Transcript
Page 1: 01 Overview of Diabetes CPG

EPIDEMIOLOGY OF DIABETES EPIDEMIOLOGY OF DIABETES

UNIT KAWALAN PENYAKIT TIDAK BERJANGKIT UNIT KAWALAN PENYAKIT TIDAK BERJANGKIT (NCD)(NCD)

JABATAN KESIHATAN NEGERI SABAHJABATAN KESIHATAN NEGERI SABAH

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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

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Prevalence of Diabetes in Malaysia (1986-2006)NHMS I

(1986)NHMS II

(1996)NHMS III

(2006)NHMS III

(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 Tolerance * / Impaired Fasting Glucose **

4.8% * 4.3% * 4.2% ** 4.7% **

In 2006, there is an estimated 1.5 million Malaysians age 18 years and above living with diabetes.

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Type 2 diabetes increases CVD risk

*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.

Coronary mortality †

4 51 2 3 6

Angina pectoris

Stroke

Men with diabetes

Women with diabetes

Age-adjusted risk ratio(1 = risk for individuals without diabetes)

Any CVD event §

§

Intermittent claudication † §

Cardiac failure § †

Sudden death N/A *

CHD †

MI § ‡

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EVERY 1%

reduction in HBA1cREDUCED

RISK*

1%

Deaths from diabetes

Heart attacks

Microvascular complications

Peripheral vascular disorders

UKPDS 35. BMJ 2000; 321: 405-12.

Better Control EqualsReduced Risk of Complications

-37%

-43%

*p<0.0001

-14%

-21%

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CPG T2DM2004

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Is NCD (CVD, DM) an important health problem ?

Is NCD (CVD, DM) an important health problem ?

Disease Burdens : Disease Burdens : Global & LocalGlobal & Local

How serious is the How serious is the problem ?problem ?

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Global Death in 2005Global Death in 2005

• 35 million – or 60% – of all deaths are 35 million – or 60% – of all deaths are caused by chronic diseasescaused by chronic 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.

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Intermediate Risk Factors

RISK FACTORS & DISEASESRISK FACTORS & DISEASES

Non-modifiable risk factors:•Age•Sex•Ethnicity•Genes

Modifiable risk factorsModifiable risk factors::•Diet - unhealthyDiet - unhealthy•Physical inactivityPhysical inactivity•Tobacco useTobacco use

•AlcoholAlcohol•StressStress

Socioeconomic, cultural & environmental determinants:

•Globalization•Urbanization•Population ageing

Diabetes CancersLung Disease

stroke

Heart Disease

Obesity/OverweightObesity/OverweightRaised blood pressureRaised blood pressureRaised blood glucoseRaised blood glucoseAbnormal blood lipidsAbnormal blood lipids

END POINT

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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

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0 10 20 30 40 50 60 70 80

PREVALENCE %

Overall NCD Risk Overall NCD Risk Factors Prevalence and Burden Prevalence and Burden 20062006

Value in the bar represent estimated population for adults aged 25 – 64 years

Common risk factors

Intermediate risk factors

Inadequate Vegetable & Fruit 8.7 million 72.8

% Physical Inactivity 7.2 million 60.1

%

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 %

Raised Blood Pressure 3.1 million 25.7 %

Raised Blood Glucose 1.3 million 11.0 %

Hypercholesterolemia 6.4 million 53.5 %

MALAYSIA NCD SURVEILLANCE - 1 2005/2006 MALAYSIA NCD SURVEILLANCE - 1 2005/2006 MyNCDS-1MyNCDS-1

Lifestyle RF

10.5 millions10.5 millions(90 %)

at least 1 RF

Intermediate RF

8 millions8 millions(70 %)

at least 1 RF

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Projected NCD Risk Factors Burden

