Diabetes Care in MalaysiaProfessor Dato Ikram Shah Ismail

University of Malaya

Conflict of interest disclosure

Committee of Scientific Affairs

None

Committee of Scientific Affairs

Malaysia: An Introduction

• Malaysia is situated in Southeast Asia and consists of 13 states and 3 federal territories with a total landmass of 329,847 square kilometers

• Multicultural society in which 67.4% of the population are ethnic Malays, 27.3% Chinese, and 7.3% Indians (2010 Census)

• Health care in Malaysia is the responsibility of the government’s Ministry of Health. Malaysia has a 2-tiered health care system that consists of a government-run universal health care system and a coexisting private health care system

National Health and Morbidity Surveys (NHMS)

• Population-based survey conducted by MOH• NHMS I (1986), NHMS II (1996), NHMS III (2006) & NHMS IV (2011)

• Latest NHMS 2015

• For NCD risk factors, now conducted every 4 years• Based on WHO STEPwise Methodology

• Sampling • National Household Sampling Frame made up of Enumeration Blocks (EBs)

derived from the Population and Housing Census, Malaysia (2010)

• Multistage Random Sampling (28 strata)

4

Prevalence of Diabetes, ≥18 years

11.6

15.2

17.5

7

7.28.3

4.5

89.2

4.24.9 4.7

0

2

4

6

8

10

12

14

16

18

20

2006 2011 2015Total Known Undiagnosed IFG

6

Pre

vale

nce

(%

)

Prevalence of Diabetes, ≥18 years, by age groups (2015)

0

5

10

15

20

25

30

35

40

18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

차트 제목

Overall Known Undiagnosed IFG

7

Pre

vale

nce

(%

)

Prevalence of Diabetes, ≥18 years, by Ethnic groups (2015)

22.1

14.6

1210.7

7.4

0

5

10

15

20

25

Indians Malays Chinese Other Bumiputras Others

Ethnic Group

8

Diabetes in the Young Adult: 18-30 years

2 2

3.1

2.1

4.95.35.5

5.9

8.9

0

1

2

3

4

5

6

7

8

9

10

18-19 20-24 25-29

차트 제목

2006

2011

2015

Age Group

Pre

vale

nce

%

CURRENT

PROJECTION

Projections for Diabetes, 2025

10

Undiagnosed

Diagnosed

6.3%8.3%

11.6%

15.2%17.5%

22.9%

35.1%

47.7%

Diabetes Prevalence 1986 to 2015

12.80% 13.10%

19.80% 17.20%

2011 2015

Hypertension Prevalence 2011 to 2015

32.6% 30.3%

Hypercholeterolaemia 2006 to 2015

Prevalence of Selected NCD Risk Factors

12

The Diabetes in Children and Adolescents Registry(2006-2008)

• The Diabetes in Children and Adolescents Registry (DiCARE) is a Ministry of Health (MOH) supported registry whose aim is to collect information about DM in children and adolescents in Malaysia.

• In this registry, 74.0 % had type 1, 18.0 % had type 2 and 8.0% had other types of DM (Up to 2009 490 children).

• T2DM is only noted in patients from 7 years onwards

• The mean HbA1c level for T1DM and T2DM were far from target.

• Only about one third of patients were on intensive regimen (30.0%,43.3% and 43.8% in the young children, children and adolescents respectively).

• About ¼ of T2DM (23.0%) patients were solely on insulin injection.

17

56.0

24.6

15.0

2.5 1.60.2

0

10

20

30

40

50

60

MOH healthclinics

MOH hospitals Private clinics Privatehospitals

Self-medicate TCM

PER

CEN

TAG

E

Usual Place of Treatment (2011)

Diabetes Care in Public Medical Facilities

• Public Hospital based Diabetes Care delivered in general Medical outpatients clinic by Medical Officers and Physicians

• Patients are referred to Public hospitals at a state level for consultations with dietitians, diabetes nurse educators, and pharmacists, mostly on an individual basis. Comprehensive care in hospital-based diabetes clinics includes regular screening for microalbuminuria, retinal photography, and foot examination as recommended by current clinical practice guidelines.

• Diabetes Resource Centers in most hospitals where trained diabetes nurse educators deliver patient-centered diabetes education to inpatients and outpatients

• The MOH has conducted training courses for diabetes nurse educators since 2004, and an estimated 900 diabetes nurse educators have been trained and practice in both primary care and hospital-based diabetes care.

Cost of Diabetes in Malaysia

• People diagnosed with diabetes have access to diabetes care and treatment in Malaysia.

