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STATUS OF
NONCOMMUNICABLE DISEASES
(NCDS) IN MALAYSIA: AN
URGENT CALL FOR ACTION.
BY: DR ZAINAL ARIFFIN OMAR AND DR FEISUL IDZWAN
MUSTAPHA
Ministry of Health
Malaysia
UPM-Mead Johnson 3rd
Nutrition Seminar (Nutritional Intervention in NCDs),
8 Nov 2012
Ministry of Health
Malaysia
Outline of the presentation
Terminology of NCD
Current Disease Burden
Future projections
Focus of WHO
MALAYSIA ‘ Responses
Commitments
Challenges
Key messages
Ministry of Health
Malaysia Noncommunicable diseases(WHO)
• Diseases which are not transmissible .
• Includes:
• CVDs (heart disease & stroke),
• Cancer
• Chronic respiratory diseases
• Diabetes
• Mental health disorders
• Substance abuse
• Injuries (including caused by violence)
• Others: vision & hearing impairment, oral diseases, bone & joint disorders, and genetic disorders.
Ministry of Health
Malaysia
National Health and
Morbidity Surveys
• Also known as NHMS
• Population-based survey conducted by MOH
• NHMS I (1986), NHMS II (1996) & NHMS III (2006)
• Latest NHMS 2011
• For NCD risk factors, now conducted every 4 years
• Based on WHO STEPwise Methodology
• Sampling Frame:
• National Household Sampling Frame made up of Enumeration Blocks (EBs) derived from the Population and Housing Census, Malaysia (2010)
• Sampling Design:
• Multistage Random Sampling (28 strata)
4
Ministry of Health
Malaysia
5
THE CAUSATION
PATHWAY FOR NCD
Underlying
Determinants
•Globalisation
•Urbanisation
•Population
Ageing
Common Risk
factors •Unhealthy diet
•Physical Inactivity
•Tobacco & Alcohol
use
•Age (non modifiable)
•Heredity
(non modifiable)
Intermediate Risk Factors •Overweight/obesity •Raised blood sugar •Raised blood pressure •Abnormal blood lipids
Main NCD •Heart Disease •Diabetes •Stroke •Cancer •Chronic resp. diseases
Source: Adapted from Preventing Chronic Disease: A Vital Investment. Geneva,
WHO. 2005.
Ministry of Health
Malaysia NCDs : DISEASE BURDEN
Ministry of Health
Malaysia
NHMS 2011,
DEFINITIONS
BMI STATUS (WHO
1998)
Overweight: 25.0 to
29.9 kg/m2
Obese ≥30 kg/m2
ABDOMINAL OBESITY
(WHO 2000)
Waist circumference
Men ≥90 cm
Women ≥80 cm
7
Ministry of Health
Malaysia
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
Pre
va
len
ce
(%
)
Prevalence of Overweight and Obesity, ≥18 years (1996, 2006 & 2011)
Overweight
Obesity
8
Ministry of Health
Malaysia
29.4
15.3
29.4
14.4
0
5
10
15
20
25
30
35
Overweight Obese
Pre
va
len
ce
(%
)
Prevalence of Overweight & Obesity , ≥18 years, by Location (2011)
Urban
Rural
9
Ministry of Health
Malaysia
14.1
18.1
21.5
30.8 33.0
37.6 37.5 39.6
35.0 36.0 34.9
29.5 30.2
9.9 10.8
15.4 15.2 17.7 16.7
18.2 16.7
20.2
16.0 14.8
6.8 5.6
0
5
10
15
20
25
30
35
40
45
Pre
va
len
ce
(%
)
Age groups
Prevalence of Obesity, ≥18 years, by age groups (2011)
Overweight
Obesity
10
Ministry of Health
Malaysia
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
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
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+
Pre
va
len
ce
(%
)
Age groups
Prevalence of Abdominal Obesity, ≥18 years, by Age groups (2011)
11
Ministry of Health
Malaysia
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 of Diabetes, ≥30 years (1996, 2006 & 2011)
Total diabetes
Known
Undiagnosed
IFG
12
Ministry of Health
Malaysia
13
0.0 0.8 0.8
2.6 3.4
7.6 9.1
15.1
17.9
23.1
25.5
20.3 19.4
2.1
4.1 4.5
6.8 7.5
10.0 11.4 11.6
13.7 13.1
11.0 10.1
12.5
2.1
4.9 5.3
9.4 10.9
17.6
20.6
26.7
31.6
36.2 36.6
30.3
31.9
4.1 3.5 4.4
5.2 5.5 4.6
6.2 6.1 5.1
4.3 5.7
4.7 5.1
