overview of obesity in malaysia

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

[email protected]

Ministry of Health Malaysia

There are Four Major Groups of Non-Communicable Diseases;Four major 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

NHMS II (1996) NHMS III (2006)

NHMS 20110

5

10

15

20

25

8.3

14.9

20.8

6.5

9.510.7

1.8

5.4

10.1

4.3 4.7 5.3

Prevalence of Diabetes, ≥30 years (1996, 2006 & 2011)

Total diabetesKnownUndiagnosedIFG

Prev

alen

ce (%

)

Source: National Health & Morbidity Surveys (NHMS)

NHMS III (2006) NHMS 20110

5

10

15

20

25

30

35 32.2 32.7

12.8

19.8

Prevalence of Hypertension, ≥18 years (2006 & 2011)

Total HPTKnownUndiagnosed

Prev

alen

ce (%

)

NHMS III (2006) NHMS 20110

5

10

15

20

25

30

35

40

20.6

35.1

8.4

26.6

Prevalence of Hypercholesterolaemia, ≥18 years (2006 & 2011)

Total HCholKnownUndiagnosed

Prev

alen

ce (%

)

3

NHMS II (1996)

NHMS III (2006)

NHMS 20110

5

10

15

20

25

30

35

16.6

29.1 29.4

4.4

14 15.1

Prevalence of Overweight & Obesity, ≥18 years (1996, 2006 & 2011)

OverweightObesity

Prev

alen

ce (%

)

Prevalence of Abdominal Obesity, ≥18 years (2006 & 2011)

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+10

20

30

40

50

60

70

19.6

28.633.6

44.748.0

51.055.7

62.8 63.2 61.4 63.2

56.2

50.4

AGE GROUPS (years)

PREV

ALEN

CE (%

)

NHMS 2006 NHMS 201120

30

40

50

60

30.1

37.1

47.1

54.1

MALES FEMALES

PREV

ALE

NCE

(%)

Prevalence of Abdominal Obesity by age groups (NHMS 2011)

4

Overweight in adults, ASEAN Region, 2010

5Viet

Nam

Cambodia La

o

Myanmar

Indonesia

Philippines

Thail

and

Singa

pore

Malaysi

aJap

an0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

MaleFemale

Prev

alen

ce %

Obesity in adults, ASEAN Region, 2010

6Viet

Nam

Cambodia La

o

Myanmar

Indonesia

Philippines

Thail

and

Singa

pore

Malaysi

aJap

an0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

MaleFemale

Prev

alen

ce %

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)

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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

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PrevalenceCI

LowerCI

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

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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

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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

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.

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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

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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

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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

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Global Monitoring Framework for NCDsIndicator 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)

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Cost effective interventions to address NCDs

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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 interventionsaddressing 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

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.

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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.

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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.

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• 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)

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• 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

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

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.

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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.

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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.

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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.

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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

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Current Approaches to NCD From Birth To Tomb

Intervention Package

Health Promotion

Intervention Package

Health Promotion

Pregnancy

Pregnancy

Pre-conceptio

n

Pre-conceptio

n

Infant/

Toddler

Infant/

Toddler

First 1,000 Days

To reduce obesity and NCDs-birth weight

Lifestyle during pregnancy – fetal health

First 1,000 Days

To reduce obesity and NCDs-birth weight

Lifestyle during pregnancy – fetal health

Pre-School

Pre-School

School-going Age

School-going Age

Garispanduan Pemasaran Makanan & Minuman kepada

Kanak-kanak

Garispanduan Pemasaran Makanan & Minuman kepada

Kanak-kanak

Garispanduan Penguatkuasaan Larangan

Penjualan Makanan & Minuman Di Luar Pagar

Sekolah

Garispanduan Penguatkuasaan Larangan

Penjualan Makanan & Minuman Di Luar Pagar

Sekolah

Higher Education

Higher Education AdultsAdults

Elderly

Elderly

School SettingSchool Setting

Workplace / Community Setting

Workplace / Community Setting

KOSPENKOSPEN

AktivitiFizikalAktivitiFizikal

Program Warga Aktif Warga Produktif

Program Warga Aktif Warga Produktif

Healthy Workplace for Healthy Workforce

Healthy Workplace for Healthy Workforce

Garispanduan Pengurusan Kantin

Sihat

Garispanduan Pengurusan Kantin

Sihat

Garispanduan Perlaksanaan Vending Machine Makanan &

Minuman Sihat dlm Perkhidmatan Awam

Garispanduan Perlaksanaan Vending Machine Makanan &

Minuman Sihat dlm Perkhidmatan Awam

Kafeteria SihatKafeteria Sihat

Hidangan Sihat Semasa Mesyuarat

Hidangan Sihat Semasa Mesyuarat

Amalan Pemakanan Sihat

Amalan Pemakanan Sihat

Jom Mama Initiatives

Jom Mama Initiatives

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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

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Management of NCDs: 7 basic principles

• Screening• Register• Clinical management• Complications• Rehabilitation• Defaulter tracing• Selfcare – Patient’s

empowerment

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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

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.

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Summary

Thank you

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overview of obesity in malaysia

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