• Diabetes costs are estimated to account for 16% of the national Malaysian healthcare budget.• placing Malaysia among the top 10 countries in the world in terms of

percentage of healthcare budget spent on diabetes.

• In 2010, an estimated RM 2.4 billion was spent on diabetes-related healthcare.

19

Zhang P. et al. Global healthcare expenditure on

diabetes for 2010 and 2030. Diabetes research

and clinical practice. 2010; 87: 293– 301.

Cost of Diabetes in Malaysia

• Cost of managing diabetes in Malaysia: ~RM19,000.00 per patient per year• Conservative estimate from a study we did in 2007

• Not ideal treatment

• Data from NHMS 2011 estimates about 1.1 million patients are on follow up at MOH hospitals and clinics• 1.1 M x RM 19k = RM 20.9 billion!!

20

NHMS 2015: Obesity and Overweight

4.4

14 15.117.7

16.6

29.1 29.4 30

0

5

10

15

20

25

30

35

NHMS II (1996) NHMS III (2006) NHMS IV (2011) NHMS V (2015)

Prevalence of Overweight and Obesity, ≥18 years

Obese Overweight

Pre

vale

nce

%

NHMS 2015: Obesity

27.1

21.1

18

11.7

7.7

INDIAN MALAYS OTHER BUMIPUTRA

CHINESE OTHERS

Obesity (BMI . 30 kg/m2)

Obesity (BMI . 30 kg/m2)

15

20.6

0

5

10

15

20

25

Male Female

Obesity (BMI > 30 kg/m2)

Obesity (BMI > 30 kg/m2)

Prevalence of Abdominal Obesity > 18 years

0

10

20

30

40

50

60

NHMS 2011 NHMS 2015

Overall

43.0%

48.6%

Pre

vale

nce

%

Abdominal Obesity (NHMS 2015)

66.2

50.7 49.9

44.7

34.3

0

10

20

30

40

50

60

70

Indian Malays OtherBumiputra

Chinese Others

NHMS 2015

NHMS 2015

38.2

60.2

73.7

89.4

0

10

20

30

40

50

60

70

80

90

100

Male Female

NHMS 2015 Diabcare 2013

DIETARY PRACTICES AMONG ADULTS:The Malaysian Adult Nutrition Surveys (MANS)

Food group Malaysian Food Pyramid

2010 recommendation

No. of servings/day

Meet recommended

servings (%)

(MANS 2003)

Meet recommended

servings (%)

(MANS 2014)

Cereal, cereal products

and

tubers

4–8 52.9 41.3

Fruits 2 17.0 14.9

Vegetables 3 13.9 7.9

Meat, poultry, and egg 1/2–2 52.4 66.8

Fish and fish products 1 20.6 31.3

Legumes and nuts 1/2–1 12.3 17.1

Milk and dairy products 1–3 21.9 24.4

• Poor adherence with lifestyle recommended highly prevalent among T2DM patients:• In a Teaching Hospital, only 16.4% adhere strictly to diet prescribed (Tan SL et al, 2011)

• Diab Care 2013, only 25.96% completely adhere to diet

• A recent study in patients with diabetes receiving treatment in tertiary care hospital reported to consume a diet high in carbohydrate and fat• Carbohydrate: 60%• Fat : 24%• Protein: 16%

(Koo et al, 2013)

Dietary Management in T2DM

28

• Increased sedentary lifestyle and physical inactivity among Malaysian adults• NHMS 2015: overall prevalence of 66.5% for physically active adults.

• Only 25.4% were very active whereas 41.1% were minimally active

• Males (71.1%); Females (61.7%)

• Among T2DM patients, 33.3% reported low physical activity in a survey at Govt Health Centre (Norsyazwani et al, 2010)

Physical Activity

29

Summary

• There has been a continuous rise in the prevalence of diabetes mellitus in Malaysia for the past two decades and is currently at a high level of almost 18%.

• This is associated with a rapid rise and the current high prevalence of overweight and obesity in the country, affecting almost 50% of adults.

• Unsatisfactory dietary practices and low physical activity levels contribute to the high prevalence of the weight problem.

