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EPIDEMIOLOGY OF DIABETES

UNIT KAWALAN PENYAKIT TIDAK BERJANGKIT


(NCD)
JABATAN KESIHATAN NEGERI SABAH
Diabetes: The Disease
• It is a common chronic disorder
• There is chronic hyperglycaemia together with
other metabolic abnormalities
• It is due to insulin resistance and/or deficiency
as well as increased hepatic glucose output
• It is a risk factor for CVD
• Currently there is no known cure but the disease
can be controlled enabling the person to lead a
healthy and productive life
• The aim of management is directed at reducing
complications (micro and macrovascular)
• 2 types – 1) IDDM
• 2) NIDDM 2
Prevalence of Diabetes in Malaysia
(1986-2006)
NHMS I (1986) NHMS II (1996) NHMS III NHMS III (2006)
(2006)
Age group ≥35 years ≥30 years ≥18 years ≥30 years
Prevalence 6.3% 8.3% 11.6% 14.9%
Known diabetes 4.5% 6.5% 7.0% 9.5%
Newly diagnosed 1.8% 1.8% 4.5% 5.4%
Impaired Glucose 4.8% * 4.3% * 4.2% ** 4.7% **
Tolerance * / Impaired
Fasting Glucose **

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 §

Angina pectoris Men with diabetes


Sudden death * Women with diabetes
N/A

Coronary mortality †

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*

Deaths from diabetes


%
1
2
-

Heart attacks
%
4
1
-

Microvascular complications
1% %
7
3
-

Peripheral vascular disorders


%
3
4
-

*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

How serious is the


problem ?
Global Death in 2005
• 35 million – or 60% – of all deaths are
caused by chronic diseases.
diseases

• 17 million deaths – approximately 30% –


are due to infectious diseases, maternal and
perinatal conditions, and nutritional
deficiencies combined.

• An additional 5 million deaths – 9% of the


total – resulted from violence and injuries.

4
RISK FACTORS & DISEASES
END POINT
Non-modifiable risk factors:
•Age Intermediate stroke
•Sex Risk Factors
•Ethnicity Heart Disease
•Genes

Modifiable risk factors:


•Diet - unhealthy
•Physical inactivity
•Tobacco use

•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.

- In the symptomatic individual, 1 abnormal glucose


value is diagnostic.
- Whereas in the asymptomatic individual, 2 abnormal
glucose values are required.

OGTT plasma glucose values (mmol/L)


Category 0- Hour 2-Hour
normal < 5.6 < 7.8
IFG 5.6 - 6.9 -
IGT 7.8 - 11.0
DM >7 > 11.1
MyNCDS-1
MALAYSIA NCD SURVEILLANCE - 1 2005/2006

Overall NCD Risk Factors Prevalence and Burden


2006
Inadequate Vegetable & Fruit
8.7 million Lifestyle RF 72.8
% 10.5 millions
Physical Inactivity 7.2 million 60.1
%
(90 %)
at least 1 RF
Current Smoker
3.0 million 25.5 %

Alcohol Consumption 1.5 million 12.2 %

Obesity 2.0 million 16.3 %

Central Obesity
5.8 million 48.6 %
Intermediate RF

Raised Blood Pressure


3.1 million 25.7 %
8 millions
(70 %)
at least 1 RF
Raised Blood Glucose 1.3 million 11.0 %

Hypercholesterolemia 6.4 million 53.5 %

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

Estimated Estimated Estimated


NCD Risk Factors Population Population Population
2005 2015 2020
Unhealthy Diet 8.7 10.8 11.8
Physical Inactivity 7.2 8.9 9.7
Current Smoker 3.1 3.8 4.1
Alcohol Consumption 1.5 1.8 2.0
Obesity 1.9 2.4 2.7
Central Obesity 5.8 7.2 7.9
Raised Blood Pressure 3.1 3.8 4.2
Raised Blood Glucose 1.3 1.6 1.8
Hypercholesterolemia 6.4 7.9 8.7
At least 1 risk factor 11.6 14.4 15.7
Prevalence of NCD Risk Factors in
Malaysia (1996-2006)
NHMS II (1996) MANS (2003) MyNCDS-1 NHMS III
(2005) (2006)
Age group ≥18 years ≥18 years 25-64 years ≥18 years
Smoking 24.8% N.A. 25.5% 21.5%
Physically Inactive 88.4% 85.6%* 60.1% 43.7%
Unhealthy Diet N.A. N.A. 72.8 N.A.
Overweight 16.6% 27.4% 30.9% 29.1%
(BMI ≥25 & <30 kg/m2)
Obesity (BMI ≥30 kg/m2) 4.4% 12.7% 16.3% 14.0%
Hypercholesterolaemia N.A. N.A. 53.5% 20.6%

