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The Rise of Chronic Non-Communicable Diseases in Southeast Asia: Time for

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Article  in  The Lancet · February 2011

DOI: 10.1016/S0140-6736(10)61506-1 · Source: PubMed

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Health in Southeast Asia 4

The rise of chronic non-communicable diseases in
southeast Asia: time for action
Antonio Dans, Nawi Ng, Cherian Varghese, E Shyong Tai, Rebecca Firestone, Ruth Bonita

Lancet 2011; 337: 680–89 Southeast Asia faces an epidemic of chronic non-communicable diseases, now responsible for 60% of deaths in the
Published Online region. The problem stems from environmental factors that promote tobacco use, unhealthy diet, and inadequate
January 25, 2011 physical activity. Disadvantaged populations are the hardest hit, with death rates inversely proportional to a country’s
DOI:10.1016/S0140-
gross national income. Families shoulder the financial burden, but entire economies suffer as well. Although attempts
6736(10)61506-1
to control non-communicable diseases are increasing, more needs to be done. Health-care systems need to be
See Comment page 619
redesigned to deliver chronic care that is founded on existing primary health-care facilities, but supported by good
See Comment Lancet 2011;
377: 355 and 534
referral systems. Surveillance of key modifiable risk factors is needed to monitor the magnitude of the problem and
See Online/Comment
to study the effects of interventions. All branches of government and all sectors of society have to get involved in
DOI:10.1016/S0140- establishing environments that are conducive to healthy living. The Association of Southeast Asian Nations is in a
6736(10)62181-2, unique position to make a united stand against chronic non-communicable diseases in the region. Inaction will affect
DOI:10.1016/S0140- millions of lives—often, the lives of those who have the least.
6736(10)61923-X, and
DOI:10.1016/S0140-
6736(10)62140-X Introduction geography is the foundation of wide variation in history
This is the fourth in a Series of The sea splits southeast Asia into a vast collection of and heritage and is the root of a rich social and cultural
six papers about health in island fragments large and small, to an extent unlike heterogeneity—not only between countries, but within
southeast Asia other regions around the world. This splintered countries as well. In recent years, however, globalisation
and technological advances have combined to create a
potent force for convergence, bringing nations closer
Search strategy and selection criteria
together in terms of accessibility, communication,
We did a Medline search to identify relevant studies published during the past 10 years that commerce, ideas, and even culture. Today, the region
used representative samples to measure the burden of non-communicable diseases or their has become an interesting mixture of historical diversity
risk factors in countries in southeast Asia. Medical Subject Heading (MESH) terms used for and contemporary convergence.
non-communicable diseases were: “cancer”, “stroke”, “myocardial infarction”, “cardiovascular One manifestation of this convergence is the rapid
diseases”, “pulmonary disease, chronic obstructive”, “diabetes mellitus”, “hypertension”, epidemiological and demographic transition in the region,1
“obesity”, “dyslipidemias”, “smoking”, “food habits”, or “exercise”. MESH terms used for
methodology were “prevalence”, “nutrition surveys”, “health surveys”, or “diet surveys”.
Free text terms for southeast Asia were “Brunei”, “Singapore”, “Malaysia”, “Thailand”, Key messages
“Philippines”, “Indonesia”, “Vietnam”, “Laos”, “Lao PDR”, “Cambodia”, “Myanmar,” or • Chronic non-communicable diseases are a major public
“southeast Asia”. From this strategy, we tracked reports on five national surveys of health problem in southeast Asia
non-communicable diseases undertaken in Thailand,5 Singapore,6 Malaysia,7 the Philippines,8 • These conditions (and their risk factors) are strongly
and Vietnam.9 However, variations in study population, sampling design, and operational linked to poverty, and are a major drain on the economy
definitions did not allow meaningful comparison or cross-country aggregation. because of avoidable morbidity and mortality
We also did a search of WHO resources and databases, and this search yielded information • Modifiable risk factors are increasing in low-income
that was more comparable. We obtained data for mortality using estimates from the Global populations because of unplanned urbanisation,
Burden of Disease database. Information from this database was limited by the fact that data marketing of unhealthy food, and inadequacies in public
from vital registration was available for only three countries (Brunei, Singapore, and health policies
Thailand). Best estimates from modelled data were used for the eight remaining countries.2 • Surveillance of chronic non-communicable diseases and
Similarly limited data for biological risk factors were mainly obtained from the WHO Global their risk factors needs to be improved, along with
InfoBase,10 in which age-adjusted projections on overweight (body-mass index ≥25 kg/m²), monitoring of the policy environment, to enable
systolic blood pressure, and cholesterol concentration were estimated for men and women countries to keep track of the effects of interventions
in 2010. Information about tobacco use and economic data for tobacco were the most • Health-care systems have to be strengthened to address
reliable. These data were obtained from the MPOWER Report on the Global Tobacco the needs of chronic non-communicable diseases through
Epidemic.11 In selected southeast Asian countries, income-quintile-specific estimates of the primary health care and appropriate referral systems
prevalence of daily smoking, inadequate intake of fruit and vegetables (fewer than five • All branches of government and all sectors of society need
servings of fruit or vegetable in a typical day), and insufficient physical activity (less than to be involved in creating an environment that is
150 min per week spent on walking or moderate to vigorous activity during the past 7 days) conducive to healthy living, in which healthy choices
were obtained from the World Health Survey database. become easy choices