• There is no shortage of data on the socio-demographic characteristics of diabetes and its associated risk factors

DiabCare Malaysia 2013: Center profiles

31

1,668 type 2 DM

19 centers(tertiary hospital – MOH, MOE)

Centralised HbA1c testing for all the patients – Gribbles Lab

Note:

• Patient recruitment was carried on a pre-selected recruitment day –“DiabCare day” at all the hospitals

• One Ad board member was present at the site to facilitate the patient selection, data collection to ensure uniformity during “DiabCare days”

1

2

318

19

9

7 8

6

4 5

10

11

12

13

14

15

16

17

DiabCare Malaysia 2013:Patient Demographic Characteristics

20081

20132

Age (Yrs) (n=1,655) 57.5 (10.7) 57.8 (11)

Sex (M/F) (n=1,667) (%) 45.7/51.3 46.5/53.5

BMI (Kg/m2) (n=1,643) 27.8 (4.5) 29.0 (4.0)*

Age at onset (yrs) (n=1,561) 44.1 (11.7) 44.9 (10.0)

Duration of Diabetes (yrs) (n=1,561) 11.53 (8.1) 12.9 (8.6)*

Duration of OAD Rx (yrs) (n=1,508) 11.4 (4.3) 11.3 (7.7)

Duration of Insulin Rx (yrs) (n=994) 4.2 (4.6) 5.6 (5.5)*

*p <0.05‘n’ values are for type 2 patients from 2013 studyAll values are mean (SD) unless stated otherwise1. Mafauzy M et al. Med J Malaysia 2011; 66(3):175-1812. Mafauzy M et al accepted for publication Med J Malaysia 2016

32

DiabCare Malaysia 2013: Clinical History

*p<0.051. Mafauzy M et al. Med J Malaysia 2011; 66(3):175-1812. Mafauzy M et al accepted for publication Med J Malaysia 2016

68.2

93.7

57.5

71.5*

8.9

48.7

0

10

20

30

40

50

60

70

80

Family History Current Smokers Alcohol Sedentary Life

% o

f Patients

2008 2013

~ Half of the patients had ‘sedentary lifestyle’

33

DiabCare Malaysia 2013: Glycaemic status

8.667.98

12.96

8.52 8.68

0

2

4

6

8

10

12

14

HbA1c FPG PPG

2008 2013

Similar HbA1c and FPG but significantly lower PPG values in 2013 vs. 2008

34

10.86*

*p<0.05

DiabCare Malaysia 2013: Glycaemic status - HbA1c

~ ¾ of patients were above ADA targets for HbA1c

35

85 87.3

0

20

40

60

80

100

2008 2013

Proportion of patients had HbA1c≥6.5%

(AACE, IDF)

71.976.3

0

20

40

60

80

100

2008 2013

Proportion of patients had HbA1c>7%

(ADA)

DiabCare Malaysia 2013: Investigations

All values are mean (SD) unless stated otherwise1. Mafauzy M et al. Med J Malaysia 2011; 66(3):175-1812. Mafauzy M et al accepted for publication Med J Malaysia 2016

36

20081 20132

Lipid levelsTotal cholesterol (mmol/L)HDL Cholesterol (mmol/L)LDL Cholesterol (mmol/L)Triglycerides (mmol/L)

4.33(2.11)1.13 (0.69) 2.69 (0.98) 1.64 (1.22)

4.71 (2.44)* 1.25 (0.51)* 2.62 (1.01)* 1.76 (1.09)*

Serum creatinine (µmol/L) - 105.17 (83)

Significantly lower LDL cholesterol; Significantly higher total cholesterol, HDL cholesterol, and triglyceride in 2013 vs. 2008

*p<0.05

1. Mafauzy M et al. Med J Malaysia 2011; 66(3):175 – 1812. Mafauzy M et al accepted for publication Med J Malaysia 2016

DiabCare Malaysia 2013:Dyslipidemia

~90% patients were treated for dyslipidemia

20081 20132

LDL>2.6 mmol/L (%) 712 (46.0%) 667 (40.0%)

HDL <1.0 mmol/L (%) 424 (27.4%) 298 (17.9%)*

TG’s > 2.2 mmol/L (%) 307 (19.8%) 326 (19.5%)

How many were treated for dyslipidemia(%)

1,316 (85.0%) 1,516 (90.9%)

37

*p<0.05

1. Mafauzy M et al. Med J Malaysia 2011; 66(3):175 – 181 2. Mafauzy M et al accepted for publication Med J Malaysia 2016

DiabCare Malaysia 2013: Hypertension

20081 20132

BP: Systolic/Diastolic (mmHg) 137 (20)/79 (12) 140 (20)/79 (12)*

Proportion of patients with BP >130/80 mmHg (%)59.3% 68.0%*

Proportion of patient taking treatments for hypertension (%)

75.0% 86.3%

Treatment for hypertensionTop 5 classes (%)

