Paper presented at the International Research Symposium on Population Health 2013, 20 November 2013, Kuala Lumpur

1. Ministry of Health
Malaysia
MOH Research Initiatives on
Non-Communicable Diseases
Feisul Idzwan Mustapha
MBBS, MPH, AM(M)
Public Health Specialist
Disease Control Division, Ministry of Health, Malaysia
International Research Symposium on Population Health 2013
20 November 2013
University Malaya, Kuala Lumpur
dr.feisul@moh.gov.my

2. Seven Strategies:
1.
2.
3.
4.
National Strategic Plan for
Non-Communicable Diseases
(NSP-NCD) 2010-2014
•
•
•
•
5.
6.
7.
Prevention and Promotion
Clinical Management
Increasing Patient Compliance
Action with NGOs,
Professional Bodies & Other
Stakeholders
Monitoring, Research and
Surveillance
Capacity Building
Policy and Regulatory
interventions
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.
2

3. Strategy 7: Policy & Regulatory
Interventions
• Main thrust of NSP-NCD
• Health promotion and education will increase awareness
and knowledge
• However changes in behaviour is strongly influenced by our living
environment
Awareness
Knowledge
Health promotion & educations
Behavioural
Change
Supportive living
environment
Policies & regulations
3

4. 4

5. 65th World Health
Assembly (May 2012):
Decided to adopt a global target of
a 25% reduction in premature
mortality from NCD by 2025.
66th World Health Assembly
(May 2013):
Adoption of the Global Action plan for
the Prevention and Control of NCDs
(2013-2020), including 25 NCD
indicators with 9 voluntary global
targets.
5

6. Global Monitoring Framework for NCDs
Indicator
Targets
1.
Premature mortality from NCD
25% relative reduction in risk of dying
2.
Harmful use of alcohol
10% relative reduction
3.
Physical inactivity
10% relative reduction
4.
Salt intake
30% relative reduction in mean population intake
5.
Tobacco use
30% relative reduction
6.
Hypertension
Contain the prevalence
7.
Diabetes & obesity
Contain the prevalence
8.
Drug therapy to prevent heart attacks &
strokes
At least 50% of eligible people receive therapy
9.
Essential NCD medicines & basic
technologies to treat major NCDs
Availability & affordability
Note: Targets for year 2025, against baseline of year 2010. Reporting to the
United Nations every five years (next will be in 2015)
6

7. 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 middleincome countries: health effects and costs. pp 2054-2061.
7

8. Cost effective interventions to
address NCDs
Population-based
interventions
addressing NCD
risk factors
-
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
Individual-based
interventions
addressing NCDs
in primary care
Tobacco use
-
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
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
-
-
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9. “My Body is Fit
aand Fabulous”
An Implementation Research
(qualitative + quantitative approaches)
MyBFF@school
MyBFF@home
INTERVENTION PROGRAMMES
TO COMBAT OBESITY IN MALAYSIA
Slide courtesy of Dr Wan Nazaimoon, IMR; nazaimoon@gmail.com
MyBFF@work
9

10. MyBFF@school
• MyBFF@school consists of:
• Small-sided football games (SSG), Intensified nutrition
intervention.
• Psychology motivation - SELF-EMPOWERMENT.
• Peer support from members of the KELAB DOKTOR MUDA &
PROSTAR).
• Involvement of teachers, parents as agent of change.
• Study sites: Selected schools in Putrajaya (standards 4, 5 &
Form 1 & 2).
• Have already obtained approval from MOE for the additional
school hours required.
Slide courtesy of Dr Wan Nazaimoon, IMR; nazaimoon@gmail.com
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11. MyBFF@home
• An intervention study to combat obesity among housewives
in Klang Valley.
• Primary aim (Phase I)
• To develop an intervention package for overweight and obese
housewives aged 18-59 years old.
• Secondary aim (Phase II)
• To determine the effectiveness of the intervention package in
reducing body weight among overweight and obese housewives.
• A proposed “package” has been developed
• 3 main components (i) diet; (ii) exercise & physical activity; and
(iii) self-monitoring behaviour.
Slide courtesy of Dr Wan Nazaimoon, IMR; nazaimoon@gmail.com
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12. MyBFF@work
• An Intervention Study to Combat Obesity among Government
Employees in Kelantan.
• Collaboration with USM.
• General Objective: To provide low cost, feasible and goaldirected, process-oriented weight loss program for overweight
and obese Malaysian civil servants.
12
Slide courtesy of Dr Wan Nazaimoon, IMR; nazaimoon@gmail.com

