS development

• Key role in red blood cell formation

• Role in immune function

• Recently found to play a role in cognitive function in

children

• Low breast milk B12 is of risk to an infant

Approach : Promote animal source foods in diet milk and

 ZINC DEFICIENCY
• Widespread globally
• Hard to assess by usual means
• Low absorption from plant-based diets (fiber and
phytate block absorbtion)
• Vital for skeletal growth
• Key role in protein synthesis
• Fetal growth
• Key role in immune system: anti-infective, wound
healing
• Role in infant child activity and cognitive develop
 IDD and ITS IMPORTANCE
• What is Iodine Deficiency Disorders (IDD) ?
(IDD is syndrome merge as result of
continuously low iodine content in human
body during a period of time)
• What is iodine ?
(Iodine is essential mineral, nature
resources in soil and water, which as a
micro nutrient for growth and development
of human being).
 CAUSES OF IODINE
DEFICIENCY
Main cause : insufficiency iodine intake
caused by:
• (1) Insufficiency daily iodine intake
• (2) Habit of consuming special food which can’t
absorb the iodine.
• (3) Pathological situation (tumor), --> to inhibit
mechanism disorder of thyroxin.
Spectrum of Iodine Deficiency Disorders (I)

Fetus (1) In the women:

* congenital abnormalities
* abortions, stillbirths
(2) After birth:
* increased perinatal mortality
* increased infant mortality;
* cretinism:
- neurological endemic cretinism
mental retardation
deaf mutism
hearing loss
spastic diplegia,
squint etc
- myxedematous endemic cretinism
dwarfism
mental retardation
hypothyroidism
Spectrum of Iodine Deficiency Disorders (II)

Neonate : - neonatal goiter

- neonatal hypothyroidism
- increased susceptibility
to nuclear radiation
Spectrum of Iodine Deficiency Disorders ( III )

Child and adolescent:

- Goiter
- Juvenile hypothyroidism
- Impaired mental function
- Retarded physical development
- Increased susceptibilityt o nuclear radiation *
Adult:
- Goiter with its complications
- Hypothyroidism
- Impaired mental function
- Iodine induced hyperthyroidism
- Increased susceptibility to nuclear radiation *

___________________________________________________

* Due to increased uptake of radioactive iodine.

Criteria for Iodine deficiency
1. Total Goiter Rate ?
School children / Pregnant
women?
2. Urinary Excretion of Iodine ?
School children /
Pregnant
women?
3. Thyroglobulin concentration ?
4. TSH ? Pregnant women ?
Neonatal ?
5. Thyroid volume ?
 HYPOTHY MENTAL
ROIDISM DEFICIENCY STATUS
Serum T4
NORMAL
NORMAL
Euthyroid ? ?
range + ENDEMIC
MENTAL
DEFICIENCY

>< MYX. CRET

+ ++ PARTIALLY
CORRECTED
Hypothyroid
range “LATE ONSET”
++ HYPOTHYROIDISM

MYX.
++ ++ ENDEMIC
+ CRTEINISM
Foetal Life Early infancy Childhood and
BIRTH adulthood
Action of thyroid hormones on CNS
Cretinism in children
 Cretinism in adolescent

 Goiter
 Hypothyroidism
 Retarded physical development
 Impaired mental function (13 IQ points)