Malaysia has implemented several salt reduction initiatives to help achieve its national target of reducing average salt intake to 6.0g per day by 2025. The initiatives include public awareness campaigns, reformulating processed foods to contain less salt, establishing research on salt intake levels, and pursuing regulatory requirements for salt labeling. Monitoring through repeated national surveys shows average salt intake remains high, around 8-9g per day, indicating more efforts are needed across multiple strategies to successfully reduce population salt consumption.

1. Salt Reduction Initiatives in
Malaysia
Feisul Idzwan Mustapha MBBS, MPH, AM(M)
Public Health Physician, NCD Section, Disease Control Division
Ministry of Health, Malaysia
Seminar Kesedaran Garam bersama Media
5 Februari 2015
Kuala Lumpur
dr.feisul@moh.gov.my
Ministry of Health
Malaysia

2. The Causation Pathway
For NCD
Underlying
Determinants
•Globalisation
•Urbanisation
•Population
Ageing
Common Risk
Factors
•Unhealthy diet
•Physical Inactivity
•Tobacco & Alcohol
use
•Age (non modifiable)
•Heredity
(non modifiable)
Intermediate
Risk Factors
•Overweight/obesity
•Raised blood sugar
•Raised blood
pressure
•Abnormal blood
lipids
Main NCD
•Heart Disease
•Diabetes
•Stroke
•Cancer
•Chronic resp.
diseases
Source: Adapted from Preventing Chronic Disease: A Vital Investment. Geneva,
WHO. 2005.
2

3. There are Four MajorGroupsof Non-
CommunicableDiseases;
Four majorlifestyles related riskfactors
Modifiable causative risk factors
Tobacco use
Unhealthy
diets
Physical
inactivity
Harmful
use of
alcohol
Noncommunicablediseases
Heart disease
and stroke    
Diabetes
   
Cancers
   
Chronic lung
disease 
3

4. Proportional mortality, Malaysia
(% of total deaths, all ages, both sexes)
4

5. Premature mortality due to NCDs,
Malaysia
5
The probability of dying between ages 30 and 70 years
from the 4 main NCDs is 20%

6. 19.4%
15.7%
8.5%
7.3%
7.0%
5.0%
2.3%
0.2%
0.1%
22.8%
1.2%
9.1%
8.1%
8.2%
7.1%
0.3%
0.2%
0.1%
25% 20% 15% 10% 5% 0% 5% 10% 15% 20% 25%
High BP
Tobacco
Diabetes Mellitus
High Cholesterol
High BMI
Physical Inactivity
Alcohol
Underweight
Poor Water & Sanitation
Male Female
Deaths attributable to risk factors
Burden of Disease Study Malaysia 2008, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health
6

7. 20.7
32.2 32.73
0
5
10
15
20
25
30
35
1996 2006 2011
Estimate
PREVALENCE OF TOTAL HYPERTENSION, ≥18 YEARS,
NHMS 1996, NHMS 2006 AND NHMS 2011
Year
7
Prevalence of hypertension (adults) 2010
Source: WHO “Global Status
Report on NCD 2010”

8. 8
Gula yang
berlebihan
Berlebihan berat
badan & obesiti
• Diabetes
• Penyakit jantung
• Strok
• Kanser
Garam yang
berlebihan
Hipertensi
Lemak yang
berlebihan
Pengambilan makanan secara
berlebihan

9. 9
Source of icons: World Heart Federation Champion Advocates Programme
Global NCD
Targets
20%15%
23%15%
HED* <1.2%
35.2%30.0%
8.76.0gm
32.2%24.0%
<15.0%
Targets for
Malaysia
* Heavy episodic
drinking

10. 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
10

11. Guideline on Sodium Intake (WHO, 2012)
< 2,000 mg
Sodium /day
1 level teaspoon of salt
WHO Recommended an intake of
5 g of salt or 2000 mg sodium
11