680 www.thelancet.com Vol 377 February 19, 2011

 Series

which is characterised by a reduction in deaths from com- Death, disability, and economic burden Department of Medicine,
municable diseases, an increase in average life expectancy, On the basis of Global Burden of Disease projections, an College of Medicine, University
of the Philippines, Manila,
and an epidemic rise in chronic non-communicable estimated 2·6 million people from the ten ASEAN Philippines (Prof A Dans MD);
diseases such as heart disease, stroke, cancer, and chronic countries died from chronic non-communicable diseases Department of Public Health
obstructive pulmonary disease (COPD).2–4 These diseases in 2005. The numbers were similar for men and women, and Clinical Medicine,
threaten a rapidly growing population of almost 600 mil- and accounted for nearly 61·5% of the total deaths in Epidemiology and Global
Health, Umeå University,
lion people in the region, most of whom are younger than these countries. With the ageing of these populations Umeå, Sweden (N Ng PhD);
65 years and are within the most productive years of their and increasing exposure to risk factors for non- Department of Public Health,
lives. Many have insufficient resources to deal with chronic communicable diseases, the numbers are projected to Faculty of Medicine, Gadjah
illness and premature death—a situation that threatens increase to 4·2 million deaths in 2030.13 When adjusted Mada University, Yogyakarta,
Indonesia (N Ng); Western
not only families, but also entire economies.1 Urgent action for age, the proportions of deaths due to chronic non- Pacific Regional Office, WHO,
is needed and southeast Asia—represented by the communicable diseases in the southeast Asian Manila, Philippines
geopolitical Association of Southeast Asian Nations population aged 15 years and older was greatest in (C Varghese MD); Division of
(ASEAN)—is uniquely poised to take a strong and united countries with the highest gross national incomes such Endocrinology, Department of
stance against chronic non-communicable diseases. as Singapore, Brunei, and Malaysia (figure 2A). However, Medicine, Yong Loo Lin School
of Medicine, National
Despite the importance of knowledge about the patterns the age-adjusted death rates per 100 000 population were University of Singapore,
and burden of chronic non-communicable diseases and greatest in low-income countries such as Myanmar, Singapore (E S Tai MB ChB);
the risk factors that predict them, such data are sparse for Cambodia, Laos, and Vietnam (figure 2B). Furthermore, China Medical Board and
southeast Asian countries. We attempt to provide about 30% of all deaths from non-communicable Harvard Global Equity
Initiative, Cambridge, MA, USA
information that will help draw attention to the problem diseases occurred in people aged 15–59 years. These (R Firestone ScD); and School of
and direct efforts to curb the epidemic (see panel for deaths represent premature and preventable mortality Population Health, University
search strategy5–11). Our specific objectives are: to in a highly productive age group—the labour force of of Auckland, Auckland, New
characterise and compare the burden of chronic non- southeast Asia. In this age group, chronic non- Zealand (Prof R Bonita PhD)