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Pre
va
len
ce
(%
)
Age groups
Prevalence of Diabetes, ≥18 years, by age groups (2011)
Known
Undiagnosed
Total diabetes
IFG
Ministry of Health
Malaysia
14
2.9 4.1
6.4
9.8 10.7
13.1
18.2
16.1 15.3
2.0
2.0 3.1
4.9 6.4
10.3
15.0
20.8
24.4
26.1
24.5
22.8
2.1
4.9 5.3
9.4 10.9
17.6
20.6
26.7
31.6
36.2 36.6
30.3
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Age groups
Prevalence of Diabetes, ≥18 years, by age groups (1996, 2006 & 2011)
NHMS II (1996)
NHMS III (2006)
NHMS 2011
Ministry of Health
Malaysia
HOW DO WE COMPARE TO
OUR NEIGHBOURING
COUNTRIES?
15
Ministry of Health
Malaysia
OVERWEIGHT IN ADULTS,
ASEAN REGION, 2010
16
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
Pre
va
len
ce
%
Male
Female
Ministry of Health
Malaysia
OBESITY IN ADULTS,
ASEAN REGION, 2010
17
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
Pre
va
len
ce
%
Male
Female
Ministry of Health
Malaysia
18
HIGH BLOOD SUGARS IN
ADULTS, ASEAN REGION,
2010
Ministry of Health
Malaysia
WHAT’S THE FUTURE? –
PROJECTIONS…
19
Ministry of Health
Malaysia
Burden of Obesity in Malaysia:
Trends & Projections by 2020
(Adults age 18 years and above)
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000
0
5
10
15
20
25
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Es
tim
ate
d p
op
ula
tio
n
Pre
va
len
ce
(%
)
Year
Est. population, 2006 Est. population, 2011
Prevalence projection, 2006 Prevalence projection, 2011
Current
projection
20
Ministry of Health
Malaysia
Burden of Diabetes in Malaysia:
Trends & Projections by 2020
(Adults age 18 years and above)
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000
0
5
10
15
20
25
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Es
tim
ate
d p
op
ula
tio
n
Pre
va
len
ce
(%
)
Year
Est. population, 2006 Est. population, 2011
Prevalence projection, 2006 Prevalence projection, 2011
Current
projection
21
Ministry of Health
Malaysia
Admissions to MOH Hospitals due
to Circulatory Diseases & Cancer:
Projections by 2020
y = 130995e0.0208x R² = 0.7959
y = 53166e0.0523x R² = 0.8716
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Circulatory diseases Malignant neoplasms
Projected, Circulatory diseases Projected, Cancer
22
Ministry of Health
Malaysia
Deaths in MOH Hospitals due to
Circulatory Diseases & Cancer:
Projections by 2020
y = 605.97x + 8657.9 R² = 0.9027
y = 305.31x + 3776.1 R² = 0.9542
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Circulatory diseases Malignant neoplasms
Projected, Circulatory diseases Projected, Cancer23
Ministry of Health
Malaysia
Primary Renal Diseases:
Projections by 2020
y = 314.5x + 1735.7 R² = 0.9634
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
New dialysis patients
New dialysis patients Projected new dialysis patients24
Ministry of Health
Malaysia
NCD prevention and
control – Focus of WHO
1. National multi-sectoral policy and plan within the national health and development plan
2. Population based, multi-sectoral actions for risk reduction
3. Health system strengthening for NCD prevention and management
4. Surveillance, monitoring and reporting
5. Sustainable partnerships and advocacy
25
Ministry of Health
Malaysia
National Policy and Plan
for NCD
NCD Multisectoral Plan
Identified
budget
Resources
Multisectoral
coordination
mechanisms
Other
Ministries
Partners
National Development Agenda
National Health Plan
26
Ministry of Health
Malaysia
Outcome of risk
reduction
At least 80% of CVD, Type 2 DM and
40% of cancers could be avoided
through a healthy diet, regular
physical activity and avoidance of
tobacco.
