By Prof Dato' Khalid Yusoff

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Noncommunicable diseases in ASEAN:
Current situation, future prospects
Khalid Yusoff
Universiti Teknologi MARA
Malaysia
Figure 4
Source: The Lancet 2012; 379:413-431 (DOI:10.1016/S0140-6736(12)60034-8)
Terms and Conditions
The Tropics

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Tropical Countries – tropical diseases:
A legacy….
Malaria
Tuberculosis
Leprosy
Waterborne diseases
Parasitic diseases
HIV/AIDS
Dengue
……… Tropical diseases
High infant / maternity mortality
Figure 2
Trends in global malaria deaths by age and geographical region, 1980 to 2010 CJL Murray, et al.The Lancet 2012; 379:413-431
Terms and Conditio

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Malaria in Malaysia
Deaths of adults due to Malaria
Number of deaths (cummulative probability of deaths per 1000 pop)
1980 1990 2000 2010
Madagascar 2232 (41.3) 4806 (67.6) 7149 (77.5) 14,200 (128.2)
Malawi 1106 ( 28.8) 4670 (78.3) 4933 (60.0) 48,476 (51.8)
Malaysia 175 (2.1) 88 (0.8) 43 (0.3) 20 (0.1)
Mali 3106 (68.7) 3690 (71.7) 6416 (99.1) 10,424 (128.9)
CRL Murray, et al. Lancet 2012; 392: 413 - 433
Lopez, et.al, Lancet, 2006

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Lopez, et.al, Lancet, 2006
WHO, 2005

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10 Leading Risk Factors for Death: World
Risk Factor Deaths (millions) Percentage of Total
1. High blood pressure 7.5 12.8
2. Tobacco use 5.1 8.7
3. High blood glucose level 3.4 5.8
4. Physical inactivity 3.2 5.5
5. Overweight and obesity 2.8 4.8
6. High cholesterol level 2.6 4.5
7. Unsafe sex 2.4 4.0
8. Alcohol use 2.3 3.8
9’. Childhood underweight 2.1 3.8
10 Indoor smoke from solid fuels 2.0 3.3 WHO, 2009
10 Leading Risk Factors for Death: LIC
Risk Factor Deaths (millions) Percentage of Total
1. Childhood underweight 2.0 7.8
2. High blood pressure 2.0 7.5
3. Unsafe sex 1.7 6.6
4. Unsafe water and poor nutrition
and hygiene
1.6 6.1
5. High blood glucose 1.3 4.9
6. Indoor smoke from solid fuels 1.3 4.8
7. Tobacco use 1.0 3.9
8. Physical inactivity 1.0 3.8
9’. Suboptimal breast-feeding 1.0 3.7
10. High cholesterol level 0.9 3.4 WHO, 2009

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10 Leading Risk Factors for Death: MIC
Risk Factor Deaths (millions) Percentage of Total
1. High blood pressure 4.2 17.2
2. Tobacco use 2.6 10.8
3. Overweight and obesity 1.6 6.7
4. Physical inactivity 1.6 6.6
5. Alcohol use 1.6 6.4
6. High blood glucose 1.3 6.3
7. High cholesterol level 1.3 5.2
8. Low fruit and vegetable intake 0.9 3.9
9’. Indoor smoke from solid fuels 0.7 2.8
10. Urban outdoor air pollution 0.7 2.8
22% of global NCD deaths occur in the 11 SEA countries; 8 million deaths per year.
34% of NCD deaths in SEA < 60 y.o (cf. 25% globally)
21% increase in NCD deaths over the next 10 years
WHO, 2011

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Total Cardiovascular Disease : Deaths
Government Hospital 1985 - 2000
6205
6058
5959
6221
6336
6574
6475
6535
6352
6715
7071
7249
7496
7307
7559
7812
Ischaemic Heart Disease Mortality Rate in
Malaysia
Disease 1998 1999 2000
Ischaemic
heart
disease
8.89 9.19 10.18
Source : Malaysia’s Health 2001
IHD Mortality rate in Government Hospitals per 100 000
population is increasing

