Download - 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
2
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
3
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 § ‡
5
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%
6
CPG T2DM2004
7
8
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 ?
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.
4
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
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
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
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.
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
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 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
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
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
“ 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 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,
000
71,0
00
55,
000
55,0
00
112
,,000
112,
,000
125
,000
125,
000
16,
000
16,0
00
135
,000
135,
000
96,
000
96,0
00
85,
000
85,0
00
290
,000
290,
000
77,
000
77,0
00
53,
000
53,0
00
164
,000
164,
000
114
,000
114,
000
14,
000
14,0
00
60,
000
60,0
00
BurdensBurdens
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,
000
86,0
00
148
,000
148,
000
196
,000
196,
000
238
,000
238,
000
228
,000
228,
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%)
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
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 )
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
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
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
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%
•1.3 million adults aged 25-64 yrs had High Blood Glucose
•Indian>Malay>Chinese
MyNCDS-1: The Facts
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
- 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 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
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.
46
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
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.
48
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 %
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).
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
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
51
Note: Based on NHMS2 1996. Prevalance rate remain constant.Disease Burden= Pi x [p0 + (pi x Td)]
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
54
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.
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)
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)
Rule of Halves in Hypertension
All hypertensives
50% 50% Aware
50% 50% Treated
50% 50% controlled
““The Tip of the iceberg”The Tip of the iceberg”
32 million heart attacks per year32 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 130/80mmHg2/3 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%
• 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
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
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
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
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”
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
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
Appropriate Treatment
• Why?
• Whose responsibility?
• How?
•Ultimate aim: Improve QoLrate of complications•(morbidity & mortality)
Everybody!!
•Trained personnel (Training/courses/seminar)•Guidelines/Protocols
Complications Monitoring
• Why?
• Whose responsibility?
• How?
•Early detection & treatment•Improve QoL
Paramedics
•Trained personnel•Guidelines/Protocols•Green book
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
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
Audit
• Why?
• Whose responsibility?
• How?
•Ensure & maintain quality of care•Gauge clinic ‘performance’
Doctors & Paramedics
•Own initiatives•Diabetes Clinic Returns•Diabetes QA
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
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
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”
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
• 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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Capacity Building• Doctors• AMO, SN• Allied health
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 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
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 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
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
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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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
“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 ?
“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
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.
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)
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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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
Health Spectrum
Healthy individual Exposure to risk
Early disease
Established Disease
Complication of Disease
Death