Symposium paper presented at the 46th Asia Pacific Academic Consortium of Public Health (APACPH) Conference in Kuala Lumpur, 17 October 2014

1. Ministry of Health
Malaysia
Epidemic of Cardiovascular Risk:
Focus on Policy Recommendations
for Diabetes Prevention in ASEAN
countries
Feisul Idzwan Mustapha MBBS, MPH, AM(M)
Public Health Physician, NCD Section, Disease Control Division
Ministry of Health, Malaysia
46th Asia-Pacific Academic Consortium for Public Health (APACPH) Conference
17 October 2014
Kuala Lumpur
dr.feisul@moh.gov.my

2. 2
Global NCD
Targets
Source of icons: World Heart Federation Champion Advocates Programme

3. Proportional mortality, Malaysia
(% of total deaths, all ages, both sexes)
3

4. Premature mortality due to NCDs,
Malaysia
4
The probability of dying between ages 30 and 70 years
from the 4 main NCDs is 20%

5. DALYs attributable to risk factors
5
Poor Water & Sanitation
Underweight
Physical Inactivity
Alcohol
High Cholesterol
High BMI
Diabetes Mellitus
10.7%
10.8%
8.3%
9.0%
3.1%
4.3%
5.2%
0.1%
0.7%
12.1%
10.8%
0.1%
0.7%
11.4%
5.1%
0.9%
4.3%
0.7%
Tobacco
High BP
15.0% 10.0% 5.0% 0.0% 5.0% 10.0% 15.0%
Male Female
Burden of Disease Study Malaysia, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health

6. Deaths attributable to risk factors
Poor Water & Sanitation
Underweight
Alcohol
Physical Inactivity
High BMI
High Cholesterol
Diabetes Mellitus
19.4%
15.7%
7.0%
7.3%
8.5%
5.0%
2.3%
0.1%
0.2%
22.8%
0.1%
0.2%
1.2%
7.1%
8.2%
8.1%
9.1%
0.3%
Tobacco
High BP
25% 20% 15% 10% 5% 0% 5% 10% 15% 20% 25%
Male Female
Burden of Disease Study Malaysia, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health
6

7. Outcome Document of the 2014 UN
General Assembly High-level Meeting
on NCDs
First High-level Meeting on NCDs (New York,
19-20 September 2011)
2011
Second high-level Meeting on NCDs (New York, 10-11
July 2014) to take stock of the progress made since
2011
2014
Third High-level Meeting on NCDs
to report on progress achieved
since 2014
2018
7
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

8. 2014 UN Outcome Document on NCDs
(resolution A/RES/68/300)
• Bottom line:
Governments committed themselves
to intensify their efforts towards a
world free of the avoidable burden of
NCDs
• Moving forward:
Maps out a set of concrete national
commitments to be implemented
between 2014 and 2018, and
provides 3 new global assignments
• Towards the world we want:
Next milestone in 2018
8
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

9. National commitments included in the
2014 UN Outcome Document on NCDs
By 2015, consider setting national targets for NCDs
By 2015, consider developing national multisectoral
policies and plans
Integrate NCDs into health-planning and national
development plans
By 2016, implement "best buys" to reduce risk factors
for NCDs
By 2016, implement "best buys" to enable health
systems to respond
Strengthen national surveillance systems
9
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

10. Global assignments included in the
2014 UN Outcome Document on NCDs
By 2015, WHO to develop an approach to register and
publish contributions of non-State actors towards the 9
global NCD targets
WHA68: Framework for country action to mobilize
sectors beyond health
OECD/DAC: Purpose code to track development
assistance for NCDs
By 2017, WHO to submit a progress report to UN
General Assembly
By 2018, UN General Assembly to convene a third High-level
Meeting
10
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

11. Global accountability framework for NCDs:
Milestones during the next three years
• WHO publishes global baseline
• WHO conducts third survey on national capacities
• WHO generates data
2015
• Progress report to WHA on 25 outcome indicators
• Progress report to WHA on 9 progress indicators 2016
• Independent evaluation (Global Action Plan)
• Progress report to the UN General Assembly 2017 11
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

