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In 2006, there is an estimated 1.5 million Malaysians age 18 years and above living
with diabetes.
3
Type 2 diabetes increases CVD risk
§
Any CVD event §
Stroke
§
Intermittent claudication †
†
Cardiac failure §
†
CHD ‡
‡
MI §
1 2 3 4 5 6
Age-adjusted risk ratio
(1 = risk for individuals without diabetes)
4
*p < 0.1; †p < 0.05; ‡p < 0.01; §p < 0.001 Adapted from Kannel WB et al. Am Heart J 1990; 120: 672–6.
Better Control Equals
Reduced Risk of Complications
EVERY 1%
reduction in HBA1c REDUCED
RISK*
Heart attacks
%
4
1
-
Microvascular complications
1% %
7
3
-
*p<0.0001 5
UKPDS 35. BMJ 2000; 321: 405-12.
CPG T2DM
2004
6
7
8
Is NCD (CVD, DM) an
important health problem ?
Disease Burdens :
Global & Local
4
RISK FACTORS & DISEASES
END POINT
Non-modifiable risk factors:
•Age Intermediate stroke
•Sex Risk Factors
•Ethnicity Heart Disease
•Genes
•Alcohol Obesity/Overweight
Raised blood pressure
•Stress Raised blood glucose Diabetes
Abnormal blood lipids
Cancers
Lung Disease
Socioeconomic, cultural &
environmental determinants:
•Globalization
•Urbanization
•Population ageing
Diagnostic values for Type 2 DM/glucose
intolerance –OGTT.
Central Obesity
5.8 million 48.6 %
Intermediate RF
0 10 20 30 40 50 60 70 80
PREVALENCE %
Value in the bar represent estimated population Common risk factors
for adults aged 25 – 64 years Intermediate risk factors
Projected NCD Risk Factors Burden
2015 / 2020 (million)
Adults aged 25 – 64 years
In 2006, there is an estimated 2.8 million Malaysians age 18 years and above are
current smokers, 5.5 million physically inactive, 3.6 million overweight and 1.7
million Malaysians obese.
17
The Malaysia Health is in Transition
30
SUMBER:HEALTH FACTS JABATAN KESIHATAN NEGERI SABAH 2005
Status of Diabetes Mellitus in
Malaysia in the past 20 years
1986 1996 2006 2006 2006
NHMS I NHMS II NHMS III NHMS III NHMS
III
Remarks 35 years old 30 years 18 years 18 – 29 30 years old
& above old & old & years old & above
above above
18
14.86 15.23 15.33
16 13.45 13.61
14 12.1 12.6 12.61
11.74 12.01 11.55
11.07 11.1
Prevalence
12 10.04
10 11.55%
7.94
8
4.93
6
4
2
0
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0 States
, 00 0 00 0 00 0 0 0 0 00
, 0 0 0 00 00
60 00
0
,0 6 4 ,
0
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6 ,0 5,0 , ,0
55 ,
, 0 ,0
, 0 4 0 0 , 0 1 1 12 112 6
14 11 1
53
,
77
, 0 ,
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0 71 46
29 1,
96
Burdens
Prevalence of All D iabetic by Age Group (aged ≥ 18 yrs)
30 26.2
24.4 24.5
25 22.8
20.8 21.6
20
15.0 13.8
15
10.3
10 6.4
Overall Prevalence
4.9 11.55%
5 3.1
c(%
2.0 2.0
) P
revaln
Age Group
0
, 00
000 000 00
000 0 00 0 00 00 0 00 00 00 00
, , ,0 6, 8, 6, 0 , 0 0 , 0
12 29 43 5 8 4 9 00 0, 28 4, 9, 19
6 1 1 8, 0
0 00 16 1 7 3
23 28,
2
11.55%
1 1 .5
(468,000 )
11 1 0 .5
1 0 .5
10
9 .5
Ur ba n Rura l
Re s ide nc e
Sig Diff
Prevalence of Diabetes by Gender
( BURDENs )
(674,000 )
12.0 11.9
Prevalence (%)
11.8
11.6 (795,000 )
National Prevalence 11.55%
11.4 11.3
11.2
11.0
Male Female
Diff-Not sig.
Prevalence of Diabetes
by Race , Aged ≥ 18 yrs
( BURDENs )
2 5.0 (221,000 )
19 .9
2 0.0
Prevalence (%)
0.0
In d ian M alay C h in e s e Oth e r Oth e r s
Bu m i
Ra c e
Sig Diff
National Prevalence Diabetes by Job
Description in Malaysia Prevalence
Job Category Burdens
%
‘000
Senior Officials & 15.9 40
Managers
Professionals 10.0
88
Technical & Associates 12.1
122
Clerical Workers 8.7
61
Service Workers & Shops 10.7
225 2
Skilled Agricultural & Fishery 9.7
87
Crafts & Related Trade Workers 6.4
48
Machine Operators & Assemblers 11.7
81
Elementary Occupations 9.0
50
Housewives 14.2 423 1
Unemployed 16.1 201 3
Unclassified 6.7
41
Glycaemic Control Status (HbA1c)
Among Diabetic in Government Facilities, 2002 - 2004
58603
60000
48833
50000
(68%) > 60%
40000 (65%) 38180
33035
Poorly
control
30000
20000 17122
(64%)
11032
10000
0
2002 2003 2004
STRATEGY.
- Screening for high risk group.
- Selective screening according to criteria.
PREGNANT WOMEN.
Should be screened if they have any of the following risk factors :
- BMI > 27
- Previous big baby weighing 4kg or more.
