Symposium paper presented at the 10th Allied Health Scientific Conference Malaysia 2014, in KL. 9 September 2014

1. Ministry of Health
Malaysia
Non-Communicable Diseases:
Role of Government versus
Individuals Responsibilities
Feisul Idzwan Mustapha MBBS, MPH, AM(M)
Public Health Physician, NCD Section, Disease Control Division
Ministry of Health, Malaysia
Symposium 1: Managing NCDs
10th Allied Health Scientific Conference Malaysia 2014
9 September 2014
Kuala Lumpur
dr.feisul@moh.gov.my

2. There are FourMajor Groups of Non-
Communicable Diseases;
Fourmajor lifestyles related risk factors
Modifiable causative risk factors
Tobacco use
Unhealthy
diets
Physical
inactivity
Harmful
use of
alcohol
Noncommunicable diseases
Heart disease
and stroke
   
Diabetes    
Cancers    
Chronic lung
disease
 2

3. Proportional mortality, Malaysia
(% of total deaths, all ages, both sexes)
3

4. Premature mortality due to NCDs,
Malaysia
4
The probability of dying between ages 30 and 70 years
from the 4 main NCDs is 20%

5. 5
Global NCD
Targets
Source of icons: World Heart Federation Champion Advocates Programme

6. Sub-analysis of NHMS 2011 data
• At least 15% (18 years and above) already with known NCD
risk factors (diabetes, hypertension or hypercholesterolemia).
• Undiagnosed high blood sugar, high blood pressure or high
cholesterol: 42.1% (18 years and above).
• Or, if include obesity: 48.3% (18 years and above).
• Therefore our high risk and at risk population: 63.3% (18
years and above)
6

7. DALYs attributable to risk factors
7
Poor Water & Sanitation
Underweight
Physical Inactivity
Alcohol
High Cholesterol
High BMI
Diabetes Mellitus
10.7%
10.8%
8.3%
9.0%
3.1%
4.3%
5.2%
0.1%
0.7%
12.1%
10.8%
0.1%
0.7%
11.4%
5.1%
0.9%
4.3%
0.7%
Tobacco
High BP
15.0% 10.0% 5.0% 0.0% 5.0% 10.0% 15.0%
Male Female
Burden of Disease Study Malaysia, slide courtesy of Dr Mohd. Azahadi Omar, Institute for public health

8. Deaths attributable to risk factors
Poor Water & Sanitation
Underweight
Alcohol
Physical Inactivity
High BMI
High Cholesterol
Diabetes Mellitus
19.4%
15.7%
7.0%
7.3%
8.5%
5.0%
2.3%
0.1%
0.2%
22.8%
0.1%
0.2%
1.2%
7.1%
8.2%
8.1%
9.1%
0.3%
Tobacco
High BP
25% 20% 15% 10% 5% 0% 5% 10% 15% 20% 25%
Male Female
Burden of Disease Study Malaysia, slide courtesy of Dr Mohd. Azahadi Omar, Institute for public health
8

9. National Strategic Plan for
Non-Communicable Diseases
(NSP-NCD) 2010-2014
Seven Strategies:
1. Prevention and Promotion
2. Clinical Management
3. Increasing Patient Compliance
4. Action with NGOs,
Professional Bodies & Other
Stakeholders
5. Monitoring, Research and
Surveillance
6. Capacity Building
7. Policy and Regulatory
interventions
• Presented and approved by the Cabinet on 17 December 2010.
• Provides the framework for strengthening NCD prevention & control
program in Malaysia.
• Adopts the “whole-of-government” and “whole-of-society approach”.
• Diabetes & obesity are used as the entry points.
9

10. Cost effective NCD interventions…
• What works, what can we afford, and what should we adopt?
• The challenge? Identify interventions that:
• are effective;
• can lead to measurable declines in NCD death rates quickly (e.g.
over 10 years);
• are affordable; and
• can easily be implemented and sustained.
The Lancet. December 8, 2007 Volume 370:
Gaziano T, Galea G and Reddy K. Scaling up interventions for chronic disease prevention: the evidence.
pp 1939-1946.
The Lancet. December 15, 2007. Volume 370:
Asaria P, Crisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and
financial costs of strategies to reduce salt intake and control tobacco use. pp 2044-2053.
Lim S, et. al. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income
countries: health effects and costs. pp 2054-2061.
10