12. NCDs in the post-2015 development
agenda: Towards the world we want
• 10 September 2014: Member States
welcomed the report of the Open Working
Group of the UN General Assembly on
Sustainable Development Goals
• Next 12 months: Proposal shall be the
main basis for integrating sustainable
development goals into the post-2015
development agenda
• Target 3.4: By 2030 reduce by one-third
pre-mature mortality from NCDs through
prevention and treatment, and promote
mental health and well-being
12
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

13. WHO Regional Response
2000
2001-03
2004-06
2008
2009-11
Healthy Islands Initiative
WPDD
Call for Action on Obesity Control
Regional plan for integrated CVD and
Diabetes Prevention 1998-2003
Regional Tobacco action plan
FCTC implementation
Regional NCD STEP Surveys
Healthy Cities Initiatives
addressing NCD and tobacco
NCD & Poverty: Pro-Poor Strategy 2006
Regional Action plans for NCD
Regional Strategy to Reduce
Alcohol related harm
Regional Initiative on multi-sectoral
intervention for NCD prevention: Obesity
Strategy & programme: Breast/cervical
cancer control
2012
National multisectoral plans
Marketing of foods/ NCD and
PHC/Surveillance
2013 Cancer Leadership and LeAd-NCD
Regional action plan (2014-2020)
2014
NCD knowledge net work
2nd Lead NCD
NCD surveillance
13
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

14. 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.
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.
14

15. Cost effective NCD interventions…
• What is effective? The intervention must:
• targets behaviours or risk factors that are causally
associated with NCDs; and
• is proven, through evidence, to lead to favourable
changes in behaviours/risk factors, thereby reducing
risk of death from NCDs.
15

16. Cost effective interventions to address
NCDs
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
interventions
addressing
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
16

17. 17

18. 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.
18

19. 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.
19

20. 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. 20

21. Objective 3 GAP NCD 2013-2020:
Healthy Diet
• 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)
21

22. Objective 3 GAP NCD 2013-2020:
Healthy Diet
• 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

23. 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

24. 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.
24

25. 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.
25

26. 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.
26

27. 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.
27

28. National Systems Response to
NCDs – ASEAN Countries
BRN
CAM
IND
LAO
MAL
MYN
PHI
SIN
THA
VIET
Has an operational NCD unit/branch or department
within MOH ✓ ✓ ✓ ✗ ✓ ✗ ✓ ✓ ✓ ✗
Has an operational multisectoral & integrated national
policy, strategy or action plan ✗ ✗ ✓ ✗ ✓ ✓ ✗ ✗ ✗ ✗
Has an operational policy, strategy or action plan to
reduce the harmful use of alcohol ✓ ✓ ✓ ✗ ✗ ✓ ✓ ✗ ✓ ✗
Has an operational policy, strategy or action plan to
reduce physical inactivity ✗ ✓ ✓ ✗ ✓ ✓ ✓ ✓ ✓ ✗
Has an operational policy, strategy or action plan to
reduce the burden of tobacco use ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Has an operational policy, strategy or action plan to
reduce unhealthy diet and/or promote healthy diets ✗ ✓ ✓ ✗ ✓ ✓ ✓ ✓ ✓ ✓
Has evidence-based national guidelines for the Mx of
major NCDs through a primary care approach ✓ ✗ ✓ ✗ ✓ ✓ ✗ ✓ ✓ ✗
Has an NCD surveillance and monitoring system in
place to enable reporting for the GMF ✗ ✓ ✗ ✗ ✓ ✗ ✗ ✓ ✓ ✓
Has a national, population-based cancer registry ✓ ✗ ✗ ✗ ✗ ✗ ✗ ✓ ✗ ✗
28

29. ASEAN Task Force for Non-
Communicable Diseases (ATFNCD)
• Strategic Objective: To ensure access to adequate and affordable healthcare,
medical services and medicine, and promote healthy lifestyles for the peoples of
ASEAN.
• Relevant health elements under ASEAN Socio-Cultural Community (ASCC)
Blueprint:
• B.4: 2 FOCUS AREA IV: PROMOTES ASEAN HEALTHY LIFESTYLE (NCDs)
• B.4.x Promote collaboration in Research and Development on health promotion,
healthy lifestyles and risk factors of non- communicable diseases in ASEAN
Member States;
• B.4.xi Promote the sharing of best practices in improved access to health products
including medicines for people in ASEAN
• B.4.xxi Strengthen existing health networking in ASEAN Member States in order to
push forward an active implementation on health services access and promotion
of healthy lifestyles, as well as continually exchange of knowledge, technology and
innovation for sustainable cooperation and development;
• Expected Outcomes: Ensured accessibility to adequate and affordable health
care, medical services and medicine and promote healthy lifestyle for the people
of ASEAN
29