2015 / 2020 (million)Adults aged 25 – 64 years

15.714.411.6At least 1 risk factor

8.77.96.4Hypercholesterolemia

1.81.61.3Raised Blood Glucose

4.23.83.1Raised Blood Pressure

7.97.25.8Central Obesity

2.72.41.9Obesity

2.01.81.5Alcohol Consumption

4.13.83.1Current Smoker

9.78.97.2Physical Inactivity

11.810.88.7Unhealthy Diet

Estimated Estimated Population Population

20202020

Estimated Estimated Population Population

20152015

Estimated Estimated PopulationPopulation

20052005NCD Risk FactorsNCD Risk Factors

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Prevalence of NCD Risk Factors in Malaysia (1996-2006)

NHMS II (1996)

MANS (2003)

MyNCDS-1 (2005)

NHMS III (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(BMI ≥25 & <30 kg/m2)

16.6% 27.4% 30.9% 29.1%

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.

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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 million2025 = expected to rise to 380 million

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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.

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Selected Non-Communicable Diseasesat Ministry of Health Facilities, 2000 &

2005

Types of DiseaseNo 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

8. Cancer 40,244 52,593 2,832 3,800Source: MOH

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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 CAUSES

169 ( 3.98 %)

DISEASE OF NERVOUS SYSTEM 118 ( 3.01 % )

CONGENITAL MALFORMATIONS,DEFORMATION AND CHROMOSOMAL ABNORMALITIES

108 ( 2.76 % )

30SUMBER:HEALTH FACTS JABATAN KESIHATAN NEGERI SABAH 2005

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Status of Diabetes Mellitus in Malaysia in the past 20 years

1986

NHMS I

1996

NHMS II

2006

NHMS III

2006

NHMS III

2006

NHMS

III

Remarks 35 years old & above

30 years old & above

18 years old & above

18 – 29 years old

30 years old & 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 Tolerance (IGT) / Fasting Glucose (IFG)

4.8% * 4.3% * 4.2%** 3.1% # 4.7% #

**based on IGT; # based on IFG

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“ 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

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Prevalence of All Diabetic by States

4.93

7.94

10.0411.07 11.1 11.74 12.01 12.1 12.6 12.61

13.45 13.6114.86 15.23 15.33

11.55

02468

1012141618

Sabah

WP L

abuan

Saraw

ak

Johor

Teren

gganu

Kelan

tan

Selan

gor

Pahan

g

WP K

uala

Lum

pur

Perak

Perlis

Kedah

Penan

g

Mel

aka

N. Sem

bilan

Natio

nal

States

Pre

vale

nce

Prevalence of Diabetes by StatesNHMS 3 (2006)

11.55%

1,46

6,00

0

1,46

6,00

0

71,

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71,0

00

55,

000

55,0

00

112

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112,

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125

,000

125,

000

16,

000

16,0

00

135

,000

135,

000

96,

000

96,0

00

85,

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00

290

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290,

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77,

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164

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164,

000

114

,000

114,

000

14,

000

14,0

00

60,

000

60,0

00

BurdensBurdens

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2.0 2.0 3.14.9

6.4

10.3

15.0

20.8

24.426.2

24.522.8 21.6

13.8

0

5

10

15

20

25

30

Pre

vale

nce

(%)

Age Group

Prevalence of All Diabetic by Age Group (aged ≥ 18 yrs)

Overall Prevalence 11.55%

19,

000

19,0

00

12,

000

12,0

00

29,

000

29,0

00

43,

000

43,0

00

65,

000

65,0

00

86,

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86,0

00

148

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148,

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196

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196,

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238

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238,

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228

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000

160

,000

160,

000

128

,000

128,

000

74,

000

74,0

00

39,

000

39,0

00

BurdensBurdens 1.2 million (~80%)1.2 million (~80%)

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National Prevalence of All Diabetes by Residence

12.1

10.5

9.510

10.511

11.512

12.5

Urban Rural

Residence

Prev

alen

ce (%

)Prevalence of Diabetes by Residence

(aged ≥18 yrs)

National Prevalence 11.55%

(997,000 ) (997,000 )

(468,000 ) (468,000 )

(BURDENs ) (BURDENs )

Sig Diff

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Prevalence of Diabetes by Gender

11.9

11.3

11.0

11.2

11.4

11.6

11.8

12.0

Male Female

Pre

va

len

ce

(%

)

National Prevalence 11.55%

Diff-Not sig.

