1. Diabetes mellitus: Strategies for control Aznida Firzah Abdul Aziz MBBS MMed (Fam Med) Department of Family Medicine Faculty of Medicine Universiti Kebangsaan Malaysia

2. Introduction Diabetes mellitus is a major global public health problem. Estimated world prevalence of diabetes among adults (aged 20–79 years) in 2010: 6.4%, affecting 285 million adults. In 2030: increase to 7.7%, and 439 million adults. 69% increase in numbers of adults with diabetes in developing countries 20% increase in developed countries. Diabetes Research and Clinical Practice 2010 87, 4-14

3. Fig. 1 Diabetes Research and Clinical Practice 2010 87, 4-14DOI: (10.1016/j.diabres.2009.10.007) Global estimates of the prevalence of diabetes 2010 & 2030

4. Epidemiology- Malaysian scenario Prevalence of diabetes 15.2%, 2.6 million Malaysians, ≥ 18yrs 1 7.2% known diabetics, 8% previously undiagnosed Inpatient: 188 admissions per 100 000 1 Outpatient: 3,123,981 attendances at MOH Health clinics / Klinik Kesihatan, 10% of total outpatient attendances 2 1 NHMS IV (2011) 2 MOH Annual Report 2011

5. Prevalence of Diabetes

7. Economic burden Ambulatory or outpatient care for diabetes patients cost the Ministry of Health RM 836 million, which took up 2.2% of the nation’s total health expenditure for 2009 Average provider cost per outpatient visit for diabetes treatment at primary care was RM393.24, compared to RM 2707.44 at Specialist diabetic clinics. 3 Wan Norlida I. 2014. The economic burden of type 2 diabetes mellitus outpatient care and comparing cost-effectiveness of diabetes care in primary health clinics and tertiary diabetic clinics. (Phd Thesis)

8. National Strategic Planning for Non-Communicable diseases (NSPNCD) 4 (2010-2014) Primary prevention Early risk factor prevention Clinical preventive services Aim to reduce long-term complications and morbidity related to diabetes

9. Risk factors Life-style related: sedentary lifestyles 5, dietary indiscretions Age –related: late onset diabetes, pancreas insufficiency Hereditary: risk in offspring of one diabetic parent: 30%, both parents: 60% Gen Y? 5 Biswas, A. Ann Intern Med. 2015;162:123-132, 146-147

10. Risk factor: Obesity Adults (≥18yrs) 33.3% (5.4 million) pre obese 27.2% (4.4 million) obese Children (<18yrs, based on weight for age) 3.9% (0.3 million) obese

11. Who should be screened? Individuals with symptoms suggestive of DM (tiredness, lethargy, polyuria, polydipsia, polyphagia, weight loss, pruritis vulvae, balanitis) Criteria for testing for pre-diabetes and diabetes in asymptomatic adult individuals: All adults who are overweight [body mass index (BMI) >23 kg/m2 or waist circumference (WC) ≥80 cm for women & ≥90 cm for men] CPG on DM 2009. Malaysian Endocrine & Metabolic Society, Ministry of Health Malaysia, Academy of Medicine Malaysia & Persatuan Diabetis Malaysia American Diabetes Association (ADA).

12. and have additional risk factors: Dyslipidaemia either HDL cholesterol 1.7 mmol/L History of cardiovascular disease (CVD) Hypertension (≥140/90 mmHg or on therapy for hypertension) Impaired Glucose Tolerance (IGT) or Impaired Fasting Glucose (IFG) on previous testing First-degree relative with diabetes Other clinical conditions associated with insulin resistance (e.g. severe obesity and acanthosis nigricans) Physical inactivity Women with polycystic ovarian syndrome (PCOS)

13. Glycaemic control* of patients with DM- what is the status? *HbA1c reflects overall glucose control over a 3 month period

14. Diabetes control in Malaysia-DiabCare 2008 M Mafauzy, Z Hussein, SP Chan. 2011. MJM 66(3):175-181

15. Glycaemic control M Mafauzy, Z Hussein, SP Chan. 2011. MJM 66(3):175-181

16. National Diabetes Registry (2009-2012) From 644 primary healthcare clinics (Klinik Kesihatan or KK) 657,839 patients registered Mean age 59.7 yrs 58.4% females Mean age at diagnosis: 53 yrs Mean duration of f/up 6.5 yrs Malays 58.9%, Chinese 21.4%, Indians 15.3% Mean HbA1c 8.1% 23.8% achieved HbA1c < 6.5% 70.1% hypertensive 55.1% dyslipidaemia

17. Glycaemic control

18. In summary Diabetes IS a major public health problem for Malaysia Economic burden is huge Efforts to control disease and reduce complications need to improve Prevention is the best investment So, what is the plan?

19. 10 th Malaysia Plan Restructuring of healthcare financing and healthcare delivery system, to ensure universal health coverage at minimal cost Using existing infrastructure Ensuring continuity of care across: programmes healthcare settings healthcare providers

20. Primary Healthcare Clinic set up Health centre Outpatient Department Diagnostic LabRehabilitation Pharmacy Maternal & Child Health Dental Health Services

21. 10 th Malaysia Plan Restructuring of healthcare financing and healthcare delivery system, to ensure universal health coverage at minimal cost Using existing infrastructure Ensuring continuity of care across: programmes healthcare settings healthcare providers

22. Public Healthcentre set up Health centre Outpatient Department RehabilitationDiagnostic LabPharmacy Maternal & Child Health Dental Health Services

23. Recommendations to enhance Clinical Preventive Services at Public Primary Care Healthcentres Identification of risk factors for diabetes among patients attending Dental Care Services Overweight/obese, family history of DM, past history of GDM, poor wound healing i.e. poor response to periodontal treatment? ±Screen for DM at Dental Clinic OR Referral to Primary Care / Outpatient Clinic at Healthcentres TRO DM Feedback from Primary Care to Dental Care, vice versa

24. Recommendations Increase awareness among healthcare providers i.e. Primary healthcare and Dental Healthcare regarding shared care approaches Include Dental health check schedules into current DM monitoring schedule (“DM Greenbook”)

25. Thank you draznida@ppukm.ukm.edu.my