communicable diseases and their risk factors in southeast communicable diseases accounted for 51% of deaths in Correspondence to:
Prof Antonio Dans, Department
Asia, with special attention to disadvantaged populations; these ten countries.2 of Medicine, College of Medicine,
to describe national responses in line with global and In terms of disability, chronic non-communicable University of the Philippines,
regional initiatives; and to suggest feasible and disease was estimated to account for 61% of total Manila 1000, Philippines
comprehensive approaches to prevention and control of disability-adjusted life years in people aged 15–59 years, tdans@skybroadband.com.ph

non-communicable disease in this region. and 84% of the burden in those aged 60 years and older
In this paper, we use the term chronic non-communicable in 2008. The burden is expected to rise to 74% and 89%, For more on the World Health
Survey see http://www.who.int/
disease to refer to major chronic disorders such as heart respectively, by the year 2030.2 These estimates were
healthinfo/survey/en/
disease, stroke, cancer, and COPD. These diseases share based on the assumption that risk factor exposures,
common, modifiable risk factors, as shown in the causal particularly tobacco use and being overweight or obese,
For the World Bank website see
pathway in figure 1. Neuropsychiatric disorders (other than will fall with economic development and improving http://www.worldbank.org
stroke) and chronic illnesses related to infectious processes health systems in countries with low and middle incomes.
(such as hepatitis B or human papillomavirus infection) Should this assumption not be met, the future burden
are not covered in this paper. Mortality, morbidity, and the from chronic non-communicable diseases is expected to
economic burden of chronic non-communicable diseases be larger than has been predicted.
will be described and comparable estimates of prevalence Death and disability from chronic non-communicable
of key modifiable biological and behavioural risk factors diseases can exert an economic burden in two ways—
will be presented. Environmental risk factors such as indirectly, through loss of productivity and income, and
globalisation, urbanisation, and poverty have been directly, through household spending on chronic
discussed in the first paper1 in this Lancet Series on health medical care, often of catastrophic proportions.15 This
in southeast Asia. We will also investigate to some extent situation has serious consequences not only at the
their role in the non-communicable disease epidemic. household level, but nationally as well.16 Using an
On the basis of World Bank income groups, the ten
countries in the southeast Asian region include four
economies with low incomes (Cambodia, Laos,
Myanmar, and Vietnam), three with lower middle Globalisation Tobacco use High blood glucose Heart disease
incomes (Indonesia, the Philippines, and Thailand), Urbanisation Unhealthy diet High blood pressure Stroke
Poverty Physical inactivity Abnormal serum lipids Cancer
one with an upper middle income (Malaysia), and two Low education High waist-hip ratio Chronic lung disease
with high incomes (Brunei and Singapore). These Stress Abnormal lung function
countries have large disparities in social, political, and Environmental Behavioural Biological risk Chronic
economic conditions,1 ranging from Myanmar, which risk factors risk factors factors non-communicable
has a gross national income of 1290 international disease

dollars, to Brunei, which has a gross national income of Figure 1: The causation pathway for chronic non-communicable disease
49 900 international dollars. Modified from reference 12.

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A
abnormal serum lipid concentrations.28 All four con-
90 ditions are on the rise in southeast Asia.
Brunei Table 1 shows the prevalence of these four risk factors
NCD deaths as proportion of total deaths (%)

80 in different countries ranked according to gross national

Singapore income. Indonesia (a middle-income country) had one of
Vietnam Malaysia
70
the highest mean levels of systolic blood pressure for men
Philippines
and women, whereas Brunei (a high-income country) had
Myanmar Thailand
Indonesia
values close to the average for the region. For total
60 Laos
cholesterol, the highest mean concentrations were seen
Cambodia
in Vietnam (a low-income country) in both men and
50
women. Mean concentrations in two high-income
countries (Brunei and Singapore) were only second to
40
those in Vietnam. Diabetes seemed to be the only risk
factor with a clear relation to affluence of a nation.
0
Diabetes prevalence was highest in Brunei, Malaysia, and
B Singapore (10·2–12·6%), and lowest in Myanmar,
900 Cambodia, Laos, Vietnam, and Indonesia (3·2–5·6%).
Myanmar
Studies show that waist-to-hip ratio is a better predictor
Laos
800 of coronary disease than is body-mass index.23 However,
NCD death rate per 100 000 population