(674,000 ) (674,000 )

(795,000 ) (795,000 )

( BURDENs )( BURDENs )

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19.9

11.9 11.4

6.0 4.5

0.05.0

10.0

15.020.025.0

Indian Malay Chinese OtherBumi

Others

Race

Prev

alen

ce (%

)Prevalence of Diabetes by Race , Aged ≥ 18 yrs

National Prevalence 11.55%

(221,000 ) (221,000 )

(823,000 ) (823,000 ) (314,000 ) (314,000 ) (78,000 ) (78,000 ) (28,000 ) (28,000 )

( BURDENs )( BURDENs )

Sig Diff

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National Prevalence Diabetes by Job Description in Malaysia

Job CategoryPrevalence BurdensBurdens

% ‘‘000000

Senior Officials & Managers

15.9 4040

Professionals 10.0 8888

Technical & Associates 12.1 122122

Clerical Workers 8.7 6161

Service Workers & Shops 10.7 225225

Skilled Agricultural & Fishery 9.7 8787

Crafts & Related Trade Workers 6.4 4848

Machine Operators & Assemblers 11.7 8181

Elementary Occupations 9.0 5050

Housewives 14.2 423423

Unemployed 16.1 201201

Unclassified 6.7 4141

1

2

3

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Glycaemic Control Status (HbA1c)Among Diabetic in Government Facilities, 2002 - 2004

17122(64%)11032

48833

(65%)33035

58603

(68%)38180

0

10000

20000

30000

40000

50000

60000

2002 2003 2004

Total HbA1c Abnormal HbA1c

Source: Disease Control Division, MOH

> 60% > 60% Poorly Poorly controlcontrol

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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 FBSControlled = 10.5%

Uncontrolled = 81.9%Indeterminable = 7.6%

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•1.3 million adults aged 25-64 yrs had High Blood Glucose

•Indian>Malay>Chinese

MyNCDS-1: The Facts

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SCREENING AND DIAGNOSISOBJECTIVE.- 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

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- 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.

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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.

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TREATMENT OF DIABETES1) 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.

) Contraindicated in DM Type 1. 45

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TREATMENT OF DIABETESMedication…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.

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EPIDEMIOLOGY OF EPIDEMIOLOGY OF HYPERTENSION HYPERTENSION

UNIT KAWALAN PENYAKIT TIDAK BERJANGKIT UNIT KAWALAN PENYAKIT TIDAK BERJANGKIT (NCD)(NCD)

JABATAN KESIHATAN NEGERI SABAHJABATAN KESIHATAN NEGERI SABAH

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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.

- The classification is based on the average of two or more readings taken at two or more visits to the doctor.

When SBP and DBP fall into different categories, the higher category should be selected to classify the

individual’s BP.

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Category Systolic Diastolic (mmHg) (mmHg)

Prevalence in Malaysia

Optimal

Prehypertension

HypertensionStage 1Stage 2Stage 3

< 120 and < 80

120 – 139 and/or 80 – 89

140 – 159 and/or 90 - 99160 – 179 and/or 100 - 109 > 180 and/or > 110

32 %

37 %

20 %8 %4 %

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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).