13. JOM MAMA
Opportunity
Focus on pre-pregnancy for prevention
1.
New DOHaD science indicates that pre-pregnancy
offers opportunity for prevention of diabetes and
other NCDs
2.
Increasing levels of obesity and hypertension in
women of reproductive age
3.
Pre-pregnancy overweight approximately doubles
the risk for hypertensive disorders, preeclampsia
and gestational diabetes. Overweight and obesity
increase the risk of stillbirths, obstetric intervention,
postpartum hemorrhage, and birth defects2.
4.
Pre-pregnancy health status affects both the shortterm and long-term health
5.
Women enter pregnancy with modifiable risk factors
1: Hanson MA & Gluckman PD. Developmental origins of
noncommunicable disease: Population and public health implications.
American Journal of Clinical Nutrition 2011; 94(6 Suppl.): 1754S1758S.
2: Zulfiqar A bhutta, Sohni V Dean, Ayesha Imam, Zohra S Lassi:
Systematic review of Preconception risks and interventions; WHO
report : 32-33
13
Slide courtesy of Priya Matzen, Novo Nordisk; pryn@novonordisk.com

14. JOM MAMA: Objective
What we want to do
To investigate if prepregnancy interventions
improves young couples
health literacy and women’s
health
Prevent/
reduce risk
of NCDs
To assess if the intervention
improves delivery and birth
outcomes.
14
Slide courtesy of Priya Matzen, Novo Nordisk; pryn@novonordisk.com

15. JOM MAMA: Approach
Evidence base
Pre-conception / young couples
Malaysia
Nurul (25) &
Khairil (27)
Academia/Partners
Implementation
Public-private partnership
Phase 1
Co-creatIon
Phase 2
Phase 3
Programme
development
Monitoring and
Evaluation
15
Slide courtesy of Priya Matzen, Novo Nordisk; pryn@novonordisk.com

16. South East Asia Community Observatory
SEACO:
Research for a healthy community
v
D.D. Reidpath & P. Allotey
16

17. Vision
To develop a world class research and training site providing high quality
infrastructure for conducting community based “whole of life research” that
informs internationally, nationally, and locally relevant, priority questions
related to population health and wellbeing.
Mission
SEACO will achieve its vision through the collection and sharing of high
quality data and methods. The protection of, and service to the
communities involved with SEACO is paramount.
Slide courtesy of Prof. Pascale Allotey, Monash University Sunway Campus; pascale.allotey@monash.edu
17

18. DHSS: A Research Platform
SEACO: A research platform
• A community-based sentinel surveillance system that
captures longitudinally, a fully enumerated population within
circumscribed geographical location.
• The data collection process explicitly captures information on
demography, morbidity and mortality from the individual,
within the context of the household, and the household
within the context of the community, as well as the physical,
social, geographical relationships between these.
18
Slide courtesy of Prof. Pascale Allotey, Monash University Sunway Campus; pascale.allotey@monash.edu

19. SEACO: Study types
Family, Community and Population Dynamics
Nested crosssectional studies
MCH
Cause of
Death
Nested
longitudinal studies
Rural-Urban
migration
19
Slide courtesy of Prof. Pascale Allotey, Monash University Sunway Campus; pascale.allotey@monash.edu

20. HOPE-4 Study
• Intervening the epidemiologic transition through innovative
means of controlling hypertension
• Collaboration between UiTM, NCD MOH, McMaster
University, Toronto University and London School of Hygiene &
Tropical Medicine
• Grand Alliance for Chronic Diseases, supported by Grand
Challenges Canada.
• Blood pressure is the biggest global risk factor for NCDs,
followed by tobacco, alcohol and poor diet (Richard Horton,
Lancet 2012; 380:2053-54.
Information courtesy of Prof. Dato’ Dr Khalid Yusoff, kyusoff@salam.uitm.edu.my
20

21. HOPE-4 Study
• 50 communities in Malaysia, Columbia, India and Sub-Sahara
Africa.
• Task shifting – non-physician healthcare workers under
supervision of doctors.
• Use of polypill.
• Objective: Develop, implement and evaluate a CVD risk
assessment, treatment and control program.
• Primary outcome: composite CV events
• CV deaths, MI, stroke, CHF, hospitalisation, revascularisation.
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Information courtesy of Prof. Dato’ Dr Khalid Yusoff, kyusoff@salam.uitm.edu.my