Cambodia
Indonesia
700
Vietnam Malaysia
Thailand
600 Philippines
500
400
0
5 10 20 30 40
Gross national income, international dollars×103
Figure 2: Gross national income versus age-adjusted mortality from NCDs, as proportion of total deaths (A) and
as death rate per 100 000 population (B), in the southeast Asian population aged 15 years and older, 2004
Population estimates were obtained from reference 14, and data for NCD mortality from reference 2.
NCD=non-communicable disease.
economic growth model that assessed the effect of
chronic diseases on national income through changes
in key inputs such as labour supply and savings,
See Online for webappendix investigators estimated that a total of seven billion US$
would be lost between 2006 and 2015 because of chronic
non-communicable diseases from just five ASEAN
countries: Myanmar, Indonesia, the Philippines,
Thailand, and Vietnam. These estimates are conservative
because they did not include cancer and COPD, medical
expenses from treatment and rehabilitation, and indirect
costs from illness.16
Risk factors
A small number of risk factors17,18 account for a large
proportion of the global burden of chronic non-
communicable diseases (figure 1). Data from the Asia-
Pacific Cohort Studies Collaboration suggest that these
risk factors have the same effects in Asian populations as
in others.19 These risk factors include raised blood
pressure,20 high body-mass index (BMI) or waist-to-
hip ratio,21–25 raised blood sugar concentrations,26,27 and
we found no comparable national data for obesity based
on waist-to-hip ratio. We did find data for obesity based
on BMI, and again, there was no clear relation with gross
national income. The highest prevalence of being
overweight was seen in the country with the highest
gross national income, Brunei. However, the next highest
Brunei
rates were seen in two low-income countries, Myanmar
Singapore and Laos.
Three major behavioural risk factors that predict non-
communicable diseases are tobacco use, inadequate
50 60 70 80 intake of fruit and vegetables, and insufficient physical
activity. These risk factors are modifiable and are amen-
able to cost-effective population-wide interventions.29
Figure 3 shows the prevalence of these risk factors across
different wealth quintiles in five southeast Asian
countries that participated in the World Health Survey.
Tobacco use is the single most important cause of death
and disability from chronic non-communicable disease.
The prevalence of current tobacco use in adult men
ranged from 36% in Singapore to 64% in Laos
(webappendix). In women, prevalence was generally low,
ranging from 2% in Vietnam and Thailand, to 15% in
Myanmar and Laos. Among children aged 13–15 years,
smoking was very common, especially in the Philippines
(28% in boys and 17% in girls).11
In 2007, the population of the ASEAN countries
consumed about 488 billion cigarettes—8% of world
cigarette production (webappendix).30 The lowest per
head annual cigarette consumptions were reported in
Myanmar (209 cigarettes) and Singapore (406 cigarettes),
whereas the highest consumptions were recorded in
Indonesia (974 cigarettes) and the Philippines
(1073 cigarettes). The prevalence of smoking was
inversely related to socioeconomic status within each
country. Smoking was twice as prevalent in the least
wealthy groups compared with the wealthiest group, and
the trend was consistent in Malaysia, Philippines, Laos,
Vietnam, and Myanmar (figure 3). These findings

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 Series

Age-adjusted estimated Age-adjusted estimated mean Age-adjusted estimated Age-adjusted estimated Age-adjusted estimated
prevalence of diabetes in systolic blood pressure in people mean cholesterol in people proportion of BMI ≥25 kg/m2 in proportion of BMI ≥30 kg/m2 in
people aged 20–79 years (%)† 15 years and older (mm Hg)‡ 15 years and older (mmol/L)‡ people 15 years and older (%)‡ people 15 years and older (%)‡
Men Women Men Women Men Women Men Women
Brunei 12·6% 120·0 118·3 5·4 5·4 58·1% 65·2% 16·6% 29·7%
Singapore 10·2% 124·3 119·1 5·4 5·3 24·1% 26·7% 1·4% 2·9%
Malaysia 11·6% 118·1 117·0 5·2 5·2 23·0% 42·2% 1·7% 11·0%
Thailand 7·1% 119·3 117·3 5·2 5·4 28·3% 39·9% 2·6% 11·1%
Philippines 7·7% 121·9 116·8 4·5 4·5 22·2% 33·6 % 1·1% 5·5%
Indonesia 4·8% 123·3 123·3 4·6 4·6 9·9% 27·1% 0·2% 3·9%
Vietnam 3·5% 119·6 116·7 5·6 5·4 7·5% 12·2% 0 0·7%
Laos 5·6% 119·7 112·5 5·1 5·1 34·9% 49·2% 3·3% 12·6%
Cambodia 5·2% 119·7 112·5 5·1 5·1 21·4% 13·8% 0·5% 0·4%
Myanmar 3·2% 120·6 114·3 5·1 5·1 32·3% 47·0% 2·7% 11·3%