11. Cost effective NCD interventions…
• What is effective? The intervention must:
• targets behaviours or risk factors that are causally associated with
NCDs; and
• is proven, through evidence, to lead to favourable changes in
behaviours/risk factors, thereby reducing risk of death from
NCDs.
11

12. Cost effective interventions to address
NCDs
Population-based
interventions
addressing
NCD
risk factors
Tobacco use - Excise tax increases
- Smoke-free indoor workplaces and public places
- Health information and warnings about tobacco
- Bans on advertising and promotion
Harmful use
of alcohol
- Excise tax increases on alcoholic beverages
- Comprehensive restrictions and bans on alcohol marketing
- Restrictions on the availability of retailed alcohol
Unhealthy
diet and
physical
inactivity
- Salt reduction through mass media campaigns and reduced salt
content in processed foods
- Replacement of trans-fats with polyunsaturated fats
- Public awareness programme about diet and physical activity
Individual-based
interventions
addressing
NCDs in
primary care
Cancer - Prevention of liver cancer through hepatitis B immunization
- Prevention of cervical cancer through screening (visual
inspection with acetic acid [VIA]) and treatment of pre-cancerous
lesions
CVD and
diabetes
- Multi-drug therapy (including glycaemic control for diabetes
mellitus) for individuals who have had a heart attack or stroke,
and to persons at high risk (> 30%) of a cardiovascular event
within 10 years
- Providing aspirin to people having an acute heart attack
12

13. Strategy 7 NSP-NCD:
Policy & Regulatory Interventions
• Main thrust of NSP-NCD
• Health promotion and education will increase awareness and
knowledge
• However changes in behaviour is strongly influenced by our
living environment
Awareness Knowledge
Behavioural
Change
Supportive living
environment
Health promotion & educations
Policies & regulations
13

14. 14

15. Individuals Populations
Lifestyle medicine Public health policy
Policy approaches:
Change the environment
Policy approaches: educate,
inform to change
behaviours
15

16. The Great Prevention Debate
Personal choice
versus
government responsibility
16

17. Personal Choice is Important
17

18. BUT …
If we want people to make healthy choices we
have to make healthy choices available,
accessible and affordable
18

19. Prevention is BOTH a personal and
government responsibility
19

20. Current Approaches to NCD From Birth To Tomb
Pregnancy
Pre-conception
Intervention
Package
 Health
Promotion
Infant/
Toddler
First 1,000 Days
To reduce obesity and NCDs-birth weight
Lifestyle during pregnancy – fetal health
Pre-
School
School-going
Age
Garispanduan Pemasaran Makanan
& Minuman kepada Kanak-kanak
Garispanduan
Pengurusan Kantin
Garispanduan Penguatkuasaan
Larangan Penjualan Makanan &
Minuman Di Luar Pagar Sekolah
NCDP1M
School Setting
KOSPEN
Workplace / Community
Setting
Higher
Education Adults Elderly
AktivitiFizikal
Program Warga Aktif
Warga Produktif
Healthy Workplace
for Healthy
Workforce
Sihat
Amalan
Pemakanan Sihat
Hidangan Sihat
SemasaMesyuarat
Kafeteria Sihat
Garispanduan Perlaksanaan
Vending Machine Makanan &
Minuman Sihat dlm
Perkhidmatan Awam
Jom Mama
Initiatives
20

21. Strategy 7 NSP-NCD: Policy & Regulatory
Interventions, Progress thus far…
• Guideline on marketing of foods and non-alcoholic beverages to
children (Self-regulatory, August 2013).
• Strengthening implementation of the Framework Convention for
Tobacco Control (FCTC).
• Guideline on food and beverages sold in school canteens (revised
guideline, January 2012).
• Banning of sale of food & beverages by mobile vendors outside of
school perimeters (2012)
• Health-promoting workplaces in the public sector
• Healthy menus during meetings
• Healthy vending machines
• Healthy cafeterias
There is still much that needs to be done….
21