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Intermediate Risk Factors

RISK FACTORS & DISEASESRISK FACTORS & DISEASES

Non-modifiable risk factors:•Age•Sex•Ethnicity•Genes

Modifiable risk factorsModifiable risk factors::•Diet - unhealthyDiet - unhealthy•Physical inactivityPhysical inactivity•Tobacco useTobacco use

•AlcoholAlcohol•StressStress

Socioeconomic, cultural & environmental determinants:

•Globalization•Urbanization

Obesity/OverweightObesity/OverweightRaised blood pressureRaised blood pressureRaised blood glucoseRaised blood glucoseAbnormal blood lipidsAbnormal blood lipids

Diabetes CancersLung Disease

ED (Erectile Dysfunction)

stroke

Heart Disease

END POINT END POINT

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Projection of Risk Factor Burden-1

Disease Disease BurdenBurden

Prev Prev RateRate

19961996NHMS2NHMS2

20022002 20062006 20102010 20202020

HPT HPT 29.9%29.9% 2,190,5042,190,504 2,631,5002,631,500 2,850,0002,850,000 2,987,9002,987,900 3,557,4003,557,400

DMDM 8.3%8.3% 608,000608,000 730,490730,490 790,400790,400 829,400829,400 987,500987,500

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Note: Based on NHMS2 1996. Prevalance rate remain constant.Disease Burden= Pi x [p0 + (pi x Td)]

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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.

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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

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Prevalence of Hypertension in Malaysia (1986-2006)

NHMS I (1986)

NHMS II (1996)

NHMS II (1996)

NHMS III (2006)

NHMS III (2006)

Age group ≥25 years ≥18 years ≥30 years ≥18 years ≥30 years

Definition of hypertension (mmHg)

≥160/95 ≥140/90 ≥140/90 ≥140/90 ≥140/90

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.

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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, 32.8) 31.0 (30.3, 31.7) 32.2 (31.6, 32.8)

Malay 33.7 (32.5, 34.8) 34.1 (33.1, 35.1) 33.9 (33.1 34.7)

Chinese 35.0 (33.2, 36.8) 29.8 (28.2, 31.4) 32.4 (31.1, 33.8)

Indians 30.9 (28.2, 33.8) 27.8 (25.6, 30.1) 29.4 (27.5,31.2)

Bumi Sabah 36.0 (33.0, 39.1) 26.4 (24.1, 28.8) 31.1 (29.2, 33.2)

Bumi Sarawak 35.6 (31.0,40.4) 33.3 (29.5,37.3) 34.4 (31.0,38.1)

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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, 42.8) 43.4 (42.5, 44.4) 42.6 (41.8, 43.3)

Malay 45.8 (44.4, 47.1) 51.2 (50.0, 52.4) 45.4 (44.3, 46.4)

Chinese 47.4 (45.4, 49.4) 42.3 (40.4, 44.3) 40.6 (39.0, 42.1)

Indians 44.1 (40.8, 47.4) 42.7 (39.9, 45.5) 40.0 (37.7, 42.3)

Bumi Sabah 36.0 (33.0, 39.1) 26.4 (24.1, 28.8) 31.1 (29.2, 33.2)

Bumi Sarawak 35.6 ( 31.0,40.4) 33.3 (29.5,37.3) 34.4 (31.0,38.1)

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Rule of Halves in Hypertension

All hypertensives

50% 50% Aware

50% 50% Treated

50% 50% controlled

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““The Tip of the iceberg”The Tip of the iceberg”

32 million heart attacks per year32 million heart attacks per year

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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 130/80mmHg2/3 Readings during last 3 consecutive clinic in last 18 mths =/below 130/80mmHg

Status of Control Status of Control Controlled = 28.5%Controlled = 28.5%

Uncontrolled = 61.3%Uncontrolled = 61.3%Indeterminable = 10.2%Indeterminable = 10.2%

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• 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

Barker’s Hypothesis The Life Course ApproachThe Life Course Approach

Risks accumulate throughout lifeRisks accumulate throughout life

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Detection test for NCD Risk FactorsDetection test for NCD Risk Factors

TOOLSTOOLS

Questionnaire

Physical

Biochemical

Fitness

Diet

Stress

DETECTIONDETECTION

Risk Factors:Risk Factors:

- Smoking

- Hypertension

- Obesity

- Dyslipidemia

- Pre/Diabetes

. Fitness level• Dietary pattern• Stress level &

coping

DETECTIONDETECTION

Risk Factors:Risk Factors:

- Smoking

- Hypertension

- Obesity

- Dyslipidemia

- Pre/Diabetes

. Fitness level• Dietary pattern• Stress level &

coping

MANAGEMENTMANAGEMENT

Behavioral Mod.Behavioral Mod.