BMI=body-mass index. *Countries ranked according to decreasing gross national income. †Data are from the International Diabetes Federation’s Diabetes Atlas .‡Data are from the WHO Global INFOBASE.10

Table 1: Estimates of prevalence and levels of biological risk factors in men and women in southeast Asia, 2010*

suggest that the poorest populations are most susceptible For the Diabetes Atlas see
A Prevalence of current daily smokers
to the hazards of tobacco use.12 50
http://www.diabetesatlas.org/
Chronic non-communicable diseases also result from
40
unhealthy dietary patterns such as high energy intake
Prevalence (%)

from total fats, excessive use of cooking oil with high 30

saturated fat (including indigenous oils such as palm oil 20
and coconut oil), high consumption of sugars and
10
sweetened beverages, high intake of dietary salt, and low
consumption of fruit and vegetables.31 Despite its 0
importance, reliable epidemiological data for salt B Prevalence of insufficient fruit and vegetable consumption
consumption in southeast Asia are scarce. Traditional 100
dietary practice is likely to be high in salt and is aggravated 80
by the rising commercialisation of fast foods and processed
Prevalence (%)

60
foods. In the Philippines, for example, the national average
of salt intake is 7–15 g per day,32 up to three times higher 40
than recommended levels of consumption. By contrast 20
with many European and North American countries,
0
where the main sources of dietary salt are from processed
foods, restaurant services, and catering, the main sources C Prevalence of insufficient physical activity
20
in southeast Asia are added sauces used in cooking, which
are available in a wide range of forms such as soy sauce, 15
Prevalence (%)

fish sauce, and shrimp paste.

Although many areas in the region are not yet 10
urbanised, consumption of fruit and vegetables is low in
5
southeast Asia. More than 80% of the population
consumes fewer than five servings of fruits and vege- 0
tables per day. Apart from the Philippines, insufficient Malaysia Philippines Vietnam Laos Myanmar
consumption was higher in the lowest quintiles of wealth Q1 (least wealthy) Q3 Q5 (most wealthy)
compared with higher quintiles (figure 3). These data are Q2 Q4

consistent with results of recent subnational district-level
studies in the Health and Demographic Surveillance
System (HDSS) settings within the International Network
for the Demographic Evaluation of Populations and Their
Health (INDEPTH) in Developing Countries, which
reports that more than 74% of the rural population of
Thailand and Vietnam and 91% of the Indonesian
population do not consume sufficient fruit and
vegetables.33 Corollary to these data, an increase has been
Figure 3: Prevalence of behavioural risk factors across income quintiles in
selected southeast Asian countries in 2003
Data are from World Health Survey 2003 country reports.
noted in calorie intake from sources such as sugar-
sweetened beverages.34 The bulk of calories consumed
are produced by large national or regional companies or
small, medium, and informal sector operators. These
companies represent substantial economic interests in