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

Epidemiological: NCD overriding CD, &


double burden of diseases

Demographic: Population ageing :


Increasing life expectancy

Lifestyles: Diets are rapidly changing


- High fat, low fiber, high salt
Physical activity reducing
Tobacco use increasing
Alcoholic

Urbanization: Growing cities : pollution


Globalisation: Increasing global influences
increased trade- foodstuffs, tobacco
DIABETES : A FORECAST
The number of people with diabetes is
expected to increase alarmingly in
the coming decades :
1985 = estimated 30 million people
with diabetes worldwide
2000 = figure had risen to 150 million
2025 = expected to rise to 380 million
5 countries with the largest number of people
with diabetes in 2007

• India = 40.9 million


• China = 39.8 million
• United States = 19.2 million
• Russia = 9.6 million
• Germany = 7.4 million
3.8 million deaths are attributed to
diabetes. Greater number die from cardio-
vascular disease made worst by diabetes
related lipid disorder and HPT.
Selected Non-Communicable Diseases
at Ministry of Health Facilities, 2000 &
2005
Types of Disease No of Discharges No. of Death
2000 2005 2000 2005
1. Hypertensive Disease 32,886 38,445 155 180
2. Ischaemic Heart Disease 33,623 39,594 2,556 2,948

3. Other Heart Disease 17,598 25,362 2,406 2,299


4. Cerebro-Vascular Disease 13,868 16,896 2,936 3,209

5. Diabetes Mellitus 27,179 39,762 323 402


6. Injury 157,823 145,127 2,689 2,661

7. Suicide and Para suicide 1,837 2,482 151 156


Source: MOH
8. Cancer 40,244 52,593 2,832 3,800
10 PRINCIPAL CAUSES OF DEATH IN
GOVERNMENT HOSPITAL 2005 (SABAH)
SEBAB BIL KEMATIAN
( PERATUS)

DISEASE OF CIRCULATORY SYSTEM 810 ( 20.67 % )


CERTAIN INFECTIOUS & PARASITIC DISEASE 666 (17.00% )
DISEASE OF RESPIRATORY SYSTEM 489 ( 12.48% )
NEOPLASMS 489 ( 12.48% )
CERTAIN CONDITION ORIGINATING IN THE PERINATAL PERIOD 312 ( 7.96% )
DISEASE OF DIGESTIVE SYSTEM 181 ( 4.62% )
DISEASE OF GENITOURINARY SYSTEM 174 ( 4.44% )
INJURY POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL 169 ( 3.98 %)
CAUSES
DISEASE OF NERVOUS SYSTEM 118 ( 3.01 % )
CONGENITAL MALFORMATIONS,DEFORMATION AND CHROMOSOMAL 108 ( 2.76 % )
ABNORMALITIES

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

Prevalence 6.3% 8.3% 11.6% 2.4% 14.9%


Known diabetes 4.5% 6.5% 7.0% 0.4% 9.5%
Newly diagnosed 1.8% 1.8% 4.5% 2.0% 5.4%
Impaired Glucose 4.8% * 4.3% * 4.2%** 3.1% # 4.7% #
Tolerance (IGT) / Fasting
Glucose (IFG)

**based on IGT; # based on IFG


“ Rise in the prevalence of diabetes, the prevalence of diabetic
complications is also expected to increase correspondingly”

- DM is the largest cause of kidney failure in developed


countries

- 10%-20% of people with DM will die of renal failure

- 2.5 million people worldwide are affected by diabetic


retinopathy

- Cardiovascular disease is the major cause of death in DM

- People with Type 2 diabetes are over twice as likely to have


heart attack or stroke who do not have diabetes
Prevalence of Diabetes by States
NHMS 3 (2006)

Prevalence of All Diabetic by States

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
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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

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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
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0 00 16 1 7 3
23 28,
2

Burdens 1.2 million (~80%)


National Prevalence of All Diabetes
Prevalence of Diabetes by Residence
by Residence
(aged ≥18 yrs)
(BURDENs )
(997,000 )
1 2 .5 1 2 .1
12 National Prevalence
Prevalence (%)