PharmacotherapyPharmacotherapy

To prevent:To prevent:

CVDCVD

HypertensionHypertension

DiabetesDiabetes

Stroke (CVA)Stroke (CVA)

CancerCancer

DepressionDepression

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62

NCD & NCD Risk Factors:The causation pathway for chronic diseases

Underlying Underlying DeterminantDeterminantss•Globalisation•Urbanization•Population Ageing

Common Risk Common Risk FactorsFactors•Unhealthy diet•Physical Inactivity•Tobacco & Alcohol use•Age (nonmodifiable)•Heredity (nonmodifiable)

Intermediate Intermediate Risk FactorsRisk Factors•Overweight/obesityOverweight/obesity•Raised blood sugarRaised blood sugar•Raised blood Raised blood pressure pressure•Abnormal blood Abnormal blood lipidslipids

Main Chronic Main Chronic DiseasesDiseases•Heart DiseaseHeart Disease•DiabetesDiabetes•StrokeStroke•CancerCancer•Chronic Resp DisChronic Resp Dis

Page 62: 01 Overview of Diabetes CPG

Untreated adults with hypertension

further increases in arterial pressure

an acceleration of the atherosclerotic process

Brain Peripheral vasculatureRenal Heart Retina

LVHCCF CHD

Sr creatininemicroalbuminuria

proteinuriaAbsence of one or more major pulse in extremities (except dorsalis pedis) with or without intermittent claudication; aneurysm

TIAStroke

Haemorrhages or exudates, with or withoutpapilloedema

Page 63: 01 Overview of Diabetes CPG

Framework of NCD program Framework of NCD program (Peranan anggota kesihatan)(Peranan anggota kesihatan)

1.1. Promotion & Protection (Health education)Promotion & Protection (Health education)2.2. Screening for risk factors/ NCDScreening for risk factors/ NCD3.3. Early intervention ( NonPham / Pham)Early intervention ( NonPham / Pham)

1. “CEGAH” 1. “CEGAH” (Prevention)(Prevention)

2. “RAWAT” 2. “RAWAT” (Treat to (Treat to Control)Control)1.1. Health education- personalisedHealth education- personalised

2.2. Screening for complicationsScreening for complications3.3. Intervention ( NonPham / Pham /Rehabilitation)Intervention ( NonPham / Pham /Rehabilitation)

– Limit disease progressLimit disease progress– Prevent complicationPrevent complication– Limit disabilityLimit disability– Improve life qualityImprove life quality

Registry, Monitoring, Defaulter tracing & “Self-Registry, Monitoring, Defaulter tracing & “Self-empowerment”empowerment”

Page 64: 01 Overview of Diabetes CPG

NCD

Well / Low Risk At Risk With Disease

•Early Detection

•Register

•Appropriate Treatment

•Complication Monitoring

•Defaulter tracing

•Self-care

•Audit

•Health Promotion

•Risk Factor Identification

•Risk Factor Intervention

Page 65: 01 Overview of Diabetes CPG

Early Detection

• Why?

• Whose responsibility?

• How?

• Only RBS/FBS? What else?

Better control, less complications

Everybody!!

•Population screening•Selective screening•Opportunistic screening

No!!

Think about other modifiable NCD R/F

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Appropriate Treatment

• Why?

• Whose responsibility?

• How?

•Ultimate aim: Improve QoLrate of complications•(morbidity & mortality)

Everybody!!

•Trained personnel (Training/courses/seminar)•Guidelines/Protocols

Page 67: 01 Overview of Diabetes CPG

Complications Monitoring

• Why?

• Whose responsibility?

• How?