22. Objective 3 GAP NCD 2013-2020:
Healthy Diet
• Three (3) relevant global targets:
• A 30% relative reduction in mean population intake of
salt/sodium
• A halt in the rise in diabetes and obesity
• A 25% relative reduction in the prevalence of raised blood
pressure or containment of the prevalence of raised blood
pressure according to national circumstances.
22

23. Objective 3 GAP NCD 2013-2020:
Healthy Diet
• Promote and support exclusive breastfeeding for the first six
months of life, continued breastfeeding until two years old
and beyond and adequate and timely complementary feeding.
• Implement WHO’s set of recommendations on the marketing
of foods and non-alcoholic beverages to children, including
mechanisms for monitoring.
23

24. Objective 3 GAP NCD 2013-2020:
Healthy Diet
• Develop guidelines, recommendations or policy measures that
engage different relevant sectors, such as food producers and
processors, and other relevant commercial operators, as well as
consumers, to:
• Reduce the level of salt/sodium added to food (prepared or
processed).
• Increase availability, affordability and consumption of fruit and
vegetables.
• Reduce saturated fatty acids in food and replace them with
unsaturated fatty acids.
• Replace trans-fats with unsaturated fats.
• Reduce the content of free and added sugars in food and non-alcoholic
beverages.
• Limit excess calorie intake, reduce portion size and energy density of
foods. 24

25. Objective 3 GAP NCD 2013-2020:
Healthy Diet
• Develop policy measures that engage food retailers and
caterers to improve the availability, affordability and
acceptability of healthier food products (plant foods, including
fruit and vegetables, and products with reduced content of
salt/sodium, saturated fatty acids, trans-fatty acids and free
sugars).
• Promote the provision and availability of healthy food in all
public institutions including schools, other educational
institutions and the workplace. (e.g. through nutrition standards for
public sector catering establishments and use of government contracts for
food purchasing)
25

26. Objective 3 GAP NCD 2013-2020:
Healthy Diet
• As appropriate to national context, consider economic tools
that are justified by evidence, and may include taxes and
subsidies, that create incentives for behaviours associated
with improved health outcomes, improve the affordability and
encourage consumption of healthier food products and
discourage the consumption of less healthy options.
• Develop policy measures in cooperation with the agricultural
sector to reinforce the measures directed at food processors,
retailers, caterers and public institutions, and provide greater
opportunities for utilization of healthy agricultural products
and foods.
26

27. Objective 3 GAP NCD 2013-2020:
Healthy Diet
• Conduct evidence-informed public campaigns and social
marketing initiatives to inform and encourage consumers
about healthy dietary practices. Campaigns should be linked
to supporting actions across the community and within
specific settings for maximum benefit and impact.
• Create health- and nutrition-promoting environments,
including through nutrition education, in schools, child care
centres and other educational institutions, workplaces, clinics
and hospitals, and other public and private institutions.
• Promote nutrition labelling, according to but not limited to,
international standards, in particular the Codex Alimentarius,
for all pre-packaged foods including those for which nutrition
or health claims are made. 27

28. Objective 3 GAP NCD 2013-2020:
Promoting Physical Activity
• Three (3) relevant global targets:
• A 10% relative reduction in prevalence of insufficient physical
activity.
• Halt the rise in diabetes and obesity.
• A 25% relative reduction in the prevalence of raised blood
pressure or contain the prevalence of raised blood pressure
according to national circumstances.
28

29. Objective 3 GAP NCD 2013-2020:
Promoting Physical Activity
• Adopt and implement national guidelines on physical activity
for health.
• Consider establishing a multi-sectoral committee or similar
body to provide strategic leadership and coordination.
• Develop appropriate partnerships and engage all stakeholders,
across government, NGOs and civil society and economic
operators, in actively and appropriately implementing actions
aimed at increasing physical activity across all ages.
29