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 (%)

1 5.0 1 1.9 (823,000


1 1.4 ) (314,000 )
6.0 (78,000 ) (28,000 )
1 0.0 4.5 National Prevalence
5.0 11.55%

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

Total HbA1c Abnormal HbA1c

Source: Disease Control Division, MOH


Study on the adequacy of outpatient
management of type II DM cases in MOH
Hospitals and Health Centres in 2006
≤6mth & HbA1c < 6.5%
Status of Control by HbA1c
Controlled = 10.4%
Uncontrolled = 46.4%
Indeterminable = 43.2%
≤6 mth & FBS < 5.6mmol/L
Status of Control by FBS
Controlled = 10.5%
Uncontrolled = 81.9%
Indeterminable = 7.6%
MyNCDS-1: The Facts

• 1.3 million adults aged 25-64


yrs had High Blood Glucose
• Indian>Malay>Chinese
SCREENING AND DIAGNOSIS
OBJECTIVE.
- To detect pre-diabetes and diabetes in specific high risk population groups
and to ensure timely and appropriate management.

STRATEGY.
- Screening for high risk group.
- Selective screening according to criteria.

WHO SHOULD BE SCREENED?


1) Symptomatic – any individual who has symptoms suggestive of DM.
( tiredness, lethargy, polyuria, polydipsia, polyphagia, weight loss, pruritus
vulvae, balanitis ) must be screened.
2) Asymptomatic – consider in all adults who are overweight (BMI > 23) or
waist circumference > 80cm for women & >90cm for men and have
additional risk factors :- HDL cholesterol < 0.9mmol/L or triglycerides(TG) >
1.7mmol/L.
- Hx of CVD.
- HPT.
- First degree relative with DM
- Physical inactivity.
- Women with polycystic ovarian syndrome (PCOS).
- Women with Hx of gestational diabetes (GDM) should be screened
for
DM annually.
- Ethnicity (those of Indian ethnic background are at higher risks of
developing DM Type 2)
For asymptomatic, screening should begin at age > 30 years.

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.

- Screening for DM should be performed annually in those with risk factors


and those > 30 years.

- In children and adolescents at risk of developing DM, screening should be


initiated at 10 years old or at onset of puberty if puberty occurs at a younger
age. Screening is performed every 2 years.

- ALL newly diagnosed DM Type 2 need to be reviewed by a medical doctor


in which screening for other cardiovascular risk need to be done or planned.
TREATMENT OF DIABETES
1) Diet and physical activity. Exercise 30 minutes 3 times a week.
2) Lose weight. Try to achieve normal BMI.
3) Medication.
- Metformin (Glucophage ) 500 mg tablet.
) Dose is 500 mg – 1 gram TDS.
) Adverse effects includes anorexia, nausea and vomiting.
) Contraindicated in patients with renal impairment, chronic liver disease
and cardiac failure.
- Glibenclamide ( Daonil ) 5 mg tablet.
) Dose is 2.5 – 15 mg daily.
) Adverse effects includes increase appetite and weight gain.
) Contraindicated in DM Type 1.
- Gliclazide ( Diamicron ) 80 mg tablet.
) Dose is 40 – 320 mg daily.
) Adverse effects includes GI disturbances and rashes. 45
) Contraindicated in DM Type 1.
TREATMENT OF DIABETES
Medication…cont
- Acarbose ( Glucobay ) 50 mg tablet.
) Dose 50 – 200 mg TDS
) Use only in DM type 2.
) Adverse effects includes flatulence and bowel sounds and diarrhoea.
) Contraindicated in patients less than 18 years, pregnant women and breast
feeding mothers.
- Insulin.
) For DM Type 1
) and also DM Type 2 that are not well controlled.

46
EPIDEMIOLOGY OF
HYPERTENSION

UNIT KAWALAN PENYAKIT TIDAK BERJANGKIT


(NCD)
JABATAN KESIHATAN NEGERI SABAH
DEFINITION AND CLASSIFICATION OF HYPERTENSION.
-Hypertension is defined as persistent elevation of systolic BP of 140 mmHg or greater and/or diastolic BP of 90
mmHg or greater.

-Classification of BP for adults age 18 and older.

Category Systolic Diastolic Prevalence in


(mmHg) (mmHg) Malaysia
Optimal < 120 and < 80 32 %

Prehypertension 120 – 139 and/or 80 – 89 37 %

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

• A risk factor can be genetic or acquired.

