of Non-Communicable Diseases in Malaysia

1. NCD
Prevention & Control Program

2. PRESENTATION OUTLINES
 NCD burden
 Cancer & Tobacco Control Program
 Violence Prevention Program
 Injury Prevention Program
 Diabetes Prevention & Control Program
 CVD Prevention & Control Program
 Blindness Prevention & Control Program
 NCD Surveillance
2

3. Global CVD-Death 16.6 million (2001)
3

4. Is NCD (CVD, DM) an important health problem ?
Disease Burdens :
c
Global & Local
How serious is the problem ?
4

5. Death, by broad cause group in year 2000
Total deaths: 55,694,000
Non-communicable
Injuries (9.1%)
conditions (59.0%)
Communicable diseases, maternal and
perinatal conditions and nutritional
deficiencies (31.9%)
5
Source: WHO, World Health Report 2001

6. The Global Death due to
Chronic Diseases (NCD)
 ~60% of the 56.5 million total reported deaths in the
world (2001)
 CVD -16.6 millions : 7 million CHD, 4.5 millions Stroke
 DM with complication- 4 millions
 COPD -2.7 millions
 Expected to increase to ~70% by 2020
 Developing countries:
 71% - IHD
 75% - stroke
 70% - diabetes
6
The world health report 2002: reducing risk, promoting healthy life.
Geneva, World Health Organization,2002

7. Leading Causes of Death in Rural Areas, China, 1998
Communicable diseases (2.6%)
Injuries (11.2%) Undiagnosed (3.3%)
Non-communicableconditions (82.9%)
Noncommunicable conditions 7
Source: Ministry of Health, China, 2000

8. High Burden in Developing Countries
Lost healthy years (000‟s) from Cardiovascular disease in 2000
5,000 10,000 15,000 20,000 25,000 30,000
SEAR D
WPR B (CHN,VTN, MAL)
EUR C
EUR A
EUR B
EMR D
AMR A Ischaemic heart disease
AMR B
Stroke
SEAR B
AFR E
Other cardiovascular dis
AFR D
EMR B
WPR A (JPN)
Source: World Health Report, 2002
AMR D
8

9. Changes in age-adjusted mortality rate, Japan
400 400
1965 Stroke
350 350 Heart disease
Tuberculosis
300
age adjusted mortality ( /100,000)
300
Pneumonia,
Males Cancer Females
Br o n c h i t i s
1965
250 250
200 200
150 150
100 100
50 50
0 0
47
50
55
60
65
70
75
80
85
90
95
47
50
55
60
65
70
75
80
85
90
95
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
year year
9

10. The proportion of lifestyle-related diseases to all death in Japan.
About 60%
others cancer
38.2 31.0%
%
Cardiovascular disease
stroke 15.3%
13.6%
hypertension
0.6%
diabetes 10
1.3% （2001）

11. The World Health is in Transition
Epidemiological: NCD overriding CD, & double
burden of diseases in many
developing countries
Demographic: Population ageing
Lifestyles: Diets are rapidly changing
Physical activity reducing
Tobacco use increasing
Urbanization: Growing cities
Globalisation: Increasing global influences

12. “The Tip of the iceberg”
32 million heart attacks per year
12

13. World Health Report 2002
 10 of the top risks explain a high
proportion of the premature
deaths and disease burden
 7 are related to diet and physical
activity
 One third of the disease burden
is due to 5 risk factors
 Concentrating on a few key major
RF will have a big impact
13

14. The Global Burden of
Chronic Diseases (NCD)
 ~46% of the global burden of disease (2001)
 DM – 177 millions
 Expected to increase to 57% by 2020
 Diabetes > 2.5 fold increased
 84 million (1995) to 228 million (2025)
14
The world health report 2002: reducing risk, promoting healthy life.
Geneva, World Health Organization,2002

15. NCD
THE LOCAL SITUATION
15

16. NCD
THE LOCAL SITUATION
10 ++ millions-
at least 1 NCD Risk Factors
16

17. Common Risk Factors of Lifestyle Diseases
Share Predisposing Conditions:
 Hypertension
 Obesity (especially central obesity)
 Diabetes Mellitus
 Cancer
And Common Risk Factors:
 Tobacco
 Physical Inactivity
 Irrational Diet (especially high fat intake)
 Alcohol over-consumption
17