27
Ministry of Health
Malaysia
Population Based Multisectoral
Actions For NCD Risk Reduction:
Control Of Tobacco
• 10 % reduction in tobacco use by 2014
• Tobacco taxation and Health Promotion
Foundations
• Plain packaging- a path-breaking approach
28
Ministry of Health
Malaysia
MALAYSIA’S RESPONSE…
29
Ministry of Health
Malaysia
National Strategic Plan for Non-Communicable Diseases (NSP-NCD) 2011-2015
• 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
30
Ministry of Health
Malaysia
Cabinet Committee for A Health
Promoting Environment
To support the implementation of NSP-NCD, the Cabinet on 17 December
2010 approved the establishment of a Cabinet-level committee, chaired by
the Right Honourable Deputy Prime Minister, and comprises of 10 members
1. Minister of Health
2. Minister of Education
3. Minister of Information, Communications, Arts & Culture
4. Minister of Rural & Regional Development
5. Minister of Agriculture and Agro-based Industry
6. Minister of Youth & Sports
7. Minister of Human Resource
8. Minister of Domestic Trade, Co-operatives and Consumerism
9. Minister of Housing and Local Governments
10. Minister of Women, Family and Social Affairs
Main TOR: To determine policies that creates a living environment which supports positive behavioural changes of the population towards healthy eating and active living
31
Ministry of Health
Malaysia
Strategy 7: 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 32
Ministry of Health
Malaysia
Policy & Regulatory
Interventions
Guideline on Marketing of food and beverages to children
• Involvement of industries
Healthy eating environment in schools
• New guideline on school canteen food & beverages
• Banning of sale of food & beverages by mobile vendors outside of school perimeters
Commitment of industries
• Decrease the salt , sugar and fat content in food and beverages
• Improvement of food labels
33 Continued…..
Ministry of Health
Malaysia
Policy & Regulatory
Interventions
Health-promoting workplaces in the public sector
• Healthy menus during meetings
• Healthy vending machines
Anti-obesity Law, year 2020
• Looking at Japan as an example
Salt reduction Strategy for Malaysia
• Formalising and strengthening current efforts in Malaysia
34
Ministry of Health
Malaysia
Potential policy interventions to
improve dietary intake for
preventing obesity in Malaysia
Policy areas Potential policy interventions Fiscal 1. Removal of subsidies on sugar, for both industries and
households.
2. Removal of subsidies on cooking oil, for both industries and
households.
3. Introduce subsidies for fruits and vegetables.
4. Introduce excise and/or sales tax on soft drinks.
5. Introduce excise and/or sales tax on sweetened condensed
milk.
Primary
production and
imports
1. Incentives for farmers to grow local fruit and vegetable.
2. Reducing import duty on fruits and vegetables.
3. Increasing import duty on cooking oils and other fat sources
(e.g. butter, ghee).
Food processing
1. Regulate maximum content of sugar and fat in processed food
products.