• ACEI 65.2% 41.1%

• ARB 36.6% 31.9%

• Ca2+ antagonists 60.0% 48.2%

• Beta blockers 46.3% 32.4%

• Diuretics 36.5% 26.4%

38

• ~90% of the population having co-morbid hypertension• ~86% patients taking treatment for hypertension as compared to ~75% in 2008 study

*p<0.05

DiabCare Malaysia 2013: Cardiovascular complications

1. Mafauzy M et al. Med J Malaysia 2011; 66(3):175 – 1812. Mafauzy M et al accepted for publication Med J Malaysia 2016

Proportion of patients (%)

20081 20132

Myocardial infarction 12.1 10.9

Angina 18.4 15.7*

Peripheral vascular disease - 5.0

Stroke/Transient Ischaemic attack 6.8 7.0

Congestive heart failure - 5.2

Atrial fibrillation - 1.8

Left ventricular hypertrophy - 7.8

CABG 13.0 10.3*

39

*p<0.05

DiabCare Malaysia 2013: Nephropathy

1. Mafauzy M et al. Med J Malaysia 2011; 66(3):175 – 1812. Mafauzy M et al accepted for publication Med J Malaysia 2016

40

Proportion of patients (%)

20081 20132

Microalbuminuria 24.7 27.8

Gross proteinuria 15.7 23.4

End-stage renal disease 1.0 1.5

Dialysis 0.9 0.8

Generally increase in incidence of renal complications in 2013 as compared to 2008

DiabCare Malaysia 2013: Eye complications

1. Mafauzy M et al. Med J Malaysia 2011; 66(3):175 – 1812. Mafauzy M et al accepted for publication Med J Malaysia 2016

Generally increase in incidence of eye complications in 2013 as compared to 2008

Proportion of patients (%)

20081 20132

Non-proliferative retinopathy 15.5 23.6

Proliferative retinopathy 9.3 12.0

Photocoagulation 10.4 13.6

Severe vision loss 1.2 2.8

Macular oedema - 1.6

Cataract 18.5 31.5

41

DiabCare Malaysia 2013: Foot complications and neuropathy

*Based on neuropathy symptoms1. Mafauzy M et al. Med J Malaysia 2011; 66(3):175 – 1812. Mafauzy M et al accepted for publication Med J Malaysia 2016

Proportion of patients (%)

20081 20132

Active ulcer 0.7 1.6

Healed ulcer 1.9 4.9

History of amputation 1.8 2.3

Peripheral neuropathy 29.2 41.0

Erectile dysfunction - 42.9

42

Generally increase in incidence of neuropathy & foot complications in 2013 as compared to 2008

DiabCare Malaysia 2013: Glucose-lowering therapies

1. Mafauzy M et al. Med J Malaysia 2011; 66(3):175 – 1812. Mafauzy M et al accepted for publication Med J Malaysia 2016

Proportion of patients (%)

20081 20132

Types of Oral Glucose Lowering Drugs (OGLD) therapy

• Biguanides 73.9 78.6*

• Sulfonylureas 45.4 35.4*

• Meglitinides 0.6 0.3

• Glucosidase inhibitors 9.4 4.6*

• Thiazolidinediones 5.0 0.7*

• DPP-4 inhibitors 1.5 10.3*

• Traditional/herbal medicine 0.4 0.5

GLP-1 analogues 0.3 0.7

43

*p<0.05

DiabCare Malaysia 2013: Insulin therapy

1. Mafauzy M et al. Med J Malaysia 2011; 66(3):175 – 1812. Mafauzy M et al accepted for publication Med J Malaysia 2016

Proportion of patients (%)

20081 20132

On insulin therapy 53.6% 65.4%*

Insulin dose (IU) per day, mean (SD) 50.9 (32.3) 60.3 (37.1)*

Number of injections, mean (SD) 2.3 (1.1) 2.6 (1.2)

Device – Pen/Syringe (%) 94.2/2.3 99.7/0.3

Type of insulin used• Basal + OGLD• Basal + Bolus• Premix OD• Premix BD• Premix TID

11.9%19.5%0.3%

23.2%0.8%

11.3%31.4%*

0.5%25.5%2.8%*

44

*p<0.05

DiabCare Malaysia 2013: Treatment adherence

46

25.96

19.12

72.54

53.96

26.26

86.75

59.17

37.53

11.75

9.95

36.39

12.29

14.87

43.35

15.71

36.09

37.35

0.96

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Diet

Exercise

Taking Medications as Prescribed-oral

Taking Medications as Prescribed-insulin

Testing yourself

Keeping appointments with health care

Completely Partially Other*

*Other includes rarely, never, no recommendation, don’t know/refused, missing data

National Diabetes Registry

• Web-based application.