18. 18

19. Smoking
 30.6% ever smokers
 24.8% current smokers
 Higher in Kelantan (31.7%), Pahang (29.8%)
and Sabah (29.3%). Lowest in Penang (20.7%)
 Higher amongst Malay, rural, males (females
only 3.5%)
19

20. Physical Inactivity
 NHMS2 – 11.6% exercised adequately, 31.7%
ever exercised
 Nearly 70% of Malaysians do not exercise
20

21. Alcohol (amongst non-Muslims)
 29.2% ever drank
 23% current drinkers
 Higher prevalence in Sabah, rural location,
males.
21

22. HYPERTENSION
Increase of cases due to;
•aging
•Smoking habit
•?life stressors
•? Excessive dietary salt
intake 22

23. MALAYSIA
 NCD is leading in the 10 leading causes of
morbidity and mortality for the last few
years.
 Double burdens in term of disease pattern:
Preexisting infectious diseases and
emerging of NCD problem.
23

24. Epidemiological Transition
 Moving from a developing to a develop
status
 Lifestyle related diseases increase
 “Double burden” of the disease
24

25. 25

26. TOTAL NUMBER OF ADMISSION (CVD) TOTAL NUMBER OF DEATHS (CVD)
TO GOVERNMENT HOSPITALS IN GOVERNMENT HOSPITALS
1985 - 1998 1965 -2000
120000
103512 108087
104751
100000
80000
58961
60000
40000
20000
0
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 '00
Admission
27

27. TOTAL NUMBER OF ADMISSION (CVA/STROKE) TO GOVERNMENT
HOSPITALS 1991 - 2000
Year Hospital Admission Death
1991 8,037 2,183
16000
1992 9,033 2,416
14000
1993 9,420 2,338
12000 1994 10,132 2,490
10000 1995 11,422 2,635
8000 1996 12,365 2,610
1997 12,985 2,790
6000
1998 14,047 2,822
4000
1999 12,416 2,674
2000
2000 13,868 2,801
0
91 92 93 94 95 96 97 98 99 2000
Sumber: Unit Sistem Dokumentasi dan informasi-KKM 2002
28

28. Leading Causes of Diseases Burden, Malaysia 2000
TOTAL DALY Status & Rank Order One DALY = one lost year of „healthy‟ life
Rank No DALY Total % Total
1 Ischaemic Heart Diseases 278,733 9.8%
2 All mental illness 206,898 7.3%
3 Cerebro-vascular Disease/stroke 180,431 6.4%
4 Road Traffic Injuries 162,736 5.7%
5 All cancers 137,675 4.9%
6 Septicemia 127,714 4.5%
7 Diabetes Mellitus 103,449 3.7%
8 Acute Lower Respiratory tract infections 87,539 3.1%
9 Hearing loss 83,560 3.0%
10 Other respiratory disease 82,032 2.9%
11 Asthma 61,005 2.2%
12 Chronic obstructive pulmonary disease 60,728 2.1%
13 Cirrhosis 54,687 1.9%
14 Other cardiovascular diseases 51,315 1.8%
29

29. DIABETES MELLITUS
•Increasing prevalence
1986 6.3%,
1995 7.7%,
1996 8.3%
due to sedentary lifestyle, obesity and
high fat diet.
30

30. Number of Diabetes Cases in
Klinik Kesihatan (2000 – 2002)
657958
525858
446847
Year 2000 Year 2001 Year 2002
31

31. Projection of Risk Factor Burden-1
Disease Prev 1996 2002 2006 2010 2020
Burden Rate NHMS2
HPT 29.9% 2,190,504 2,631,500 2,850,000 2,987,900 3,557,400
DM 8.3% 608,000 730,490 790,400 829,400 987,500
Stroke* 12,365
IHD* 33,070
Note: Based on NHMS2 1996. Prevalance rate remain constant.
Disease Burden= Pi x [p0 + (pi x Td)]
32