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Association of risk factors with acute myocardial infarction in men
and women after adjustment for age, sex, and geographic region
Yusuf et.al., Lancet 2004

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The Raub
Heart Study
Prevalence of Hypertension,
Diabetes and Obesity
1993 1998
Males
Hypertension 26.2 30.6
Diabetes 4.4 4.7
Obesity 3.1 5.2
Overweight 17.7 30.9
Females
Hypertension 29.4 31.7
Diabetes 3.5 7.5
Obesity 10.5 12.3
Overweight 25.3 31.1
Nawawi, J CVR 2002

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PURE / REDISCOVER Studies:
Community profiling of coronary risk factors -
Urban – rural ‘divide’, impact of urbanisation
Ketereh
Jeli
Pekan
Morib
KL & SA Total: 12294
Urban: 6390
Rural: 5904
Males: 5369
Females: 6925
Sibu
Raub
K. Marudu
PURE / REDISCOVER Studies
Prevalences of Risk Factors by 2012
RISK FACTORS N=12,234 Overall Males Females Urban Rural
Hypertension
N=11,742 (95.5%)
50.0 51.7 46.7 45.9 49.6
Diabetes (FG > 7.0 mmol/L)
N= 10091 (82.1%)
15.5 17.7 13.9 17.0 13.8
Hyperlipidaemia (TC > 6.5 mmo/l)
N= 10,294 (83.3%)
30.8 31.8 30.0 34.6 26.3
Low HDL ( < 1.0 mmol/L)
N= 10169 (83.1 %)
23.1 33.8 15.1 20.3 26.4
Body mass index N=11,691 (95.1%)
Overweight (BMI: 23.0 – 27.49)
Obesity (BMI >27.0)
38.3
33.6
42.2
30.1
35.3
36.3
40.2
36.7
36.2
30.3
Waist-Hip ratio, N= 11671 (94.9%)
males > 0.9, females > 0.8
66.2 60.1 70.8 66.4 65.9
Smoking, N = 11,464 (93.2%)
Current
Previous
13.0
11.1
27.0
22.2
2.3
2.5
10.7
10.7
15.5
11.5

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Projection of Risk Factor Burden
Note: Based on NHMS2 1996. Prevalence rate increase proportionately.
Disease
Burden
1996
NHMS2
2002 2006 2010 2020
HPT 2,190,504
(29.9%)
3,476,435
(39.5%)
4,383,450
(45.9%)
5,226,300
(52.3%)
8,126,100
(68.3%)
DM 608,000
(8.3%)
836,200
(9.5%)
983,650
(10.3%)
1,109,200
(11.1%)
1,558,600
(13.1%)
THE RISING EPIDEMIC OF HYPERTENSION
National Health Morbidity & Mortality Surveys I, II & III (1986-2006)

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Figure 1. Global mortality and burden of cardiovascular disease and major risk factors for people aged
30 years Kaplan et.al, Lancet 2006
Figure 7. Risk of acute myocardial infarction associated with self-reported hypertension, overall and by region
after adjustment for age, sex, and smoking
Yusuf et.al., Lancet 2004

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WHO Fact Sheet, 2011
WHO Fact Sheet, 2011

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WHO Fact Sheet, 2011
WHO Fact Sheet, 2011

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WHO Fact Sheet, 2011
AWARENESS,TREATMENT & CONTROL
OF HYPERTENSION
0%
5%
10%
15%
20%
25%
30%
35%
40%
Awareness Treatment Control
33%
23%
26%
36%
32%
26%
NHMS II
NHMS III
National Health Morbidity Surveys (NHMS) II (1996) & III (2006)
NHMS III: OVERALL RATE OF CONTROL OF HT IS 8.2%