- Previous GDM.
- Bad obstetrics Hx.
- Glycosuria at the first prenatal visit.
- Current obstetrics problems (essential HPT, PIH and polyhydrmnios)
- Age above 25 years.
HOW IS SCREENING DONE?
- Screening can be done by measuring RBS (capillary blood) using
glucometer and strips.
- In pregnant women, do OGTT using 75 gm glucose at least once at 24
weeks gestation.
46
EPIDEMIOLOGY OF
HYPERTENSION
Hypertension
- The classification is based on the average of two or more readings taken at two or more visits to the doctor.
Stage 1 140 – 159 and/or 90 - 99
When SBP and DBP fall into different categories, the higher category should be selected to classify the
20 %
Stage 2 BP.
individual’s 160 – 179 and/or 100 - 109 8%
Stage 3 > 180 and/or > 110 4%
48
What is a Risk Factor ?
• A risk is condition that places an individual at
risk developing a health-related problem.
– has causal association e.g SMOKING -------- LUNG CANCER
• It may be identified as :
a disease, (eg hypertension)
a single measurement (eg. weight )
lifestyle characteristic (eg. Unhealthy diet, Smoking).
RISK FACTORS & DISEASES
END POINT
Non-modifiable risk factors:
•Age Intermediate stroke
•Sex Risk Factors
•Ethnicity
•Genes
Heart Disease
•Alcohol Obesity/Overweight
Raised blood pressure
•Stress Raised blood glucose Diabetes
Abnormal blood lipids
Cancers
Lung Disease
Socioeconomic, cultural &
environmental determinants:
ED
•Globalization
(Erectile Dysfunction)
•Urbanization
Projection of Risk Factor Burden-1
51
Hypertension
Hypertension is a major health problem
due to : 1) its high prevalence.
2)lack of awareness amongst
the general population.
3)its poor control and
4)its impact on
cardiovascular morbidity
and mortality.
Globally
• 26·4% of the adult population in year 2000 had hypertension
– 26·6% of men and
– 26·1% of women ,
Age group ≥25 years ≥18 years ≥30 years ≥18 years ≥30 years
Definition of ≥160/95 ≥140/90 ≥140/90 ≥140/90 ≥140/90
hypertension
(mmHg)
Prevalence 14.4% 29.9% 32.9% 32.2% 42.6%
54
Prevalence of HPT by sex and race amongst Malaysian
Residents Aged ≥ 18 years in 2006 (N=33,976)
All hypertensives
2/3 Readings during last 3 consecutive clinic in last 18 mths =/below 130/80mmHg
Status of Control
Controlled = 28.5%
Uncontrolled = 61.3%
Indeterminable = 10.2%
Barker’s Hypothesis
The Life Course Approach
• Risk of chronic disease begins in fetal
life and continue into old age
• “Tracking” of conventional R/F from
childhood adult
• Chronic disease: risks occur at all age
• All ages are part of opportunities for
prevention and control
Underlying Intermediat
Common Risk Main Chronic
Determinant e Risk
Factors Diseases
s •Unhealthy diet Factors
•Physical Inactivity •Overweight/obesity •Heart Disease
•Globalisation •Raised blood sugar
•Tobacco & Alcohol •Diabetes
•Urbanization •Raised blood
use •Stroke
•Population •Age (nonmodifiable) pressure
•Abnormal blood •Cancer
Ageing •Heredity
•Chronic Resp Dis
(nonmodifiable) lipids
62
Untreated adults with hypertension
Sr creatinine TIA
LVH Haemorrhages
microalbuminuria Stroke
CCF or exudates,
proteinuria
CHD with or without
Absence of one or
more major pulse in papilloedema
extremities (except dorsalis
pedis) with or without
intermittent claudication;
aneurysm
Framework of NCD program
(Peranan anggota kesihatan)
1. “CEGAH” (Prevention)
1. Promotion & Protection (Health education)
2. Screening for risk factors/ NCD
3. Early intervention ( NonPham / Pham)
2. “RAWAT” (Treat to
Control)
1. Health education- personalised
2. Screening for complications
3. Intervention ( NonPham / Pham /Rehabilitation)
– Limit disease progress
– Prevent complication
– Limit disability
– Improve life quality
•Early Detection
•Health •Risk Factor
Promotion Identification •Register
– rehabilitation
• To limit disability at the earliest
possible stage
• To restore an affected individual
to a useful, satisfying & when
possible, self sufficient role in
society
Framework of NCD program
( Supporting Components)
• Capacity Building
• Marketing Health
Capacity Building
• Doctors
• AMO, SN
• Allied health
78
Proper training(very important)
Service Delivery
Underlying Intermediate
Common Risk Main Chronic
Determinants Risk Factors
Factors Diseases
Advocacy
Research & Surveillance
“Whole of government” response Health Sector Response
Political will Health sector governance
Political leadership Health sector leadership
Healthy public policies and laws Integration of NCD prevention & control
into national health strategy
84
PHASE 1 HLSC- Disease Oriented 1991-1996
HEALTHY EATING
RECIPE FOR GOOD HEALTH
1997 EXERCISE 1998 PREVENT INJURY 1999
4 elements:
Physical activity, diet,
smoking, stress
87
NCD Prevention & Control
DESCRIBE or PRESCRIBE ?
Describe…..
Exercise 30 minutes, 3 times a week
3 Categories of Clients
DESCRIBE or PRESCRIBE ?
93
Health Spectrum
Healthy
individual Exposure to risk
Early disease
Established Disease
Complication of Disease
Death