32. Projection of Risk Factor Burden -2
Disease 1996 2002 2006 2010 2020
Burden NHMS2
HPT 2,190,504 3,476,435 4,383,450 5,226,300 8,126,100
(29.9%) (39.5%) (45.9%) (52.3%) (68.3%)
DM 608,000 836,200 983,650 1,109,200 1,558,600
(8.3%) (9.5%) (10.3%) (11.1%) (13.1%)
Note: Based on NHMS2 1996. Prevalence rate increase proportionately.
33

33. Projection of Risk Factor Burden-1
Burden of Risk Prev 1996 2002 2006 2010 2020
Factor
Smoking 24.8% 1,816,900 2,182,700 2,368,400 2,478,300 2,950,600
Obesity 4.6% 322,348 387,248 420,200 459,700 547,300
Overweight 16.6% 1,216,326 1,460,982 1,585,300 1,658,800 1,957,000
Physical 88.4% 6,476,300 7,780,200 8,442,200 8,853,700 10,597,000
Inactivity
IGT 4.3% 315,022 378,447 410,650 429,700 511,600
Alcohol 23%
Note: Based on NHMS2 1996. Prevalence rate remain constant.
Disease Burden= Pi x [p0 + (pi x Td)]
34

34. Projection of Risk Factor Burden -2
Diseases Current/Latest 2005 2010 2020
2002
Cancers (All forms) 26,089 cases 27,840 30,883 38,021
(NCR 2002)
Assumptions:
1. Population growth at 2.1% yearly is constant with similar growth in number of males and females
2. Incidence rate of cancer remain constant in both sexes
36

35. % of Most Common Cancers in Penang
by Gender, 1994-1998
MALE FEMALE
 Lung (20.2%)  Breast (24.4%)
 Colorectal (10.6%)  Cervix (12.2%)
 Nasopharynx ( 8.5%)  Colorectal ( 8.7%)
 Stomach ( 8.0%)  Lung ( 5.8%)
 Liver ( 5.0%)  Ovary ( 4.9%)
 Prostate ( 4.6%)  Stomach ( 4.5%)
Source: Penang Cancer Registry report 1994-1998
37

36. The Malaysia Health is in Transition
Epidemiological: NCD overriding CD, &
double burden of diseases
Demographic: Population ageing :
Increasing life expectancy
Lifestyles: Diets are rapidly changing
- High fat, low fiber, high salt
Physical activity reducing
Tobacco use increasing
Alcoholic
Urbanization: Growing cities : pollution
Globalisation: Increasing global influences
increased trade- foodstuffs, tobacco

37. NCD Prevention & Control Program:
Malaysia Experience

38. LIFESTYLES CHANGES (Individuals)
Intensify Prevention and Promotion Activities
 Adopt healthy lifestyle, be active
 Regular Exercise
 Eat Right – Low Sugar, Low Salt, Low Fat,
High Fibre.
 No Smoking, No Alcohol
40

39. Determinants of CVD (NCD)
BEHAVIORAL
BEHAVIORAL
 Tobacco
 Tobacco
 Diet
 Diet
 Physical Activity
 Physical Activity
 Alcohol
 Alcohol
ENVIRONMENTAL
ENVIRONMENTAL INTERMEDIATE
INTERMEDIATE END-POINTS
 Socio-cultural
 Socio-cultural RISK FACTORS
RISK FACTORS END-POINTS
Ischemic Heart Dis.
 Policy
 Policy Hypertension
Hypertension Ischemic Heart
Stroke
Dis.
 Economic
 Economic Blood lipids
Diabetes Peripheral Vasc. Dis.
Stroke
 Physical
 Physical Obesity
Diabetes Cancer
Peripheral Vasc.
NON-MODIFIABLE
NON-MODIFIABLE Blood lipids
Obesity Chronic Lung Dis.
Dis.
 Age, Sex, Genes
 Age, Sex, Genes
41

40. RISK FACTORS
Non-modifiable risk factors:
age,sex,ethnic, genes
Intermediate risk
factors: END POINTS
Behavioural risk factors:
hypertension CHD
smoking
blood lipids
alcohol Stroke
obesity
diet
overweight
PVD
physical activity Cancers
diabetes
stress COPD
depression
Emphysema
Mental condition
Socio-economic risk factor:
Cultural & environment
42