• Went live on 1 January 2011.

• Supports the implementation of the annual “Diabetes Clinical Audit” amongst Type 2 Diabetes patients in MOH Health Clinics.

• First report, “NDR Report, Volume 1, 2009-2012” was published in August 2013, available at the MOH website http://www.moh.gov.my/index.php/pages/view/115.

47

Diabetes Clinical Audit (2013)

Variable TargetsTotal no.

of tests (n)Meeting

Target (%)Mean 95% CI

HbA1c < 6.5 % 91,944 25.6 8.1 8.1 - 8.1

BP: Systolic < 130 mmHg 106,842 47.6 135.1 135.0 - 135.2

BP: Diastolic < 80 mmHg 106,828 69.2 77.7 77.6 - 77.8

Blood Pressure < 130 / 80 mmHg 106,809 41.2

Total cholesterol < 4.5 mmol/l 91,214 29.0 5.2 5.1 - 5.2

TG ≤ 1.7 mmol/l 90,593 61.8 1.8 1.8 - 1.8

HDL ≥ 1.1 mmol/l 67,354 66.6 1.3 1.3 - 1.3

LDL ≤ 2.6 mmol/l 67,090 37.3 3.1 3.1 - 3.1

BMI < 23 kg/m2 96,954 16.4 27.4 27.4 - 27.4

Waist circumference

< 90 cm (Male) 31,790 33.7 94.0 93.9 - 94.1

< 80 cm (Female) 50,008 14.4 90.7 90.6 - 90.8

Total 115,254 Patients

Diabetes Clinical Audit (2013)

ComplicationsPresent Absent Not known

n % n % n %

Retinopathy 8,640 7.50% 89,118 77.32% 17,488 15.17%

Ischaemic Heart Disease

6,133 5.32% 94,448 81.95% 14,665 12.72%

Cerebrovascular Disease

1,519 1.32% 99,490 86.32% 14,237 12.35%

Nephropathy 10,476 9.09% 90,693 78.69% 14,077 12.21%

Diabetic Foot Ulcer

1,470 1.28% 101,211 87.82% 12,565 10.90%

Amputation 726 0.63% 102,034 88.53% 12,486 10.83%

Concomitant Co-Morbidity

Yes No Not known

n % n % n %

Hypertension 83,765 72.68% 25,898 22.47% 5,583 4.84%

Dyslipidaemia 69,157 60.00% 38,145 33.10% 7,944 6.89%

SummaryBasic Patient Data, Clinical History, Measurements and Investigation

• The diabetes duration was 13 years with the median duration of OAD and insulin treatment were

10.3 years and 5.6 years respectively

• BMI has increased to 29 kg/m2 (DiabCare 2013) from 27.8 kg/m2 (DiabCare 2008)

• Over 2/3 of patients had a family history of DM, 49% led a sedentary lifestyle

• The lipid levels and blood pressure readings remain similar in 2008 & 2013

• Mean HbA1c reduced from 8.66% (DiabCare 2008) to 8.52% (DiabCare 2013)

• 76.3% of patients were above ADA target

• 87.3% of patients reported above AACE target(Malaysian CPG)

50

SummaryDiabetes Complications and Diabetes Management

51

• The majority of patients (90%) had co-morbidities such as hypertension

• The rate of microvascular complications especially nephropathy & retinopathy continues to increase

• Neuropathy (41%), erectile dysfunction (43% of the male patients) ,cataract (31%) and non-

proliferative retinopathy (24%) were observed

• Increased rates of gross proteinuria and nephropathy observed

• 87% were receiving OADs ; biguanides and sulphonylureas were the most commonly used OADs

among treated patients

• 98% of patients had dyslipidemia, with 91% receiving lipid-lowering agents with improvement in LDL,

HDL and TG levels

SummaryInsulin Treatment & Psychosocial Assessment

52

• There has been increase in use of insulin from 53% in 2008 to increased to 65% in 2013

• The most commonly prescribed insulin regimens were premix (45%), basal-bolus (31%), and basal

(19%)

• Patients in this study perceived a healthy state of overall well-being (mean EQ-VAS of 71.7)

• However, the most affected domains reported were pain or discomfort (44%), mobility (29%), and

anxiety or depression (28%)

• Completely adherence to ‘Exercise (19%)’, ‘self-monitoring (26%)’ and ‘administer insulin (53%)’ were

reported