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BP Control among hypertensives
Pts > 18 yrs from 23 centres
Pre-JNC-7 Post-JNC-7 p value
(Jun 98 – Mar 03) (Dec 03-Apr 06)
N 15,359 2,012
Mean age (yrs) 61.5 62.3
Females (%) 56.2 65.0
Hyperlipidaemia 52.4 59.5 <0.0001
Diabetes 22.1 27.0 <0.0001
BP control (%) 39.3 53.2 <0.0001
BP control w DM 16.7 29.2 <0.0001
No Rx 21.4 6.4
Monotherapy 45.8 36.7
Dual therapy 23.2 37.3
>Triple therapy 9.6 19.6
Diuretics 24.8 32.9 <0.0001
Beta-blockers 22.0 25.4 0.0007
ACE inhibitors 21.9 23.6 NS
CaCBs 20.9 23.6 NS
Fixed dose combo 10.1 26.7 <0.0001
Jackson, et al. AHA Circ 2006; 114: II - 828
Periera M, et al. JH 2009;27:963-5

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• Blood pressure is the biggest global risk factor for
disease, followed by tobacco, alcohol, and poor
diet.
Richard Horton
Lancet 2012; 380: 2053 -54
Future prospects?
• NCDs are dominating health-care needs in SEA
• Health systems are currently ill-equipped to
tackle NCDs
• Lack of access to affordable medicines and
health-care services
WHO, 2011

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New approaches to controlling HT
• Polypill
• Task shifting
- GACD grant from Grand Challenges Canada:
Malaysia (UiTM and Ministry of Health), Columbia, McMaster and
Toronto Universities, LSH&TM (HOPE-4 Study; 50 communities )
• Identifying individuals with hypertension:
community screening and programmes
Ford, et.al., NEJM 2007

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Epidemics – treated by town planners
and sociologists!
• Plaques of Europe, ‘Black death’
London: 1603, 1625, 1665
Yersinia pestis
Rodents esp rats
• Rheumatic fever - rheumatic heart disease
Controlled before advent of effective antibiotics
- better housing, less congestion, less slums, improve
sewerage, increase natural lighting, better nutrition, clean
water, better hygiene, ….
‘25 by 25’ NCD Goal
Ten targets:
• Blood pressure control
• Tobacco smoking cessation
• Salt intake reduction
• Increase in physical activity
• Obesity control
• Reduction in fat intake
• Reduction in alcohol consumption
• Reduction in total cholesterol
• Availability of generic drugs and basic technologies
• Availability of drug therapy to prevent heart attacks and
strokes

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Choice of targets depend on…
• Strong scientific basis
• Sensitivity to change
• Major impact on NCD mortality
• Achievable with cost-effective interventions
• Assessing progress
Beaglehole, et al. 2012
Chose: Cigarette smoking, salt reduction, multi-drug
therapy, alcohol reduction and physical inactivity
What would it be for SEA?
Cooney, et al
JACC 2009

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A turning point….
• Epidemiologic transition
• Need good data… not just recording what
happens but anticipate what can happen and
test ways to best handle the future
• Overcome silo’s, be interdependent; create an
Alliance across the SEAR?
• Reach-out: Communicate with the public and
engage institutions (MOH, IHLs, politicians,…)
• Prepare appropriate work force
Thank you
Acknowledgements: PURE REDISCOVER Team,
Ministry of Higher Education, Ministry of Health
Ministry of Science, Technology and Innovation

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Cost of Managing Stroke
• Per admission treating stroke (without
complications)* - RM3,420
• Per admission treating stroke (with minor
complications) - RM4,276
• Per admission treating stroke (with
major complications) - RM6,129
• Managing stroke in 2010 – at least
RM101.6 Million
Ministry of Health stats

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Cost of Managing ESRD
• The cost of dialysis in MOH facility, per patient
per year in 2005 - RM33,000
• The total cost to the country to treat
hypertensive patients that needed dialysis in
year 2011 - RM318.3 million
Ministry of Health stats
LIMIC have 5% of the finances to deal with 80% of
the burden of cancer
- Knaul, et a. Harvard Global Equity Initiative 2012: 3 - 28

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