41. NCD
Prevention & Control Program
Programs:
• Diabetes Prevention and Control Program
• CVD Prevention and Control Program
• Blindness Prevention and Control Program
• Injury Prevention and Control Program
• Violence Intervention Program
• Substance Abuse Program
• Non-Communicable Disease Surveillance

42. Should We Attempt To Prevent
A Chronic Disease (NCD) ?
 An Important health problem
 Natural history is established
 Early detection test available
 Effective intervention
 Cost effective program
44

43. NCD Prevention & Control Program
General OBJECTIVES
 To reduce morbidity and premature mortality of
NCD
 To reduce NCD modifiable risk factors such as
hypertension, smoking, hypercholesterolemia,
diabetes mellitus, obesity and physical inactivity in
the community.
 To improve the quality of life of people with NCD
45

44. NCD Prevention & Control Program
 Promotion
 Assessment
 Intervention
46

45. LEVELS OF PREVENTION
Healthy individual Risk factors & Established Complication
Early Disease Disease
Health Specific Disability Rehab
Promotion Protection Screening Early Detections
& App Rx
Primary Prevention Secondary Prevention Tertiary Prevention
47

46. NCD Prevention & Control Program
ACTIVITIES
 Health Promotion &  To prevent risk factors
Health Education  To prevent diseases
 Screening /assessment  To identify Risk factors
 To diagnose diseases
 Intervention:  To control diseases :
 appropriate treatment - treat at the earliest possible stage
 Behavioral modification - slow disease progression
 Pharmacotherapy
 Surgical , etc
 To prevent complications
 rehabilitation  To limit disability at the earliest possible
stage
 To restore an affected individual to a
useful, satisfying & when possible, self
sufficient role in society
Evaluation / audit / surveillance
Capacity building
Inter & intra sectoral coordination and collaboration : smart partnership
48

47. CVD (NCD) Prevention & Control Program
Policy and Decision Maker
Program Managers
Health
Promotion & Education
Evaluation: Health
Audit & Research Assessment
Customized
personalised
INTERVENTION:
Behavior Modification
Pharmacotherapy
Customized, personalised, self-empowerment,
family & community involvement
49

48. Natural History disease and Hierarchy of Action
Under the scope of Hospital care and
Clinical specialist Severe Apparent
follow up form diseases
Primary care Mild form
Mild
Under the scope of
public health Physician form
Secondary
Remove causes prevention Unapparent
and risk diseases
Eradicate Primary
Eliminate prevention Pathogenesis started
Reduce burden Pathogenesis Occur
Exposure
Control
Early detection Availability of disease determinants
50

49. Framework for the prevention and control of CVD (NCD)
Comprehensive NCD strategy
Integrated national NCD plans; STEPS surveys
Direction &
Infrastructure
Changing Changing Reorienting
Environments Lifestyles Health Services
Model community-based prevention programs Evidence-based guidelines;
Demonstration NCD prevention & control projects Capacity-building
51

50. NCD Prevention & Control Program
STRATEGY
 Two strategies are used :
i) The population strategy
ii) The individual or high risk strategy.
 They are complementary and reduction of
Cardiovascular diseases are likely to be most
successful where both are pursued simultaneously.
52

51. NCD Prevention & Control Program
Studies show that appropriate intervention can reduce
the morbidity and mortality due NCD
High Risk & Population approaches
POPULATION Approach
Target: General population
Aim to correct/modify underlying
causes or risk factors of CVD in
the community.
To lower the mean of risk factors
and to shift the whole distribution
of exposure in favourable Reduce a small amount of risk in a
direction large number of people (e.g. reduce
salt intake - promoting healthy
lifestyle).
Lifestyle change plus environmental
approach.
53

52. NCD Prevention & Control Program
Studies show that appropriate intervention can reduce
the morbidity and mortality due NCD
High Risk & Population approaches
+
Truncate high risk end of Reduce a small amount of risk in a
exposure distribution (e.g. large number of people (e.g. reduce
organise an obesity clinic or a salt intake).
quit smoking clinic).
Lifestyle change plus environmental
Clinical approach to disease approach.
prevention.
54

53. POPULATION APPROACH/STRATEGY
 Aim to correct/modify underlying causes or risk
factors of NCD in the community.
 To lower the mean of risk factors and to shift the
whole distribution of exposure in favourable
direction
55