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 Series

the region, and so regulation of marketing, nutrient
quality, and food safety is difficult. Additionally, although
ASEAN countries contributed to only 3% of the global
non-alcoholic, sweetened, or flavoured water import
statistics, the import has grown by more than 2000% in
the past 5 years in Vietnam, Myanmar, and Cambodia.
These emerging economies have become the focus of
marketing efforts of transnational food industries. In
Laos, data showed a massive increase in sweetened and
flavoured beverage import during the past 5 years, with a
trade value of US$16·5 million.35
Inadequate physical activity was not widespread in the
southeast Asian countries shown in figure 3. The
problem was greatest in Malaysia, where the prevalence
of physical inactivity was greater than 15% across all
wealth quintiles. The lowest prevalences were observed
in the Philippines and Vietnam. As expected, prevalence
rates were highest in the wealthiest quintiles, possibly as
a consequence of urbanisation and changes in transport
patterns. On the basis of standardised WHO STEP-wise
approach to Surveillance (STEPS) methods,36,37 the
reported prevalence of physical inactivity was 13% in the
INDEPTH HDSS site in Vietnam, 19% in Indonesia,
and 20% in Thailand.33
Responses to chronic disease in southeast Asia
Several WHO initiatives have drawn attention to the high
burden of non-communicable diseases and the importance
of intervention to curb this epidemic. The global call for
prevention and control of non-communicable diseases
has been spearheaded by the Framework Convention on
Tobacco Control38 and the Global Strategy on Diet, Physical
Activity and Health,39 and, more recently, the WHO
2008–2013 Action Plan for the Global Strategy for the
Prevention and Control of Noncommunicable Diseases.40
This action plan, together with regional plans for
prevention and control of non-communicable diseases,41,42
offer guidance to countries to establish national strategies.
Table 2 summarises country reports on selected indicators
of national capacity in response to the epidemic of chronic
non-communicable diseases, including existence of an
operational integrated strategy for these diseases; an
operational strategy for behavioural risk factors;
population-based data for non-communicable diseases in
national health reporting systems; and population
coverage by insurance for services related to non-
communicable-diseases.
The data shown in table 2 suggest that individual
countries are beginning to respond to the burden of non-
communicable diseases. With the exception of a few,
most countries report that national policies and
programmes are being launched, governance structures
are improving, dedicated non-communicable disease
units are being established in ministries of health, and
policies for behavioural change—both population-wide
through legislation and regulation and at a personal
level—are being promoted. The most common
deficiencies are inadequate surveillance for diseases, risk
factors, and outcomes (especially mortality), and
inadequate coverage by insurance, but even here, pockets
of activity are emerging. Many of these efforts are in their
infancy, but a few case studies are worth describing.
In the Philippines, after much collaboration and
consultation, an integrated prevention and control
programme for non-communicable diseases has been
approved and is underway. The major feature of this
programme is a multisectoral approach to control of
behavioural risk factors, involving not only the national
health office, but smaller regional, provincial, and
municipal health units. Local communities have actively
participated, coming up with creative ideas for disease
control. Other stakeholders outside the health sector
(education, agriculture, the food industry, social welfare,
and public works) are also actively engaged.43

Existing operational Existing operational strategy for specific Existing population-based data for NCDs in Population covered by insurance
integrated NCD strategy behavioural risk factors the national health reporting system for NCD-related services
Unhealthy diet Physical inactivity Tobacco Cause-specific mortality NCD risk factors
related to NCDs
Brunei No Yes No Yes Yes No No
Singapore Yes Yes Yes Yes Yes Yes Yes (data for % NA)
Malaysia Yes Yes Yes Yes No Yes Yes (100%)
Thailand Yes Yes Yes Yes Yes Yes Yes (100%)
Philippines Yes No No Yes No Yes Yes (20–50%)
Indonesia Yes Yes No Yes Yes Yes Yes (20–50%)
Vietnam Yes No No Yes No No Yes (20–50%)
Laos No NA NA No No Yes Yes (5%)
Cambodia Yes No No Yes No No No
Myanmar No Yes No Yes No Yes No

Data are preliminary results from the ongoing WHO global survey on NCD country capacity, June 2010 (Riley L, WHO, Geneva, Switzerland, personal communication). NCD=non-communicable disease. NA=not
available. *Countries ranked according to decreasing gross national income.