22. Potential policy interventions to improve dietary
intake for preventing obesity in Malaysia
Policy areas
Fiscal
1.
2.
3.
4.
5.
Primary production
and imports
1.
2.
3.
Food processing
1.
2.
Potential policy interventions
Removal of subsidies on sugar, for both industries and households.
Removal of subsidies on cooking oil, for both industries and households.
Introduce subsidies for fruits and vegetables.
Introduce excise and/or sales tax on soft drinks.
Introduce excise and/or sales tax on sweetened condensed milk.
Incentives for farmers to grow local fruit and vegetable.
Reducing import duty on fruits and vegetables.
Increasing import duty on cooking oils and other fat sources (e.g. butter, ghee).
Regulate maximum content of sugar and fat in processed food products.
Incentives (e.g. Healthy Choice endorsement) for industries to improve food
composition.
22
This policy-mapping analysis grid is adapted from G. Sacks, B. Swinburn & M. Lawrence: Obesity Policy Action framework and
analysis grids for a comprehensive policy approach to reducing obesity. Obesity Reviews (2008)

23. Potential policy interventions to improve dietary
intake for preventing obesity in Malaysia
Policy areas
Food marketing /
information
1.
2.
3.
4.
5.
Potential policy interventions
Comprehensive restrictions for all marketing of unhealthy food to children under 16
years in all media, including television, the internet and other electronic media.
Introduce a nutrition signposting system (Healthy Choice tick, keyhole or traffic light
labelling) as a front pack labelling to indicate food products with less fat, sugar and
salt, and more whole grain and fibre.
Banning television advertising of foods high in fat and/or high in sugar during prime
time viewing (7pm to 9pm).
Mandatory for fast food outlets to display nutrition information about each product on
menus, menu boards and drive-through boards at the point of sale, and on tags next
to self-service cabinets and food displays.
Mandatory for vending machine operators to display nutrition information about the
products at the front of vending machines.
23
This policy-mapping analysis grid is adapted from G. Sacks, B. Swinburn & M. Lawrence: Obesity Policy Action framework and
analysis grids for a comprehensive policy approach to reducing obesity. Obesity Reviews (2008)

24. Potential policy interventions to improve dietary
intake for preventing obesity in Malaysia
Policy areas
Food distribution &
retail
1.
2.
3.
4.
5.
6.
7.
8.
Potential policy interventions
Limiting the sales of high fat & high sugar food/ beverages in schools & learning
institutions (canteen, cafeteria & co-operative shop).
Control of vending machines in schools, higher education institutes and public
buildings.
Control the licensing for food vendors within close proximity (e.g. <500m) from schools.
Density controls over new fast food outlets, in all areas, both urban and rural.
Restrict retail hours of fast food outlets, restaurants and hawker stalls (e.g. to be closed
at 10 pm.)
Compulsory inclusion of healthy choices (e.g. drinking water, low sugar/fat/ salt snacks)
in vending machines.
Restricting the sale of energy-dense and nutrient-poor foods in workplace canteens.
Compulsory to have a fruit/salad stall at any food outlet in public institutions (e.g.
schools, universities, offices, hospitals).
24
This policy-mapping analysis grid is adapted from G. Sacks, B. Swinburn & M. Lawrence: Obesity Policy Action framework and
analysis grids for a comprehensive policy approach to reducing obesity. Obesity Reviews (2008)

25. Potential policy interventions to improve dietary
intake for preventing obesity in Malaysia
Policy areas
Food service
1.
2.
3.
Potential policy interventions
Implementation of healthy food service policies in public institutions (e.g. schools,
universities, government departments, hospitals).
Mandatory for cafeteria operators and caterers to be trained and accredited on
healthy food provisions and preparations.
Compulsory for every food service to include fruits and vegetables in every set meal .
25
This policy-mapping analysis grid is adapted from G. Sacks, B. Swinburn & M. Lawrence: Obesity Policy Action framework and
analysis grids for a comprehensive policy approach to reducing obesity. Obesity Reviews (2008)

26. National Diabetes Registry
• Web-based application.
• Went live on 1 January 2011.
• Supports the implementation of the
annual “Diabetes Clinical Audit” and the
“Diabetes Quality Assurance Programme”
amongst Type 2 Diabetes patients in MOH
Health Clinics.
• First report, “NDR Report, Volume 1, 20092012” was published in August 2013,
available at the MOH website, under
“publications”.
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27. Summary
• We know what needs to be done for the prevention and
control of NCD.
• What we do not know is how best to implement in real
life situations and within the socio-cultural context of
Malaysia.
• Implementation-type research, including behavioural (qualitative
research) can provide evidence in answering this question.
• Multisectoral approach, not only in implementation but in
research as well.
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28. Thank you
dr.feisul@moh.gov.my
Facebook: Feisul Mustapha
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