54. NCD Prevention & Control Program
HIGH RISK STRATEGY
Target: High risk population
Activities :
 Identifying high risk individual:
 CVD screening programme
 Health Status Surveillance (My HeSS)
 Appropriate management of the risk factors
56

55. NCD Prevention & Control Program
ACTIVITIES
 Health Promotion &  To prevent risk factors
Health Education  To prevent diseases
 Screening /assessment  To identify Risk factors
 To diagnose diseases
 Intervention:  To control diseases :
 appropriate treatment - treat at the earliest possible stage
 Behavioral modification - slow disease progression
 Pharmacotherapy
 Surgical , etc
 To prevent complications
 rehabilitation  To limit disability at the earliest possible
stage
 To restore an affected individual to a
useful, satisfying & when possible, self
sufficient role in society
Evaluation / audit / surveillance
Capacity building
Inter & intra sectoral coordination and collaboration : smart partnership
57

56. NCD Entry point
DIABETES HYPERTENSION PIKAM Program
PROMOTION &
World Diabetes Day Awareness week World Heart Day
EDUCATION
SCREENING Diabetes Clinic Hpt Clinic CVD screening
Behavior Behavior
INTERVENTION PIKAM Packages
Diabetes CPG Hpt CPG
Audit Audit Surveillance
EVALUATION
Research: SDM Research Research
58

57. Components of the CVD (NCD) Program
PROMOTION & SCREENING/ INTERVENTION SURVEILLANCE/
EDUCATION ASSESSMENT Behavior & Phm EVALUATION
Healthy Lifestyle My HeSS Guidelines
My HeSS
Campaign Health provider Developed
Demonstration Individual/ PHC staff is being
National Survey
Project Family trained
IEC plus Env.
community Quality is Audited Audit/HSR
Interventions
POLICY MAKER INTERSECTORAL SMART
COLLABORATION
PROG. MANAGER COMMITTEE PARTNERSHIP
59

58. Health Promotion
&
Health Education
(10 Prevention)

59. HEALTH PROMOTION
 Incorporate into Healthy Lifestyle campaigns
- adopt healthy lifestyle
- good nutrition
- weight reduction
- increase physical activity
61

60. HEALTH PROMOTION
 Phase 1 – 1991 to 1996
 Disease oriented campaign-yearly themes
 Phase 2- 1997 to 2002
 Behavioral oriented- yearly themes
 Phase 3- 2003 to 2008
 Behavioral oriented -2 yearly
 Focus to special target groups : school children,
work place
 4 elements: Physical activity, diet, smoking, stress
62

61. PHASE 1 HLSC- Disease Oriented
1991-1996
 LOVE YOUR HEART 1991
 CLEAN FOOD, HEALTHY
FAMILY 1993
AIDS KILL 1992
HEALTHY CHILDREN. STAY AHEAD PREVENT DIABETES
THE NATIONS FUTURE OF CANCER 1996
1994 1995
63

62. PHASE 2 HLSC - Behavioural Oriented
1997-2002
HEALTHY EATING
RECIPE FOR GOOD HEALTH
1997 EXERCISE 1998 PREVENT INJURY 1999
ADOPT A HEALTHY LIFESTYLE
PRACTISE GOOD MENTAL HEALTH TOWARDS A HARMONIOUS
2000 AND HEALTHY FAMILY 2001
64

63. 65

64.  World Heart Day Theme:
 2000: "Exercise”
 2001
 2002 Nutrition, obesity and physical activity
 2003: women, heart diseases and stroke
 2004: children, adolescent and heart disease
 Partners:
66

65. PARTNERS IN CVD:
NGO, INDUSTRY
• 1. Working closely with agencies, NGO:
-Heart Foundation, Hypertension Soc., MASSO etc.
• 2. Organize with MOH in the following area:
 NCD Resource centre (CVD/DM)
 Health Promotion and education
 Training
67