Table 2: National capacities for control of NCDs in southeast Asia*

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In Thailand, collaboration with lawmakers has had
great success in the realm of tobacco control. In addition
to a strict marketing ban, implementation of health
warnings, clean air measures, and a strong media
campaign, the country successfully increased government
levies on cigarettes to 83·5%, representing 57% of the
actual retail pack price. These strategies reduced smoking
rates from 30% in 1992, to 18% in 2007, preventing an
estimated 31 867 smoking-attributable deaths in 2006.44
Additionally, this policy has earned huge sums for the
Thai Health Promotion Foundation through an
earmarked 2% excise tax, which produces annual
revenues of about US$35 million.11
A further example of an effective control strategy
comes from Singapore, where a National Healthy
Lifestyle Programme was launched in 1992. Key
strategies to promote a healthy lifestyle included
community empowerment and collaboration with
public, private, and community organisations. Activities
were monitored by national surveys in 1992, 1998, and
2004. These surveys showed an increase in regular
exercise and reductions in the prevalence of diabetes,
high cholesterol, and smoking. The prevalence of
obesity and hypertension were also reduced or main-
tained. Application of Singapore’s experience in less
affluent countries with varying sociopolitical contexts is
a challenge. Nevertheless, the programme is an
excellent example of how a few carefully chosen, cost-
effective measures can lead to important changes in
population levels of key risk factors for chronic non-
communicable disease.6
Discussion
We have reported the burden from chronic non-
communicable disease and its risk factors in southeast
Asia. Although studies show that the relative importance
of these risk factors are similar in countries around the
world, some aggravating factors in the southeast Asian
population might be worth emphasising. First, diabetes
prevalence is peaking faster in many Asian countries
than it is elsewhere. Between 1970 and 2005, the
prevalence of diabetes quadrupled in Indonesia, Thailand,
India, and China compared with an increase of only
1·5 times in the USA.22 This difference is likely to be the
result of a rapid change in lifestyle brought about by
urbanisation and globalisation in southeast Asia.
Second, obesity (especially abdominal obesity) might be
more important in people of southeast Asian origin than
in those from other parts of the world. In the
INTERHEART study, waist-to-hip ratio was a better
predictor of coronary disease than was BMI.23 This finding
was especially true in southeast Asian people, in whom a
high waist-to-hip ratio (>0·83 in women and >0·90 in
men) increased the likelihood of coronary disease almost
four times (OR 3·63, 95% CI 2·91–4·52) compared with a
two-fold rise in the world population (OR 1·77, 1·67–1·88).
Additionally, the prevalence of obesity in southeast Asian
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people in the control group of the INTERHEART study
was only 5·7% when a BMI greater than 30 kg/m² was
used as the definition. This result increased ten times to
57% when a high waist-to-hip ratio was used.23
Third, high blood pressure might have special
importance in the causation of chronic non-
communicable disease in southeast Asia. The likelihood
of acute myocardial infarction was six times higher
(OR 5·6, 99% CI 4·3–7·5) in southeast Asian populations
with self-reported hypertension as compared with less
than a three-fold rise (OR 2·5, 99% CI 2·3–2·7) in the
world population.17
Fourth, Asian populations have lower mean LDL
cholesterol concentrations but a similar risk of acute
myocardial infarction attributable to LDL cholesterol
compared with those of non-Asian populations.18 In the
Asia-Pacific Cohort Studies Collaboration, triglyceride
and HDL cholesterol had higher predictive values for
coronary heart disease and cardiovascular diseases than
did total cholesterol alone.28
Fifth, and last, although the prevalence of obesity is
increasing in the region, there is a paradoxical persistence
of undernutrition. In Laos, for example, where 39% of
the population live below the national poverty line, more
than 21% of the total population are undernourished,45
yet 35% of men and 49% of women are overweight. This
double burden of malnutrition (undernutrition and
overnutrition)46 presents a difficult public health challenge
for poorer countries in the region because catch-up
weight gain after perinatal and postnatal growth
restriction has been postulated to increase risk of diabetes
and cardiovascular disease.47
Together with globalisation and urbanisation,
idiosyncrasies in biological risk factors among southeast
Asian populations have resulted in an unprecedented
burden of chronic non-communicable diseases in the
region. The situation reflects a failure to anticipate and to
control the epidemic, and a failure to mount a timely
response. Many factors are responsible for the limitation
in chronic non-communicable disease control in
southeast Asia. One major problem is the weakness of
health information systems for chronic non-
communicable diseases in most countries in the region.
Although we report on the burden from non-
communicable disease in these countries, the estimates
are based on modelled data from WHO. In fact, not all
these countries collect cause-specific mortality data, or
are committed to regular surveillance of risk factors that
predict non-communicable disease.
Another difficulty is that, similar to surveillance
systems, health-care delivery systems in southeast Asia
evolved to deal with the acute nature of most infectious
diseases. Workforce and infrastructure have not been
designed to deliver chronic care services required for
treatment and control of non-communicable diseases.
One glaring consequence of this fact is the unexpected