•Early detection & treatment•Improve QoL

Paramedics

•Trained personnel•Guidelines/Protocols•Green book

Page 68: 01 Overview of Diabetes CPG

Defaulter Tracing

• Why?

• Whose responsibility?

• How?

•Ensure patients not loss to follow-up•Determine reason for defaulting

Paramedics

•You decide – depends on clinic setup.Need appointment book

Page 69: 01 Overview of Diabetes CPG

Self-Care

• Why?

• Whose responsibility?

• How?

•Chronic disease, life-long•Patient (& family) needs to take responsibility

Paramedics

•Counselling skills•Involve family members•Need Diabetes Resource Centre (DRC)

Patient empowerment

Page 70: 01 Overview of Diabetes CPG
Page 71: 01 Overview of Diabetes CPG

Audit

• Why?

• Whose responsibility?

• How?

•Ensure & maintain quality of care•Gauge clinic ‘performance’

Doctors & Paramedics

•Own initiatives•Diabetes Clinic Returns•Diabetes QA

Page 72: 01 Overview of Diabetes CPG

NCD

Well / Low Risk At Risk With Disease

•Early Detection

•Register

•Appropriate Treatment

•Complication Monitoring

•Defaulter tracing

•Self-care

•Audit

•Health Promotion

•Risk Factor Identification

•Risk Factor Intervention

Page 73: 01 Overview of Diabetes CPG

Risk Factor Identification

• Why?

• Whose responsibility?

• How?

• Where?

•Initiate early RF intervention•Prevent development of NCD

Everybody!!

•Population screening•Selective screening•Opportunistic screening

Everywhere, within all services given at the clinic

Page 74: 01 Overview of Diabetes CPG

Risk Factor Intervention

• Behavioral interventions: including changing diet and increasing physical activity.

And/or• Pharmacological interventions: utilising

pharmaceutical agents to control the blood pressure / cholesterol / glucose.

It has to be “structured”

Page 75: 01 Overview of Diabetes CPG

NCD Prevention & Control Programme• Health Promotion &

Health Education

• Screening /assessment

• Management– appropriate treatment

• Behavioral modification

• Pharmacotherapy• Surgical , etc

– rehabilitation

• To prevent risk factors• To prevent diseases

• To identify Risk factors• To diagnose diseases early

• To control diseases : - treat at the earliest possible stage- slow disease progression

• To prevent complications

• To limit disability at the earliest possible stage

• To restore an affected individual to a useful, satisfying & when possible, self sufficient role in society

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• Capacity Building

• R & D (research and development)• Surveillance/ Research / audit/ registry / returns / guidelines /

etc

• Intersectoral collaboration (local & global)

• Marketing Health

Framework of NCD program Framework of NCD program ( Supporting Components)( Supporting Components)

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78

Capacity Building• Doctors• AMO, SN• Allied health

Proper training(very important)

Page 78: 01 Overview of Diabetes CPG

Service Delivery

• PRIMARY HEALTH CARE Is the thrust of Health Service.

• Provision Of Comprehensive Services At First Point Of Contact

• Reduce Urban-Rural Differentials

Page 79: 01 Overview of Diabetes CPG

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

Page 80: 01 Overview of Diabetes CPG

Intervention pathway for chronic diseases

Underlying Underlying DeterminantsDeterminants

Common Risk Common Risk FactorsFactors

Intermediate Intermediate Risk FactorsRisk Factors Main Chronic Main Chronic

DiseasesDiseases

“Whole of government” responsePolitical willPolitical leadershipHealthy public policies and laws

Health Sector ResponseHealth sector governanceHealth sector leadershipIntegration of NCD prevention & control into national health strategy

Health Systems StrengtheningHealth workforce developmentHealth services organization/deliveryFinancingPeople-centred systems of careFocus on prevention

“Whole of society” responseCommunity leadershipIntersectoral partnershipsCommunity mobilization

AdvocacyResearch & Surveillance

Page 81: 01 Overview of Diabetes CPG

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.

82

Page 82: 01 Overview of Diabetes CPG

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.