• 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

Modifiable risk factors:


•Diet - unhealthy
•Physical inactivity
•Tobacco use

•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

Disease Prev 1996 2002 2006 2010 2020


Burden Rate NHMS2

HPT 29.9% 2,190,504 2,631,500 2,850,000 2,987,900 3,557,400

DM 8.3% 608,000 730,490 790,400 829,400 987,500

Note: Based on NHMS2 1996. Prevalance rate remain


constant.
Disease Burden= Pi x [p0 + (pi x Td)]

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 ,

• 29·2% were projected to have this condition by 2025


– 29·0% of men and
– 29·5% of women

• The estimated total number of adults with hypertension in 2000


was 972 million (957–987 million);
– 333 million in economically developed countries
– 639 million in economically developing countries.

• The number of adults with hypertension in 2025 was predicted


to increase by about 60% to a total of 1·56 billion

Source: Global burden of hypertension: analysis of worldwide data,


Lancet 2005; 365: 217–23
Prevalence of Hypertension in
Malaysia (1986-2006)
NHMS I NHMS II NHMS II NHMS III NHMS III
(1986) (1996) (1996) (2006) (2006)

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%

In 2006, there is an estimated 4.8 million Malaysians age 18 years and


above living with hypertension.

54
Prevalence of HPT by sex and race amongst Malaysian
Residents Aged ≥ 18 years in 2006 (N=33,976)

Age (Years) Sex, % (95% CI)


Male Female Both sexes
All races 33.3 (31.6, 31.0 (30.3, 32.2 (31.6,
32.8) 31.7) 32.8)
Malay 33.7 (32.5, 34.1 (33.1, 33.9 (33.1
34.8) 35.1) 34.7)
Chinese 35.0 (33.2, 29.8 (28.2, 32.4 (31.1,
36.8) 31.4) 33.8)
Indians 30.9 (28.2, 27.8 (25.6, 29.4
33.8) 30.1) (27.5,31.2)
Bumi Sabah 36.0 (33.0, 26.4 (24.1, 31.1 (29.2,
39.1) 28.8) 33.2)
Prevalence of HPT by sex and race amongst
Malaysian residents aged ≥ 30 years in 2006
(N=24,796)
Age (Years) Sex, % (95% CI)
Male Female Both sexes
All races 41.7 (40.7, 43.4 (42.5, 42.6 (41.8,
42.8) 44.4) 43.3)
Malay 45.8 (44.4, 51.2 (50.0, 45.4 (44.3,
47.1) 52.4) 46.4)
Chinese 47.4 (45.4, 42.3 (40.4, 40.6 (39.0,
49.4) 44.3) 42.1)
Indians 44.1 (40.8, 42.7 (39.9, 40.0 (37.7,
47.4) 45.5) 42.3)
Bumi Sabah 36.0 (33.0, 26.4 (24.1, 31.1 (29.2,
39.1) 28.8) 33.2)
Rule of Halves in Hypertension

All hypertensives

50% 50% Aware

50% 50% Treated

50% 50% controlled


“The Tip of the iceberg”

32 million heart attacks per year


Study on the adequacy of outpatient
management of Essential HPT cases in MOH
Hospitals and Health Centres in 2006

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

Risks accumulate throughout life


Detection test for NCD Risk Factors
TOOLS DETECTION MANAGEMENT
Questionnaire Risk Factors:
Physical - Smoking Behavioral Mod.
Biochemical
- Hypertension
Pharmacotherapy
- Obesity
To prevent:
- Dyslipidemia CVD
- Pre/Diabetes Hypertension
Diabetes
Fitness . Fitness level Stroke (CVA)
Diet • Dietary pattern Cancer
Stress • Stress level & Depression
coping
NCD & NCD Risk Factors:
The causation pathway for chronic diseases

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

an acceleration of the atherosclerotic process

further increases in arterial pressure

Heart Renal Peripheral vasculature Brain Retina

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

Registry, Monitoring, Defaulter tracing & “Self-


NCD

Well / Low Risk At Risk With Disease

•Early Detection
•Health •Risk Factor
Promotion Identification •Register

•Risk Factor •Appropriate


Intervention Treatment
•Complication
Monitoring
•Defaulter tracing
•Self-care
•Audit
Early Detection

• Why? Better control, less complications


• Whose responsibility? Everybody!!
• How? •Population screening
•Selective screening
•Opportunistic screening

• Only RBS/FBS? What else? No!!