66. Screening
Health Assessment

67. CARDIOVASCULAR DISEASES ACTIVITIES
 CVD Risk Factors Screening (1999)
- plan to be incorporated into Well-Adult Clinic & Life-
Time Health Record ( LHR )
- Initially one center per district
- Screening of : Body Mass Index (BMI) for Obesity
: Blood Pressure
: Blood Glucose for Diabetes
: Blood Cholesterol
: Smoking Status
: Family History of Heart Disease
69

68. My HeSS (2004)
My Health Status Surveillance
 An Initiative
 An assessment tools/ enabler:
 Socio-demography
 Health Assessment :
 medical & life style history :
smoking, diet, alcohol, DM, Hpt
 Clinical : weight, BMI, BP, body
composition
 Biochemical : glucose & lipid
profiles
 Physical fitness Assessment
(ACSM)
 Diet Assessment & Management
 Stress Assessment
70

69. What MyHeSS offers ?
TOOLS DETECTION
Questionnaire Risk Factors: INTERVENTION
Physical - Smoking
Biochemical
- Hypertension Behavioral Mod.
- Obesity
- Dyslipidemia Pharmacotherapy
- IGT/Diabetes
To prevent:
Fitness
CVD
Diet Fitness level
Hypertension
Stress Dietary pattern Diabetes
Stress level & coping Stroke (CVA)
Cancer
71

70. CVD (NCD) Prevention & Control Program
Policy and Decision Maker
Program Managers
Health
Promotion & Education
Evaluation: Health
Audit & Research Assessment
My Health Status Surveillance System
Customized
personalised
INTERVENTION:
Behavior Modification
Pharmacotherapy
Customized, personalised, self-empowerment,
family & community involvement
72

71. My Health Surveillance System (MyHeSS)
Socio- Health Physical Stress Diet
demography Assessment Fitness Assessment Management
Profile Module Module Module Module
NCD
Surveillance
Database
Analysis Report Intervention

72. INTERVENTION
Behavioral Modification
Pharmacotherapy
Surgical, etc.

73. Intervention
 Physical activity
 Quit smoking
 Healthy diet
 Avoid alcohol
 Handle stress
 Weight reduction
75

74. CVD (NCD) Prevention & Control Program
Policy and Decision Maker
Program Managers
Health
Promotion & Education
Evaluation: Health
Audit & Research Assessment
My Health Status Surveillance System
Customized
personalised
INTERVENTION:
Behavior Modification
Pharmacotherapy
Customized, personalised, self-empowerment,
family & community involvement
76

75. Intervention
Health Clinic:
Prevention :10 20 30
 Hypertension clinic
 Diabetes clinic
 NCD clinic (2004)
Hospital
Prevention: 20 30
77

76. INTERVENTION
 PIKAM
 Malaysia Cardiovascular
Intervention Project (2000/2001)
 Malaysia Cardiovascular
Intervention Program
 Behavioral Modification modules
for :
 Physical activity
 Diet
 Smoking
 Hypertension
 Obesity
 IGT / DM
 Dyslipdemia
 Stress
78

77. CLINICAL PRACTISE GUIDELINES
 CPG on The Management of Hypertension 2002
 CPG for Treatment of Tobacco Smoking and Dependence 2003
 CPG on Management of Obesity 2003
 CPG on Dyslipidaemia 2003
 Consensus Statement on The Management of Ischemic Stroke
2000
 CPG on Myocardial Infarction 2001
 CPG on Heart Failure 2000
79

78. Appropriate facilities and equipments
 NCD Resource Center
 At district/clinics
 Manpower, machine,
materials & management
80

79. TRAINING for Diabetes Program
• Short term
• 3 days diabetes management courses for paramedic from
PHCs.
• 3 months courses for diabetes nurses and MA of diabetes
team
• Refresher courses for doctors.
• 6 months courses for diabetes management.
• Special courses in Diabetic foot, diabetes retinopathy and
nephropathy.
Long term
• Diabetologist.
• Dietitian.
• Podiatrist.
81

80. EVALUATION :
Audit & Research
 MyHeSS
 NCD Risk Factor Study
 Physical Activity Study
 Physical Fitness Study
 Diet Study
 Stress Study
 NCD Surveillance in the Community
 Work Place related Disease
 Audit for Hypertension & Diabetes Mx
 NCD Research
 Hypertension Registry (Hi-Trax)
 Diabetes Registry
82

81. Thank You