2. Incentives (e.g. Healthy Choice endorsement) for industries to improve food composition.
35 This policy-mapping analysis grid is adapted from G. Sacks, B. Swinburn & M. Lawrence: Obesity Policy Action framework and
analysis grids for a comprehensive policy approach to reducing obesity. Obesity Reviews (2008)
Ministry of Health
Malaysia
Potential policy interventions to
improve dietary intake for
preventing obesity in Malaysia
Policy areas Potential policy interventions Food marketing / information
1. Comprehensive restrictions for all marketing of unhealthy food to
children under 16 years in all media, including television, the
internet and other electronic media.
2. Introduce a nutrition signposting system (Healthy Choice tick,
keyhole or traffic light labelling) as a front pack labelling to
indicate food products with less fat, sugar and salt, and more
whole grain and fibre.
3. Banning television advertising of foods high in fat and/or high in
sugar during prime time viewing (7pm to 9pm).
4. Mandatory for fast food outlets to display nutrition information
about each product on menus, menu boards and drive-through
boards at the point of sale, and on tags next to self-service
cabinets and food displays.
5. Mandatory for vending machine operators to display nutrition
information about the products at the front of vending machines.
36 This policy-mapping analysis grid is adapted from G. Sacks, B. Swinburn & M. Lawrence: Obesity Policy Action framework and
analysis grids for a comprehensive policy approach to reducing obesity. Obesity Reviews (2008)
Ministry of Health
Malaysia
Potential policy interventions to
improve dietary intake for
preventing obesity in Malaysia
Policy areas Potential policy interventions Food
distribution & retail
1. Limiting the sales of high fat & high sugar food/ beverages in
schools & learning institutions (canteen, cafeteria & co-operative
shop).
2. Control of vending machines in schools, higher education
institutes and public buildings.
3. Control the licensing for food vendors within close proximity (e.g.
<500m) from schools.
4. Density controls over new fast food outlets, in all areas, both
urban and rural.
5. Restrict retail hours of fast food outlets, restaurants and hawker
stalls (e.g. to be closed at 10 pm.)
6. Compulsory inclusion of healthy choices (e.g. drinking water, low
sugar/fat/ salt snacks) in vending machines.
7. Restricting the sale of energy-dense and nutrient-poor foods in
workplace canteens.
8. Compulsory to have a fruit/salad stall at any food outlet in public
institutions (e.g. schools, universities, offices, hospitals). 37 This policy-mapping analysis grid is adapted from G. Sacks, B. Swinburn & M. Lawrence: Obesity Policy Action framework and
analysis grids for a comprehensive policy approach to reducing obesity. Obesity Reviews (2008)
Ministry of Health
Malaysia
Potential policy interventions to
improve dietary intake for
preventing obesity in Malaysia
Policy areas Potential policy interventions Food service 1. Implementation of healthy food service policies in public
institutions (e.g. schools, universities, government departments,
hospitals).
2. Mandatory for cafeteria operators and caterers to be trained and
accredited on healthy food provisions and preparations.
3. Compulsory for every food service to include fruits and
vegetables in every set meal .
38 This policy-mapping analysis grid is adapted from G. Sacks, B. Swinburn & M. Lawrence: Obesity Policy Action framework and
analysis grids for a comprehensive policy approach to reducing obesity. Obesity Reviews (2008)
Ministry of Health
Malaysia
Commitment 1: National
Leadership & Ownership
By 2013, establish and strengthen multisectoral national NCD policies and plans
Integrate NCD policies and programmes into national health planning and development agendas
Promote whole-of-government approaches across sectors
39
Ministry of Health
Malaysia Commitment 2: Prevention
Promote health in all policies approach
Advance implementation and strengthening of cost-effective, population wide interventions to reduce NCD risk factors
Promote healthy diets through implementation of WHO recommendations on marketing of foods and non-alcoholic beverages to children; the elimination of trans-fats; reduction of salt, sugars and saturated fats; and encourage policies that support production of healthy foods
Increase physical activity by giving greater priority to physical education in schools, urban planning, active transport, work-site healthy lifestyle programmes and increased availability of safe environments in public parks and recreational spaces
Promote the inclusion of NCD prevention and control within sexual and reproductive health and maternal and child health programmes, including breastfeeding for the first 6 months