30. ATFNCD Workplan
• STRATEGY I: Revitalise and implement ‘ASEAN Healthy Life Style
2002
• Engage in advocacy opportunities at regional/international platforms
• Policy advocacy on NCD concerns that includes but not limited to:
• Labeling and standards for healthy low salt food
• Ethical advertising of food products for children
• Alcohol consumption reduction
• Strategy II: Facilitating enabling environment for ensuring
promotion of healthy lifestyle for the people of ASEAN
• Networking among ASEAN Cancer Data and Registry Information
System
• Key indicators on Healthy Lifestyle especially on 4 selected NCDs
• Regional Workshop to harmonize guidelines on physical activity in
collaboration with WHO
• Regional framework for NCD screening and management 30

31. Consultation on Overweight, Obesity, Diabetes and
Law in the Western Pacific Region, April 2014
• Co-organised by the International Development Law
Organisation (IDLO), University of Sydney (Faculty of Law and
Boden Institute of Obesity, Nutrition and Exercise) and WHO
WPRO.
• Several themes and areas for action were identified :
• Generating and sharing evidence for action
• Capacity-building: Strengthen the linkages between health and
the law, building the capacity of each profession to understand
and work with one another. Suggestions for achieving this
included:
• Training the legal and health workforces through changes to
academic curricula;
• Conducting workshops and forums to encourage greater dialogue
between government and civil society, and
• Developing a multidisciplinary group of public health law experts.
31

32. Consultation on Overweight, Obesity, Diabetes and
Law in the Western Pacific Region, April 2014
• Promising interventions: In-depth technical advice on specific
promising interventions, including
• Regulation and taxation of sugar-sweetened beverages;
• Restriction of marketing unhealthy food products and beverages to
children;
• Requirements for interpretative front-of-pack labelling on packaged
foods; and
• Legislation to facilitate environments that are conducive to physical
activity.
• Social mobilization: The support and participation of civil society is
crucial to the development, implementation and enforcement of
innovative legal approaches to overweight, obesity and diabetes.
• Actions to address industry interference: Clear guidelines are
needed to avoid conflicts of interest and to ensure that government
interactions with the food industry are transparent and constructive,
and do not jeopardise public health goals. 32

33. 65th Regional Committee Meeting for the
Western Pacific, 13-17 Oct 2014
• One of the main agenda items is Tobacco free initiative:
Regional Action Plan 2015–2019
• Malaysia made a strong statement on this issue
33
“I think it will be fool hardy
for us to expect that the
tobacco industry will not
interfere. By virtue of being
the Tobacco industry itself it
is their duty to interfere and
they will continue to
interfere”

34. 65th Regional Committee Meeting for the
Western Pacific, 13-17 Oct 2014
Malaysia’s stand:
• We cannot handle the issue of tobacco without looking at the
trade and economical aspects of tobacco
• Malaysia is quite consistent in this idea that we should try to
exclude tobacco in all forms of trade agreements e.g. in TPPA.
• Must address issue of illicit tobacco and transboundary
smuggling – need multisectoral involvement.
• Increasing excise duty.
• Need to gather further evidence to support policy
implementation.
34

35. 65th Regional Committee Meeting for the
Western Pacific, 13-17 Oct 2014
35
Involvement of Public Health Physician
trainees: First time ever for Malaysia

36. 6th Session of the Conference of Parties (COP)
to the WHO Framework Convention on
Tobacco Control (FCTC) – 13-18 Oct 2014
36
• Malaysia continues to fight for carving out
tobacco from trade agreements.
• Met with strong opposition from several
countries.
• Malaysia is currently hosting a drafting
group on this issue.

37. 37

38. Thank you
dr.feisul@moh.gov.my
Facebook: Feisul Mustapha
38