Presentation at the Dietetics Update held in Putrajaya, 11 August 2014

1. Overview on Obesity, Aetiology
and Epidemic in Malaysia:
How serious is the problem?
Feisul Idzwan Mustapha MBBS, MPH, AM(M)
NCD Section, Disease Control Division
Ministry of Health, Malaysia
Clinical Dietetic Update in Weight Management
11 August 2014
Putrajaya
dr.feisul@moh.gov.my
Ministry of Health
Malaysia

2. There are Four MajorGroupsof Non-
CommunicableDiseases;
Four majorlifestyles related riskfactors
Modifiable causative risk factors
Tobacco use
Unhealthy
diets
Physical
inactivity
Harmful
use of
alcohol
Noncommunicablediseases
Heart disease
and stroke    
Diabetes
   
Cancers
   
Chronic lung
disease 
2

3. 8.3
14.9
20.8
6.5
9.5
10.7
1.8
5.4
10.1
4.3 4.7 5.3
0
5
10
15
20
25
NHMS II (1996) NHMS III
(2006)
NHMS 2011
Prevalence(%)
Prevalence of Diabetes,
≥30 years (1996, 2006 & 2011)
Total diabetes
Known
Undiagnosed
IFG
Source: National Health & Morbidity Surveys (NHMS)
32.2 32.7
12.8
19.8
0
5
10
15
20
25
30
35
NHMS III (2006) NHMS 2011
Prevalence(%)
Prevalence of Hypertension,
≥18 years (2006 & 2011)
Total HPT
Known
Undiagnosed
20.6
35.1
8.4
26.6
0
5
10
15
20
25
30
35
40
NHMS III (2006) NHMS 2011
Prevalence(%)
Prevalence of Hypercholesterolaemia,
≥18 years (2006 & 2011)
Total HChol
Known
Undiagnosed
3

4. 16.6
29.1 29.4
4.4
14.0 15.1
0
5
10
15
20
25
30
35
NHMS II
(1996)
NHMS III
(2006)
NHMS 2011
Prevalence(%)
Prevalence of Overweight & Obesity,
≥18 years (1996, 2006 & 2011)
Overweight
Obesity
PrevalenceofAbdominalObesity,≥18years
(2006&2011)
19.6
28.6
33.6
44.7
48.0
51.0
55.7
62.8 63.2
61.4
63.2
56.2
50.4
10
20
30
40
50
60
70
18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
PREVALENCE(%)
AGE GROUPS (years)
30.1
37.1
47.1
54.1
20
30
40
50
60
NHMS 2006 NHMS 2011
PREVALENCE(%)
MALES FEMALES
Prevalence of Abdominal
Obesity by age groups
(NHMS 2011)
4

5. Overweight in adults, ASEAN
Region, 2010
5
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
Prevalence%
Male
Female

6. Obesity in adults, ASEAN Region,
2010
6
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
Prevalence%
Male
Female

7. 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).
• Alternatively, if include obesity: 48.3% (18 years and above).
• Therefore our high risk and at risk population: 63.3% (18
years and above)
7

8. Sub-analysis of NHMS 2011 data
Prevalence CI Lower CI Upper
Est.
population
Diabetes (known) 7.2 1,247,366
Diabetes (known) only, without
hypertension (total) or without
hypercholesterolaemia (total) 1.22 1.04 1.43 209,532
Diabetes (known) and
hypertension (total) 5.18 4.78 5.61 893,578
Diabetes (known) and
hypertension (total) +
hypercholesterolaemia (total) 3.31 3.00 3.64 567,494
8

9. Sub-analysis of NHMS 2011 data
Prevalence
CI
Lower
CI
Upper
Est.
population
Hypertension (known) 12.8 2,271,995
Hypertension (known) only,
without diabetes (total) or
without hypercholesterolaemia
(total) 3.47 3.16 3.81 596,157
Hypertension (known) and
hypercholesterolaemia (total) 7.62 7.10 8.17 1,338,920
Hypercholesterolaemia (known) 8.4 1,478,453
Hypercholesterolaemia only,
without hypertension (total) or
without diabetes (total) 2.25 1.95 2.59 386,473
9

10. Sub-analysis of NHMS 2011 data
Prevalence CI Lower CI Upper
Est.
population
Obesity 15.1 2,462,152
Obesity only, without diabetes
(total) or without hypertension
(total) or without
hypercholesterolaemia (total) 3.72 3.35 4.12 587,966
10

11. Sub-analysis of NHMS 2011 data
WHO/ISH CVD 10-year risk
prediction: Risk Levels among those
with UNDIAGNOSED DIABETES OR
UNDIAGNOSED HYPERTENSION OR
UNDIAGNOSED
HYPERCHOLESTEROLAEMIA Prevalence CI Lower CI Upper
Est.
population
<10% 85.58 84.53 86.57 6,250,178
10% to <20% 7.42 6.73 8.16 541,584
20% to <30% 2.98 2.55 3.48 217,693
30% to <40% 1.71 1.42 2.06 125,124
40% and above 2.31 1.92 2.76 168,440 11

