Diabetes mellitus is a major global public health problem. The rise in global prevalence is expected to reach 5.4% or 300 million worldwide by 2025, with developed countries carrying a larger burden (1). Malaysia is not spared from this phenomena, with an alarming rise in prevalence of Type 2 diabetes mellitus (T2DM) over the past fifteen years, from 8.3% (NHMS 1, 1996) to 20.8% (NHMS IV, 2011) (2). What is most worrying is the figure for undiagnosed diabetics, which recorded almost a ten-fold increase (from 1.8% to 10.1%) within the same period. The national economic burden for provision of ambulatory or outpatient care for diabetes patients alone was estimated to cost the Ministry of Health RM 836 million, which took up 2.2% of the nation’s total health expenditure for 2009 (3). The average provider cost per outpatient visit for diabetes treatment at primary care was RM393.24, compared to RM 2707.44 at Specialist diabetic clinics. Treatment at primary care health centres was also highly cost effective compared to Specialist diabetic clinics (4). Due to the chronic nature of the disease, its many related complications and the progress in medical expertise, the costs to provide health care for the this group can only be expected to escalate in years to come. Strategies to effectively treat the chronic diseases (i.e. NCDs and T2DM) have been in place since the 1990s, however, the National Strategic Planning for Non-Communicable Diseases, (NSPNCD)(5) recommends that efforts should be channeled towards primary prevention, early NCD risk factor identification and NCD risk factor intervention or “clinical preventive services”. The clinical preventive services however, need to be emphasised, as early preventive measures can reduce long-term complications and morbidity related to diabetes. The risk factors which should trigger clinicians to provide clinical preventive measures include: obesity, sedentary lifestyles, dietary indiscretions, elderly (for late onset diabetes, pancreas insufficiency), family history of diabetes (risk in offspring of one diabetic parent: 30%, both parents: 60%). The 10th Malaysian Plan : Country Health Plan aims to restructure the national healthcare financing and healthcare delivery system to ensure universal health coverage of healthcare services to be provided at minimal cost using the existing infrastructure in delivering continuity of care across programmes, across healthcare settings and across healthcare providers (6). To reduce the fragmentation of care which commonly occurs in most NCD programmes, there is a need to involve healthcare providers within the healthcare service to be orientated in their roles and contribution in providing a seamless long-term care programme. It is hoped that this effort will benefit not only the patients but also provide relevant feedback on quality of healthcare service provision by the stakeholders. The current public health centre set up which combines Outpatient Primary Care

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)
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,
≥ 18yrs1
• 7.2% known diabetics, 8% previously undiagnosed
• Inpatient: 188 admissions per 100 0001
• Outpatient: 3,123,981 attendances at MOH Health clinics /
Klinik Kesihatan, 10% of total outpatient attendances2
1NHMS IV (2011)
2MOH Annual Report 2011

5. Prevalence of Diabetes

6. 8.3
14.9
20.8
6.5
9.5
10.7
1.8
5.4
10.1
4.3
4.7
5.3
0
5
10
15
20
25
NHMS II (1996) NHMS III (2006) NHMS 2011
Prevalence(%) Prevalence of Diabetes, ≥30 years
(1996, 2006 & 2011)
Total diabetes
Known
Undiagnosed
IFG

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.
3Wan 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. NationalStrategic Planningfor
Non-Communicablediseases(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 lifestyles5,
dietary indiscretions
• Age –related: late onset
diabetes, pancreas
insufficiency
• Hereditary: risk in
offspring of one diabetic
parent: 30%, both
parents: 60%
• Gen Y?
5Biswas, 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 <0.9 mmol/L or TG >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. Diabetescontrolin Malaysia-DiabCare2008
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
Table 6 below shows the mean HbA1c and the percentage of patients reaching clinical targets for
HbA1c. Mean HbA1c has decreased slightly over 4 years, from 8.3% in 2009 to 8.1% in 2012 with most
audited patients recording HbA1c between 8.0% to 10.0%. In 2012, 23.8% of patients achieved the
Malaysian glycaemic target of HbA1c <6.5% compared to 19.4% in 2009. Assessed against the
international treatment target of HbA1c <7.0%, 37.9% of patients in 2012 would be considered to have
achieved glycaemic control.
Table 6. Mean HbA1c and patients achieving glycaemic targets* [Audit Dataset]
HbA1c 2009 2010 2011 2012
Mean %, (95% CI) 8.3 (8.3 - 8.3) 8.0 (8.0 - 8.0) 8.2 (8.2 - 8.2) 8.1 (8.1 - 8.1)
Distribution, n (%)
<6.5%** 10,559 (19.4) 12,079 (24.8) 11550 (22.6) 22,992 (23. 8)
<7.0% 17,266 (31.3) 18,948 (38.9) 18002 (35.3) 36,620 (37.9)
<8.0% 28,822 (52.9) 28,584 (58.6) 28169 (55.2) 55,635(57.5)
≥10.0% 11,480 (21.1) 8,803 (18.1) 10327 (20.2) 18,764 (19.4)
No. of patients with
HbA1c test results*
54,440 48,774 51,026 96,694
Note:
*The denominator for the percentage achieving target was the number of patients with HbA1c test results
**Good glycaemic control as defined by the Malaysian CPG on T2DM (2009)
Table 7 below shows that the achievement of HbA1c treatment target (<6.5%) varied across the states.
The national HbA1c treatment achievement rate was 23.8% in 2012. The achievement rate by states
ranged from 54.0% in Labuan and 39.1% in Sarawak to 17.6% and 14.9% in Terengganu and Kelantan,
respectively. In line with the overall increasing proportion of patients achieving treatment target at

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. 10th 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
centreOutpatient
Department
Diagnostic Lab
Rehabilitation
Pharmacy
Maternal &
Child Health
Dental Health
Services

21. 10th 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
centreOutpatient
Department
Rehabilitation
Diagnostic Lab
Pharmacy
Maternal &
Child Health
Dental Health
Services

23. Recommendationsto enhance
Clinical PreventiveServicesat
PublicPrimaryCare 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