Everyone has fat (lipids) in the blood, i.e. cholesterol, triglycerides and high and low-density lipoproteins. Abnormal levels of lipids (dyslipidaemia) contribute to the development of atherosclerosis.
This is a condition in which there is a build-up of plaque – which consists of fat, cholesterol, calcium and other substances – in the arteries, leading to narrowing of the arteries, and consequently, a reduction in oxygen-rich blood flow to various organs.
Atherosclerosis can result in cardiovascular disease, which is manifested by heart attacks, strokes and even death.
Cardiovascular disease (CVD) is the leading cause of death in Malaysian men and women. It includes coronary heart disease (CHD), cerebrovascular disease and peripheral arterial disease.
CHD ranges from angina, which is chest pain or discomfort due to poor blood flow through the blood vessels in the heart, usually during excessive physical activity, to heart attack (acute coronary syndrome, ACS) when blood flow to the heart is blocked.
The causes of dyslipidaemia may be primary (genetic) or secondary to various conditions, such as excessive dietary intake of fat, diabetes, chronic kidney disease, hypothyroidism, excessive alcohol consumption and some medicines like thiazides and beta-blockers.
Data from National Health and Morbidity Surveys
The overall prevalence of hypercholesterolaemia (known and undiagnosed) among adults of 18 years and above in the 2015 survey was 47.7%.
The prevalence in the rural areas was the same as that in the urban areas. (Source: Institute for Public Health 2015. National Health and Morbidity Survey [NHMS] 2015. Vol. II: Non-Communicable Diseases, Risk Factors & Other Health Problems, 2015]
The prevalence was 20.7%, 32.6% and 47.7% in 2006, 2011 and 2015 respectively, with the increase due to an increase of undiagnosed hypercholesterolaemia from 26.6% in 2011 to 38.6% in 2015.
The findings from NHMS 2015 of the overall prevalence of hypercholesterolaemia (known and undiagnosed) were:
• There was an increase in overall prevalence with age, increasing from 22.0% in the 18-19 years age group to a peak of 68.8% among the 55-59 years age group;
• The overall prevalence in females was 52.2% and 43.5% in males;
• Malays and Indians had the same prevalence at 50.1%, followed by the Chinese at 47.5%.
Of the known hypercholesterolaemia, the findings included:
• The prevalence of known hypercholesterolaemia was 9.1%, increasing from 0.2% in the 18-19 years age group, reaching a peak of 25.2% in the 60-74 years age group;
• The prevalence in females was the same as in males;
• The prevalence in urban areas was 9.7% and 7.1% in the rural areas;
• Indians had a prevalence at 12.3%, followed by Other Bumiputras at 11.2%, Chinese at 11.0%, and Malays at 8.7%;
• 66.8% claimed to be on oral drugs within the past two weeks; 84.4% had received specific diet advice from healthcare personnel; 70.3% claimed to have been advised by healthcare personnel to lose weight, and 83.1% had been advised to be more physically active or start exercising;
• With regards to their usual place of treatment, more than half of them sought treatment at Health Ministry (MOH) health clinics (50.0%), followed by private clinics (23.07%), MOH hospitals (19.1%), and private hospitals (4.6%);
• About 2.3% self-medicated by purchasing medications directly from pharmacies;
• 0.3% took traditional and complementary medicine.
Of the undiagnosed hypercholesterolaemia, the findings included:
• The prevalence of undiagnosed hypercholesterolaemia was 38.6%, increasing from 21.9% in the 18-19 years age group to a peak of 48.5% in the 55-59 years age group;
• The prevalence in the rural areas was at 40.5% and 38.0% in the urban areas;
• The prevalence in males was 35.0% and 42.4% in females;
• Malays had a prevalence at 41.4%, followed by Indians at 37.8% and Chinese at 36.5%.
Too many undiagnosed and inadequately controlled
There was one person diagnosed with hypercholesterolaemia compared to four with undiagnosed hypercholesterolaemia, i.e. a ratio of 1:4 in NHMS 2015, which was similar to NHMS 2011.
Control of hypercholesterolaemia was inadequate, with only 53.8% of those aged 60 years or more in NHMS 2011 having adequate control (Source: Hypercholesterolaemia Prevalence, Awareness, Treatment and Control among the Elderly: The 2011 National Health and Morbidity Survey, Malaysia. British Journal of Medicine & Medical Research 13(6): 1-9, 2016).
CVD has been the leading cause of death in Malaysian men and women in the past decade. Malaysians get ACS at a younger age than Thais, mainland Chinese and Westerners.
CHD and cerebrovascular disease were the first and second causes of deaths in 2016, with an increase of 39.6% and 23.8% respectively since 2005. They were also the top two causes of death and disability combined.
According to the local National Cardiovascular Disease – Acute Coronary Syndrome (NCVD-ACS) Registry for 2011-2013, 96.8% of patients had at least one cardiovascular risk factor, i.e. high blood pressure (65%), diabetes (46%) and dyslipidaemia (37%).
These risk factors have been on an increasing trend. These data are not surprising seeing as the numbers of undiagnosed and inadequately controlled hypercholesterolaemia are so high.
The magnitude of the dyslipidaemia problem needs particular attention. Screening in primary care settings and frequent health promotion to enhance increased community awareness and commitment to healthy living and care need to be continually emphasised.
The MOH’s target for 2025 is that there be no increase in the prevalence of hypercholesterolaemia from the 47.7% in 2015 (Source: National Plan of Action for Nutrition of Malaysia 2016-2025, page 82).
The task of reducing the prevalence of hypercholesterolaemia may appear daunting but the consequences of not even trying would impact negatively on the healthcare delivery system in general, and on individuals and families in particular.
How will the MOH’s approach towards hypercholesterolaemia contribute to its target of reducing the risk of premature mortality from non-communicable diseases from 20% to 15% by 2025?