MOH Research Initiatives on NCDs

MOH Research Initiatives on Non-Communicable Diseases

Feisul Idzwan Mustapha MBBS, MPH, AM(M)Public Health Specialist

Disease Control Division, Ministry of Health, Malaysia

International Research Symposium on Population Health 201320 November 2013

University Malaya, Kuala Lumpur

[email protected]

Ministry of Health Malaysia

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”.• Diabetes & obesity are used as the entry points.

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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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 environmentHealth promotion & educations

Policies & regulations

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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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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 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.

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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.

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

MyBFF@school

MyBFF@home

MyBFF@work

“My Body is Fit aand Fabulous”

INTERVENTION PROGRAMMES TO COMBAT OBESITY IN MALAYSIA

An Implementation Research (qualitative + quantitative approaches)

Slide courtesy of Dr Wan Nazaimoon, IMR; [email protected]

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MyBFF@school• MyBFF@school consists of:

• Small-sided football games (SSG), Intensified nutrition intervention.• Psychology motivation - SELF-EMPOWERMENT.

• Peer support from members of the KELAB DOKTOR MUDA & PROSTAR).

• Involvement of teachers, parents as agent of change.• Study sites: Selected schools in Putrajaya (standards 4, 5 & Form

1 & 2).• Have already obtained approval from MOE for the additional

school hours required. 10


MyBFF@home• An intervention study to combat obesity among housewives

in Klang Valley.• Primary aim (Phase I)

• To develop an intervention package for overweight and obese housewives aged 18-59 years old.

• Secondary aim (Phase II)• To determine the effectiveness of the intervention package in

reducing body weight among overweight and obese housewives.• A proposed “package” has been developed

• 3 main components (i) diet; (ii) exercise & physical activity; and (iii) self-monitoring behaviour.

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MyBFF@work• An Intervention Study to Combat Obesity among Government

Employees in Kelantan.• Collaboration with USM.• General Objective: To provide low cost, feasible and goal-

directed, process-oriented weight loss program for overweight and obese Malaysian civil servants.

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OpportunityFocus on pre-pregnancy for prevention

1. New DOHaD science indicates that pre-pregnancy offers opportunity for prevention of diabetes and other NCDs

2. Increasing levels of obesity and hypertension in women of reproductive age

3. Pre-pregnancy overweight approximately doubles the risk for hypertensive disorders, preeclampsia and gestational diabetes. Overweight and obesity increase the risk of stillbirths, obstetric intervention, postpartum hemorrhage, and birth defects2.

4. Pre-pregnancy health status affects both the short-term and long-term health

5. Women enter pregnancy with modifiable risk factors

1: Hanson MA & Gluckman PD. Developmental origins of noncommunicable disease: Population and public health implications. American Journal of Clinical Nutrition 2011; 94(6 Suppl.): 1754S-1758S.2: Zulfiqar A bhutta, Sohni V Dean, Ayesha Imam, Zohra S Lassi: Systematic review of Preconception risks and interventions; WHO report : 32-33

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JOM MAMA

Slide courtesy of Priya Matzen, Novo Nordisk; [email protected]

JOM MAMA: Objective

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What we want to do

To investigate if pre-pregnancy interventions improves young couples

health literacy and women’s health

To assess if the intervention improves delivery and birth

outcomes.

Prevent/reduce risk

of NCDs


JOM MAMA: Approach

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Public-private partnership Implementation

Nurul (25) & Khairil (27)

Academia/Partners

Evidence base Pre-conception / young couples Malaysia

Phase 1Co-creatIon

Phase 2Programme

development

Phase 3Monitoring and

Evaluation


v

South East Asia Community Observatory

SEACO: Research for a healthy

communityD.D. Reidpath & P. Allotey

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VisionTo develop a world class research and training site providing high quality infrastructure for conducting community based “whole of life research” that informs internationally, nationally, and locally relevant, priority questions related to population health and wellbeing.

MissionSEACO will achieve its vision through the collection and sharing of high quality data and methods. The protection of, and service to the communities involved with SEACO is paramount.

Slide courtesy of Prof. Pascale Allotey, Monash University Sunway Campus; [email protected]

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DHSS: A Research PlatformSEACO: A research platform• A community-based sentinel surveillance system that

captures longitudinally, a fully enumerated population within circumscribed geographical location.

• The data collection process explicitly captures information on demography, morbidity and mortality from the individual, within the context of the household, and the household within the context of the community, as well as the physical, social, geographical relationships between these.


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Nested cross-sectional studies Nested

longitudinal studies

Cause ofDeath

Rural-Urbanmigration

MCH

Family, Community and Population Dynamics

SEACO: Study types


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HOPE-4 Study• Intervening the epidemiologic transition through innovative

means of controlling hypertension• Collaboration between UiTM, NCD MOH, McMaster

University, Toronto University and London School of Hygiene & Tropical Medicine• Grand Alliance for Chronic Diseases, supported by Grand

Challenges Canada.• Blood pressure is the biggest global risk factor for NCDs,

followed by tobacco, alcohol and poor diet (Richard Horton, Lancet 2012; 380:2053-54.

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Information courtesy of Prof. Dato’ Dr Khalid Yusoff, [email protected]

HOPE-4 Study• 50 communities in Malaysia, Columbia, India and Sub-Sahara

Africa.• Task shifting – non-physician healthcare workers under

supervision of doctors.• Use of polypill.• Objective: Develop, implement and evaluate a CVD risk

assessment, treatment and control program.• Primary outcome: composite CV events

• CV deaths, MI, stroke, CHF, hospitalisation, revascularisation.21

Information courtesy of Prof. Dato’ Dr Khalid Yusoff, [email protected]

Potential policy interventions to improve dietary intake for preventing obesity in Malaysia

Policy areas Potential policy interventionsFiscal 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.

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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)


Policy areas Potential policy interventionsFood 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.

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Policy areas Potential policy interventionsFood 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).

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Policy areas Potential policy interventionsFood 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 .

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National Diabetes Registry

• Web-based application.• Went live on 1 January 2011.• Supports the implementation of the annual

“Diabetes Clinical Audit” and the “Diabetes Quality Assurance Programme” amongst Type 2 Diabetes patients in MOH Health Clinics.

• First report, “NDR Report, Volume 1, 2009-2012” was published in August 2013, available at the MOH website, under “publications”.

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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.27

Thank you

[email protected]: Feisul Mustapha

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mailto:[email protected]

MOH Research Initiatives on NCDs

Health & Medicine

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