Think about other modifiable NCD
R/F
Appropriate Treatment
• Why? •Ultimate aim: Improve QoL
rate of complications
•(morbidity & mortality)

• Whose responsibility? Everybody!!


• How? •Trained personnel
(Training/courses/seminar)
•Guidelines/Protocols
Complications Monitoring
• Why? •Early detection & treatment
•Improve QoL

• Whose responsibility? Paramedics


• How? •Trained personnel
•Guidelines/Protocols
•Green book
Defaulter Tracing
• Why? •Ensure patients not loss to follow-up
•Determine reason for defaulting

• Whose responsibility? Paramedics


• How? •You decide – depends on clinic
setup.Need appointment book
Self-Care
• Why? •Chronic disease, life-long
•Patient (& family) needs to take
responsibility
Patient empowerment
• Whose responsibility? Paramedics
• How? •Counselling skills
•Involve family members
•Need Diabetes Resource Centre
(DRC)
Audit
• Why? •Ensure & maintain quality of care
•Gauge clinic ‘performance’

• Whose responsibility? Doctors &


Paramedics

• How? •Own initiatives


•Diabetes Clinic Returns
•Diabetes QA
NCD

Well / Low Risk At Risk With Disease

•Health •Risk Factor •Early Detection


Promotion Identification
•Register
•Risk Factor
•Appropriate
Intervention
Treatment
•Complication
Monitoring
•Defaulter tracing
•Self-care
•Audit
Risk Factor Identification
• Why? •Initiate early RF intervention
•Prevent development of NCD

• Whose responsibility? Everybody!!


• How? •Population screening
•Selective screening
•Opportunistic screening

• Where? Everywhere, within all services


given at the clinic
Risk Factor Intervention
• Behavioral interventions: including
changing diet and increasing physical
activity. It has to be
And/or “structured”
• Pharmacological interventions: utilising
pharmaceutical agents to control the blood
pressure / cholesterol / glucose.
NCD Prevention & Control Programme
• Health Promotion & • To prevent risk factors
Health Education • To prevent diseases

• Screening /assessment • To identify Risk factors


• To diagnose diseases early
• Management
– appropriate treatment • To control diseases :
• Behavioral - treat at the earliest possible
modification stage
• Pharmacotherapy - slow disease progression
• Surgical , etc • To prevent complications

– 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

• R & D (research and development)


• Surveillance/ Research / audit/ registry / returns / guidelines /
etc

• Intersectoral collaboration (local & global)

• Marketing Health
Capacity Building
• Doctors
• AMO, SN
• Allied health

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 Proper training(very important)
Service Delivery

• PRIMARY HEALTH CARE Is the


thrust of Health Service.
• Provision Of Comprehensive
Services At First Point Of Contact
• Reduce Urban-Rural Differentials
Appropriate Facilities
Community-based Wellness Clinic
• Screening test
• Module and protocols, CPG, Drugs
• Supporting services
 Clinical care and excellence centre Clinic
• Quality in Hypertension/Diabetes Management
• Appropriate equipments
 Hypertension/Diabetes Resource Centre
Intervention pathway for chronic diseases

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

“Whole of society” response Health Systems Strengthening


Community leadership Health workforce development
Intersectoral partnerships Health services organization/delivery
Community mobilization Financing
People-centred systems of care
Focus on prevention
TREATMENT OF HYPERTENSION

1) Diuretics - Example is Chlorothiazide 250 – 500 mg OD


- Adverse effects uncommon, unless high doses are used.
Includes increased serum cholesterol, glucose and uric acid
(beware in gout patient) and erectile dysfunction.
2) Beta–Blockers - Example are Atenolol 50 – 100 mg OD and
Metoprolol 50 – 200 mg BD.
- Adverse effects includes dyslipidaemia and erectile
dysfunction.
- Contraindicated in patients with obstructive airways
disease, severe peripheral vascular disease and heart
block (2nd and 3rd degree) .
3) Calcium Channel Blockers - Examples are Nifedipine 10 – 30 mg TDS and
Amlodipine 5 – 10 mg OD.
- Adverse effects includes tachycardia, headache,
flushing, constipation and ankle oedema.
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TREATMENT OF HYPERTENSION
4) Angiotensin Converting Enzyme (ACE) Inhibitors
Examples are Captopril 25 – 50 mg TDS, Enalapril 2.5 – 20 mg BD and
Peridopril 2 – 8 mg OD.
In Diabetic patient, ACE Inhibitors have been shown to reduce
cardiovascular mortality. Have also shown to reduce morbidity and
mortality in patients with congestive heart failure..
Adverse effect include persistent dry cough. May increase foetal and
neonatal mortality and therefore are contraindicated in pregnancy and
should be avoided in those planning pregnancy.