12. 65th World Health
Assembly (May 2012):
Decided to adopt a global target of
a 25% reduction in premature
mortality from NCD by 2025.
66th World Health Assembly
(May 2013):
Adoption of the Global Action plan for
the Prevention and Control of NCDs
(2013-2020), including 25 NCD
indicators with 9 voluntary global
targets.
12

13. Recent UN/WHO Mandates
• High-level meeting of the General Assembly on the
comprehensive review and assessment of the progress
achieved in the prevention and control of NCDs (10-11 July
2014)
• Global Action Plan for the Prevention and Control of NCDs
2013-2020
13

14. High-level meeting of the General
Assembly on the comprehensive
review and assessment of the
progress achieved in the prevention
and control of NCDs
• Specific commitments on (among others):
• Leadership & governance
• Prevention & risk factor exposure
• Health systems
• Monitoring and evaluation
14

15. Global Action Plan for the
Prevention and Control of NCDs
2013-2020
• Six (6) objectives
• Nine (9) voluntary global targets
• Appendix 3: Menu of policy options and cost effective
interventions
15

16. Global Monitoring Framework for NCDs
Indicator Targets
1. Premature mortality from NCD 25% relative reduction in risk of dying
2. Harmful use of alcohol 10% relative reduction
3. Physical inactivity 10% relative reduction
4. Salt intake 30% relative reduction in mean population
intake
5. Tobacco use 30% relative reduction
6. Hypertension Contain the prevalence
7. Diabetes & obesity Contain the prevalence
8. Drug therapy to prevent heart
attacks & strokes
At least 50% of eligible people receive
therapy
9. Essential NCD medicines & basic
technologies to treat major NCDs
Availability & affordability
Note: Targets for year 2025, against baseline of year 2010. Reporting to the
United Nations every five years (next will be in 2015)
16

17. Cost effective interventions to
address NCDs
17
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

18. 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.
18

19. 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.
19

20. 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. 20

21. 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)
21

22. 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. 22

23. 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.
23

24. 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.
24

25. 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.
25

26. 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.
26

27. 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.
27

28. National Strategic Plan for
Non-Communicable Diseases
(NSP-NCD) 2010-2014
• 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”
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
28

29. Current Approaches to NCD From Birth To Tomb
Intervention
Package
 Health
Promotion
Pregnancy
Pre-
conception
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 Penguatkuasaan
Larangan Penjualan Makanan &
Minuman Di Luar Pagar Sekolah
Higher
Education
Adults Elderly
School Setting
Workplace / Community
Setting
KOSPEN
AktivitiFizikal
Program Warga Aktif
Warga Produktif
Healthy Workplace
for Healthy
Workforce
Garispanduan
Pengurusan Kantin
Sihat
Garispanduan Perlaksanaan
Vending Machine Makanan &
Minuman Sihat dlm
Perkhidmatan Awam
Kafeteria Sihat
Hidangan Sihat
Semasa Mesyuarat
Amalan
Pemakanan Sihat
Jom Mama
Initiatives
29

30. Multi-disciplinary care
team (in health clinics)
Post-basic training
for paramedics
Clinical practice
guidelines
Quality improvement
programs
Clinical
information
systems
Patient resource
centres
Community
empowerment
Strengthening Chronic Disease
Management at the primary care level
30

31. Management of NCDs:
7 basic principles
• Screening
• Register
• Clinical management
• Complications
• Rehabilitation
• Defaulter tracing
• Selfcare – Patient’s
empowerment
31

32. Initiatives to Improve Clinical Outcome
• The formation of Diabetes Team which consists of Diabetes Educator,
Medical Officer, Family Medicine Specialist (FMS), Nutritionist and
Pharmacist in every clinic as appropriate to their burden of diabetes
patients.
• FMS or senior Medical Officer in the clinic to do regular audits on green
book.
• Intensify and more frequent supervision especially by FMS of clinical staff to
ensure compliance to CPGs and related guidelines.
• Regular training and CMEs on diabetes care for all clinic staffs, and the state
office to monitor the numbers of training sessions conducted.
• Availability of module for health education for patients and a set of pre- and
post-test for patients, as published by Disease Control Division, MOH.
• The usage of the Diabetes Conversation Map.
• Further development of a Peer Support Group.
• Personalized care by Medical Officer in clinics with low to moderate burden
of loads, as appropriate in the individual clinic settings.
32

33. Overview of a Peer Support Group
• Patients becomes a trainer / facilitator, training his/her fellow
colleagues with the same disease.
• MOH responsible for developing the training modules,
conduct training and develop the implementation guidelines.
• Successful implementation of a Peer Support Group Program
has been shown to:
• Help patients understand their disease better;
• Help patients achieve good disease control; and
• Reduce rates of referral to hospitals due to complications.
• Rationale – patients are more likely to accept advise from
their peers or people living with the same condition.
33

34. 34
Summary

35. Thank you
dr.feisul@moh.gov.my
35