12. 0
1
2
3
4
5
6
7
8
9
10
2012 2015 2017 2019 2021 2023 2025 2027 2029
30% reduction by
2025
WHO
recommendation
Note:
1. Survey among 445 healthcare workers in 2012 showed an
average salt intake of 8.7g/day
2. Target reduction set at 0.5g/day for each year
Malaysia salt reduction targets
Saltintake(g/day)
6.0
5.0
9.0
Average
intake
Global
NCD
Target
Recommended
12

13. Salt Reduction Initiatives
Strategy 1 PREVENTION AND PROMOTION
Public awareness campaigns and related educational
activities
 Media
 Press statement by Minister Of Health (WSAW)
 Health professionals
 Individual/consumers
- Consumer education/awareness campaign
- Dietary recommendation
 Restaurant, stalls, food vendors
 NGOs and consumer associations (to strengthen
advocacy)
 Healthy eating campaign in Schools, cafeteria
 “KOSPEN”
13

14. World Salt Awareness Week
“themes”
201020112012
•Salt and men’s health
2014
14
2013

15. Campaign with the media
15

16. Salt Awareness Week 2015 –
Healthier Futures
16

17. Salt Reduction Initiatives
Strategy 2 CLINICAL MANAGEMENT
Include clinical practise guidelines, evidence-based
decision support tools to ensure the appropriate and
timely screening, diagnosis and treatment of chronic
disease.
17

18. Salt Reduction Initiatives
Strategy 3 INCREASING PATIENTS COMPLIANCE
• Health care education programme
• Developed intervention packages to help pts with NCD to
monitor & manage their disease
• Appropriate trained staff, equipped equipment, tool
18

19. Salt Reduction Initiatives
Strategy 4 ACTION WITH NGOS, PROFESSIONAL BODIES & OTHERS
STAKEHOLDERS
Different government
ministries and agencies
 Ministry of Health
 Ministry of Education
 Ministry of Agriculture and Agro-based Industry
 Ministry of Domestic Trade, Cooperatives and Consumerism
 Ministry of International Trade and Industry
Food industry All sectors, including retail associations and catering groups
Professional
organisations
Including universities, research institutes
Mass media TV,Radio, Newspaper, magazine, etc
NGOs & consumer
groups
e.g: MASRI (Malaysian Alliance of Salt Reduction Initiatives),
Malaysian Society Of Hypertension (MSH), MDA (Malaysian
Dieticians Association), NSM (Nutrition Society Of Malaysia) etc.
19

20. Salt Reduction Initiatives
Strategy 5 MONITORING, RESEARCH & SURVEILANCE
Establish baseline data on salt intake and health through:
 24-hour urine collection and analyses
 Food consumption survey (24-hour dietary recall- FFQ)
 Spot urine analysis
20

21. 21
SURVEY
(RESEARCH)
TITLE YEAR/
DURATION
TARGET
GROUP /AGE
DAILY MEAN SALT INTAKE (g)
(24 HOURS URINARY
SODIUM )
/NO OF SAMPLE
FFQ ( 24 hours
dietary recalled)
/NO OF SAMPLE
(SPOT URINE )
/NO OF
SAMPLE
Survey 1
(MANS 2003)
MANS 2003 2003 Adult > 18
years
6.4 g
Survey 2
(IPH,2013)
Estimating Dietary
Sodium Intake ,
Among Ministry Of
Health Staff: A Pilot
Study
Dec 2011-
Feb 2012
Adult > 18
years
(445 sample)
8.7 g
Survey 3
(Maryam K.J ,
Nani N.
Rahman A.R)
Cyberjaya
University
(Un Published)
Correlation
between spot urine
sodium , 24 hour
urinary sodium and
FFQ in estimation
of salt intake in
healthy individuals
(unpublished)
2011 20 – 30 yrs
old/
34 sample
( 157 mmol/day)
= 9.18 g
120 sample
(81.56 mmol/day)
= 4.9 g
120 sample
( 148 mmol/L)
= 8.6 g
Daily Mean salt intake in six (6) studies in Malaysia using different methods