5) Angiotensin receptor blockers (ARBs)


Example is Losartan 50 – 100 mg OD.
Unlike ACE Inhibitors, it causes less cough.
Effective in preventing progression of Diabetic Nephropathy.
Contraindicated in pregnancy.
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HEALTH PROMOTION
HEALTY LIFESTYLE CAMPAIGN
 LOVE YOUR HEART 1991

• Phase 1 – 1991 to 1996


• Disease oriented campaign-yearly
themes

• Phase 2- 1997 to 2002 PREVENT DIABETES


STAY AHEAD 1996
• Behavioral oriented- yearly themes OF CANCER
1995

• Phase 3- 2003 to 2008


• Behavioral oriented -2 yearly
• Focus to special target groups :
school children, work place
• 4 elements:
Physical activity, diet, EXERCISE 1998 HEALTHY EATING
RECIPE FOR GOOD HEALTH

smoking, stress 1997

84
PHASE 1 HLSC- Disease Oriented 1991-1996

 LOVE YOUR HEART 1991

 CLEAN FOOD, HEALTHY


FAMILY 1993
AIDS KILL 1992

HEALTHY CHILDREN. STAY AHEAD PREVENT DIABETES


THE NATIONS FUTURE OF CANCER 1996
1994 1995
PHASE 2 HLSC - Behavioural Oriented 1997-2002

HEALTHY EATING
RECIPE FOR GOOD HEALTH
1997 EXERCISE 1998 PREVENT INJURY 1999

ADOPT A HEALTHY LIFESTYLE


PRACTISE GOOD MENTAL HEALTH TOWARDS A HARMONIOUS
2000 AND HEALTHY FAMILY 2001
HEALTH PROMOTION
PHASE 3 HLSC - Behavioural Oriented 2003-2008

Focus to special target groups :


School children, work
place

4 elements:
Physical activity, diet,
smoking, stress
87
NCD Prevention & Control

DESCRIBE or PRESCRIBE ?

“Healthy” At Risk Disease


Low Risk (High)

Describe…..
Exercise 30 minutes, 3 times a week
3 Categories of Clients

DESCRIBE or PRESCRIBE ?

“Healthy” At Risk Disease


Low Risk (High)

Prescription : personalised & customized


Assess + prescribe + coach
Self-empowerment
Conclusion
• NCD is a main health problem.
• NCD can be prevented through nation-wide,
community-based approach
• Focus on three principle risk factors:
– Unhealthy diet
– Physical inactivity
– Tobacco use
• Changing environment through legislations &
regulations (inc. taxation & subsidies), and
specific policies.
OBJECTIVES

• To reduce morbidity and premature


mortality

• To reduce all modifiable risk factors

• To improve the quality of life


(i.e. DALY)
Recommendations for follow-up on initail BP
measurement for adult
Initai BP (mmHg) Follow-up Recommended

<130 and <85 Recheck in 1 years

130-139 and 85-89 Recheck in 3-6 months

140-159 and/or 90-99 Confirmed within 2 months

160-179 and/or 100-109 Evaluate within 1months or treat if


confirmed

180-209 and/or 110-119 Evaluate within 1 week and treat if


confirmed

≥210 and/or ≥120 Initiate drug treatment


immediately
Module 1: The criteria for Hypertension Screening

• Age 35 and above • Having sign and symptoms of


• Physically not active diabetes
• Overweight/obese – Polyuria
• History of pregnancy induced hypertension
– Nocturia
• History of giving birth big baby > 4 kg
Parent history of diabetes and hypertension – Thirsty

Family history of heart attack or AMI – Itchiness at genital area

– Loss of weight
– Increase of appetite
• No health screening/examination done within a – Lethargy
year

• Having sign and symptoms of


hypertension
– Dizziness
– Numbness
– Loss of consciousness

93
Health Spectrum
Healthy
individual Exposure to risk

Early disease

Established Disease

Complication of Disease

Death