83

Page 83: 01 Overview of Diabetes CPG

84

HEALTH PROMOTIONHEALTY LIFESTYLE CAMPAIGN

• Phase 1 – 1991 to 1996• Disease oriented campaign-

yearly themes

• Phase 2- 1997 to 2002• Behavioral oriented- yearly

themes

• Phase 3- 2003 to 2008• Behavioral oriented -2 yearly• Focus to special target groups :

school children, work place• 4 elements:

Physical activity, diet, smoking, stress

LOVE YOUR HEART 1991LOVE YOUR HEART 1991

HEALTHY EATING RECIPE FOR GOOD HEALTH

1997

EXERCISE 1998

PREVENT DIABETES1996STAY AHEAD

OF CANCER1995

Page 84: 01 Overview of Diabetes CPG

PREVENT DIABETES1996

STAY AHEAD OF CANCER

1995

HEALTHY CHILDREN. THE NATIONS FUTURE

1994

CLEAN FOOD, HEALTHY FAMILY 1993

PHASE 1 HLSC- Disease Oriented 1991-1996

AIDS KILL 1992

LOVE YOUR HEART 1991

Page 85: 01 Overview of Diabetes CPG

HEALTHY EATING RECIPE FOR GOOD HEALTH

1997 EXERCISE 1998 PREVENT INJURY 1999

PRACTISE GOOD MENTAL HEALTH2000

ADOPT A HEALTHY LIFESTYLE TOWARDS A HARMONIOUS AND HEALTHY FAMILY 2001

PHASE 2 HLSC - Behavioural Oriented 1997-2002

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87

HEALTH PROMOTION

Focus to special target groups : School children, work place

4 elements: Physical activity, diet, smoking, stress

PHASE 3 HLSC - Behavioural Oriented 2003-2008PHASE 3 HLSC - Behavioural Oriented 2003-2008

Page 87: 01 Overview of Diabetes CPG

“Healthy”Low Risk

At Risk(High)

Disease

NCD Prevention & Control

Describe…..Describe…..Exercise 30 minutes, 3 times a weekExercise 30 minutes, 3 times a week

DESCRIBE or PRESCRIBE ? DESCRIBE or PRESCRIBE ?

Page 88: 01 Overview of Diabetes CPG

“Healthy”Low Risk

At Risk(High)

Disease

3 Categories of Clients

DESCRIBE or PRESCRIBE ? DESCRIBE or PRESCRIBE ?

Prescription : personalised & customizedPrescription : personalised & customizedAssess + prescribe + coach Assess + prescribe + coach Self-empowermentSelf-empowerment

Page 89: 01 Overview of Diabetes CPG

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.

Page 90: 01 Overview of Diabetes CPG

OBJECTIVESOBJECTIVES

• To reduce morbidity and premature To reduce morbidity and premature mortality mortality

• To reduce all modifiable risk factorsTo reduce all modifiable risk factors

• To improve the quality of life To improve the quality of life (i.e. DALY)(i.e. DALY)

Page 91: 01 Overview of Diabetes CPG

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

180-209 and/or 110-119

≥210 and/or ≥120

Evaluate within 1months or treat if confirmed

Evaluate within 1 week and treat if confirmed

Initiate drug treatment immediately

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93

Module 1: The criteria for Hypertension Screening

• Having sign and symptoms of diabetes– Polyuria– Nocturia – Thirsty – Itchiness at genital area– Loss of weight– Increase of appetite – Lethargy

• Having sign and symptoms of hypertension – Dizziness – Numbness – Loss of consciousness

• Age 35 and above• Physically not active• Overweight/obese• History of pregnancy induced

hypertension • History of giving birth big baby

> 4 kg• Parent history of diabetes and

hypertension • Family history of heart attack

or AMI

• No health screening/examination done within a year

Page 93: 01 Overview of Diabetes CPG

Health Spectrum

Healthy individual Exposure to risk

Early disease

Established Disease

Complication of Disease

Death


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