22. 22
SURVEY
(RESEARCH)
TITLE YEAR/
DURATIO
N
TARGET
GROUP
/AGE
DAILY MEAN SALT INTAKE
(24 HOURS
URINARY
SODIUM )
/NO OF
SAMPLE
FFQ ( 24 hours
dietary
recalled)
/NO OF
SAMPLE
(SPOT URINE )
/NO OF SAMPLE
Survey 4
Maryam K.J , Nani N.
Rahman A.R)
Cyberjaya University
Estimation of sodium intake
among healthy individuals
using 24 hour urine and spot
urine sample
(unpublished)
2012 19-30 YRS
old
84 sample
( 148.4
mmol/Day)
= 8.67g
426 sample
Mean spot urine
( 158.9 mmol/L)
= 9.29g
Survey 5
DrHazreen Abdul
Majid
(hazreen@ummc.e
du.my)
An Exploratory Study On Risk
Factors For Chronic Non
Communicable Diseases
among adolescents :
Malaysian Health and
Adolescents Longitudinal
Research Study(MyHeARTs)
(Unpublished )
2013 Adolescents
aged 13
years
(837)Sample
5.77g
Survey 6
Dr Hazreen Abdul
Majid
(hazreen@ummc.edu.
my)
Participatory Action Research
Through Negotiation &
Empowerment of the
Residents(PARTNER)
(Unpublished)
2014 Adult >18
Yrs old
( at PPR
Lembah
Pantai)
(117 ) sample
5.80 g
Daily Mean salt intake in six (6) studies in Malaysia using different methods

23. Salt Reduction Initiatives
23
Strategy 5 MONITORING, RESEARCH & SURVEILANCE
Research: New product development
 Reformulate processed foods
Partnership with food industries (voluntary or self regulatory)
since 2011
– Up to now there are 30 foods items with reduced sodium
content ranging from 2% to 40% reduction from previous
formula
Tahun Jenis Produk Bilangan
2011 Biskut 2
Kicap 1
Mee Segera 8
JUMLAH 11
2012 Makanan ringan 2
Daging beku 1
Kicap 2
JUMLAH 5
2013 Perasa tiruan 11
Sapuan roti 3
JUMLAH 14
JUMLAH KESELURUHAN 30
Source: Nutrition Division 2014

24. TopTen food sources of Highest Sodium Consumption and Mean Sodium Intake
•
24
• Soy sauce was the most popular seasoning consumed daily which contributed to
the highest daily sodium intake.
• Fried rice, nasi lemak, fried meehoon and soups also appeared to increase the
sodium intake.
• This was followed by roti canai, oyster sauce, anchovy sauce and tomato / chilli
sauce.
Source:IPH 2013

25. Salt Reduction Initiatives
25
Strategy 7 POLICY AND REGULATORY INTERVENTIONS
Legislation
• Writing to Food , Safety and Quality Division to request
for mandatory labeling of sodium in all products.
• Regulation in specific settings (e.g. school meals, catering
in civil services)

26. Next steps for KKM
• Educating the public
• Working with the media
• Labelling of food/beverages – on salt/sodium content
• Database on salt/sodium content
• Targeting specific groups
• School-children
• Housewives
• Food operators/hawkers
• Working together with food and beverages industries
• Product reformulation
26Empowering individuals and communities to
achieve behavioural change

27. 27
Source of icons: World Heart Federation Champion Advocates Programme
Global NCD
Targets
20%15%
23%15%
HED* <1.2%
35.2%30.0%
8.76.0gm
32.2%24.0%
<15.0%
Targets for
Malaysia
* Heavy episodic
drinking

28. Thank you
dr.feisul@moh.gov.my
Facebook: Feisul Mustapha
28