30. Objective 3 GAP NCD 2013-2020:
Promoting Physical Activity
• Develop policy measures in cooperation with relevant sectors to
promote physical activity through activities of daily living, including
through “active transport,” recreation, leisure and sport, for example:
• National and sub-national urban planning and transport policies to
improve the accessibility, acceptability and safety of, and supportive
infrastructure for, walking and cycling.
• Improved provision of quality physical education in educational settings
(from infant years to tertiary level) including opportunities for physical
activity before, during and after the formal school day.
• Actions to support and encourage “physical activity for all” initiatives for
all ages.
• Creation and preservation of built and natural environments which
support physical activity in schools, universities, workplaces, clinics and
hospitals, and in the wider community, with a particular focus on
providing infrastructure to support active transport i.e. walking and
cycling, active recreation and play, and participation in sports.
• Promotion of community involvement in implementing local actions
aimed at increasing physical activity.
30

31. Objective 3 GAP NCD 2013-2020:
Promoting Physical Activity
• Conduct evidence-informed public campaigns through mass
media, social media and at the community level and social
marketing initiatives to inform and motivate adults and young
people about the benefits of physical activity and to facilitate
healthy behaviours. Campaigns should be linked to supporting
actions across the community and within specific settings for
maximum benefit and impact.
• Encourage the evaluation of actions aimed at increasing
physical activity, to contribute to the development of an
evidence base of effective and cost-effective actions.
31

32. Ministry of
Health Malaysia
KOmuniti Sihat, PErkasa Negara
(KOSPEN):
Empowering Communities,
Strengthening the Nation

33. Background of KOSPEN
• Empowering individuals and communities in self-care to
reduce the exposure to NCD risk factors.
• Blue Ocean Strategy between MOH and other government
departments and agencies with existing programs and
activities at the grassroot levels
• E.g. KEMAS (Department of Community Department), Rukun
Tetangga (NeighbourhoodWatch)
• Attempts to add value to the existing program and activities of
these different departments and agencies, but incorporating
elements of NCD risk factor screening and intervention.
33

34. KOSPEN: Empowering individuals
and communities in healthy living
1. Increasing awareness
2. Translation of knowledge into
sustainable actions
3. Health-promoting living environment
Five (5) scopes of healthy living
Three (3)
Main
Strategies
• Not smoking or smoke-free
• Weight management
• Healthy eating
• Active living
• Early detection of NCD risk factors
34

35. Behavioural Changes through
intervention in KOSPEN
Scope Behavioural Changes
Healthy eating 1. Culture: separating sugar / creamer from hot beverages.
2. Culture: increasing availability of fruits and vegetables.
3. Culture: increasing availability of plain drinking water.
Not smoking /
smoke-free
1. Enforcement or implementation of smoke-free areas – both
by regulation and volunteerism (e.g. smoke-free house,
smoke-free events).
Active living 1. Creation of 10,000-steps walking tracks in the
community/village.
Weight
management
1. Self-monitoring of body mass index (BMI) at set and regular
intervals.
Know your
health status
1. Self-monitoring of BMI, blood pressure and blood sugar at
set and regular intervals.
2. Use of health diaries. 35

36. KOSPEN Launching Ceremony, National
level, 13 February 2014, Segamat, Johor
36

37. Lessons learned from the past and current
attempts to work with other sectors
• Go for the path of least resistance.
• Perhaps less impact, but at least establish the link and develop
trust.
• Compromise, find the “middle path”
• You cannot force the other sectors to go 100% your way.
• Be creative – think “out-of-the-box”
• Use other existing mechanisms not previously used to move the
NCD prevention agenda forward.
• Be sensitive to current global/national trends.
• Use any opportunity to move the NCD prevention agenda
forward.
37

38. Summary
• We know what needs to be done for the prevention and
control of NCD.
• What we do not know is how best to implement in real
life situations and within the socio-cultural context of
Malaysia.
• Implementation-type research, including behavioural (qualitative
research) can provide evidence in answering this question.
• Multisectoral approach, not only in implementation but in
research as well.
38

39. 39
Summary

40. Thank you
dr.feisul@moh.gov.my
Facebook: Feisul Mustapha
40