40
Ministry of Health
Malaysia Commitment 2: Prevention
Guideline on Marketing of food and beverages to children
• TWG formed in January 2012
• Involvement of private sector
Commitment of industries
• Decrease the salt, sugar and fat content in food and beverages
• Improvement of food labels – New front of pack labelling of energy
41 Continued…..
Ministry of Health
Malaysia Commitment 2: Prevention
Healthy eating environment in schools
• New guideline on school canteen food & beverages
• Banning of sale of food & beverages by mobile vendors outside of school perimeters
42 Continued…..
Ministry of Health
Malaysia Commitment 2: Prevention
Health-promoting workplaces in the public sector
• Healthy menus during meetings
• Healthy vending machines
43
Ministry of Health
Malaysia Commitment 2: Prevention
Anti-obesity Law, year 2020
• Looking at Japan as an example
44
Stage 1: School setting (including pre-schools) – targeting school-going
children and adolescent. Create an environment which promotes healthy
eating and active living;
Stage 2: Institutes of higher learning – targeting young adults, again
creating an environment that promotes healthy eating and active living;
Stage 3: Workplace setting – targeting adults. This will include
introducing policies that incorporates certain clinical parameters or criteria
to be monitored, as well as policies that encourages healthy eating and
active living in the workplaces.
Ministry of Health
Malaysia
Commitment 3: Collaborative
Partnerships with NGOs
Foster collaborative partnerships between government and civil society
Ensure the full and active participation of people with NCDs in national responses
Promote capacity building of NCD-related NGOs at national and regional levels
45
Ministry of Health
Malaysia
Commitment 3: Collaborative
Partnerships with NGOs
• Establishment of the Malaysian Health Promotion Board
• Also known as “MySihat”; as a statutory body under the
MOH in 2006
• Governed by representatives from relevant Ministries,
NGOs and professional
• The main role of MySihat is to promote the adoption of
healthy lifestyles and healthy environment
• Empowerment of individuals, organisations and
communities via trainings and other capacity building
initiatives.
• Special funds – from 2011 onwards, emphasis on NCD
risk factor interventions
• Have produced several training modules (obesity, physical
activity, healthy eating, smoking cessation etc.)
46
Ministry of Health
Malaysia
Commitment 4: Monitoring
& Evaluation
Strengthen country-level surveillance and monitoring systems
By 2012, develop a comprehensive global monitoring framework for NCDs and a set of voluntary global targets and indicators
Consider national targets and indicators
47
Ministry of Health
Malaysia
Commitment 4: Monitoring
& Evaluation
48
• Dr Margaret Chan,
the Director
General of WHO,
had said “What
gets measured gets
done”
NHMS for NCD risk
factors every 4 years
For 2012, KPIs on NCD for all
MOH Specialists and Senior Officers
DG: 7 KPIs on NCD in 2011
Ministry of Health
Malaysia Challenges
• The main challenge in policy and regulatory interventions
remain that they are mostly under the responsibilities of
ministries and departments other than Ministry of Health
• Ministry of Health needs to take leadership role
• Need to find a win-win solution – “mutuality of interest”
• Economic and “political” consideration remains paramount
and needs to be acknowledged
• For Malaysia, the establishment of the Cabinet Committee
was an important initial step to achieve the “whole-of-
government approach”
49
Ministry of Health
Malaysia Key Messages
1. NCDs are already leading health problems in almost all
countries and their magnitude is still increasing
2. Shared risk factors
3. Premature deaths
4. The poor are disproportionately affected
5. Negative impact on socioeconomic development
6. As countries continue to develop, market forces will
further promote unhealthy patterns.
7. Action is urgently needed
50
Ministry of Health
Malaysia
All Waterfalls Start As Small
Streams….
51
Ministry of Health
Malaysia
Thank you
52