finding that deaths from non-communicable diseases in
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For the Lancet Series on chronic
diseases and development see
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series/chronic-diseases-and-
development
686
the region are highest in countries that are economically
poor. If this inequity is to be corrected, health-care
delivery has to be restructured in a manner that
maximises use of scarce resources and strikes a careful
balance between public health interventions and clinical
services. Public health interventions have an advantage
in that they do not entail investments in expensive
equipment and drugs. However, they do require a strong
determination to implement the policies.48
A further challenge is that, although we are witnessing
the emergence of national policies and non-communicable
disease control programmes in the region, these efforts
have yet to gain significant momentum. Funding for
control is low, human resources are inadequate, and
support from national leadership could be stronger. The
role of the international community in support of
national will is crucial. The Millennium Development
Goals successfully rallied leaders to focus attention on
the plight of the world’s poorest, especially children and
mothers.49 Unfortunately, chronic non-communicable
diseases were not included when the goals were
established, resulting in failure of international agencies
to provide adequate funding commensurate with the
non-communicable disease burden. There are signs of
improvement. The US Institute of Medicine, for example,
recently called for a greater focus on salt reduction as the
most appropriate solution to raised blood pressure in
developing countries.31 The Bloomberg Initiative and the
Bill & Melinda Gates Foundation have placed significant
funds into tobacco control.50,51 In September, 2011, a
special high-level session on non-communicable diseases
will be held at the UN General Assembly. This meeting
represents a unique opportunity for ASEAN countries to
make a unified stand.
The way forward
Because of the effect on health and productivity of the
population, the epidemic of non-communicable disease
in southeast Asia requires urgent attention. Many
countries in the region are still trying to cope with old
infectious diseases as well as new and emerging
infections. If neglected, however, chronic non-
communicable diseases could threaten national
development and ultimately jeopardise the capacity of
nations to respond to health needs at large. Therefore, a
comprehensive and coherent non-communicable disease
programme cannot await control of communicable
diseases. Both must take place at the same time.12
Building on global and regional action plans for
prevention and control of non-communicable diseases,
we propose four strategies for moving forward, each of
which could be started through a basic package of core
interventions, tailored to suit national capacity according
to the resources required to implement them.40–42 As more
resources become available for health, these strategies
can be gradually scaled up to cover expanded interventions
that cost more.12
If control of chronic non-communicable disease is to
become a priority in southeast Asia, countries in the
region need to improve the quality and coverage of
death certificate information and undertake regular
surveillance that will measure the population levels of
risk, establish trends over time, and evaluate the
effectiveness of control measures.52 To usefully guide
policy, however, such surveillance has to generate
reliable and comparable estimates of mortality and
economic burden arising from non-communicable
disease, including the prevalence of biological and
behavioural risk factors. The WHO STEPS approach36
offers feasible, affordable, and standardised methods to
track trends in population levels of a few key modifiable
risk factors. Apart from Brunei, all southeast Asian
countries have undertaken at least a baseline STEPS or
STEPS-equivalent survey, and are using the data to
inform programmes and policy for non-communicable
disease prevention and control.
In addition to surveillance, operational research is also
needed that will evaluate which public health strategies
work and which do not. Such studies are essential
because the region faces unique problems in non-
communicable disease control such as salt consumption
from a wide range of dietary sources, double burden
from malnutrition and obesity, abdominal obesity (on
the basis of waist-to-hip ratio), an epidemic of diabetes,
and a high prevalence of tobacco use among children.
These are areas of research in which scientists in the
region can lead the way.
Rather than develop a separate system for care, non-
communicable disease control programmes need to be
integrated into existing systems to achieve synergy with
competing national health priorities.53 This process will
require reforms in health-care delivery, financing, and
manpower training. The package of care to be provided
should be comprehensive, providing public health
services and programmes that promote healthy
behaviours as well as clinical services for chronic care of
patients with non-communicable disease or who have
risk factors for these disorders,54 as shown in figure 1.
Great gains can be made from a few, well selected
population-based strategies for non-communicable
disease control. Interventions to reduce salt consumption
and tobacco use, for example, have been estimated to
cost only US$0·40 and US$1·00 per person per year,
respectively, while preventing hundreds of thousands of
deaths from non-communicable disease in the region
(table 3).29,55 Similarly, provision of chronic care need not
be expensive. Clinical interventions can be cost effective,
even in low-income countries. Scaling up of the use of a
multidrug regimen with off-patent drugs (aspirin,
β blockers, thiazide diuretic agents, angiotensin-
converting enzyme inhibitors, and statins) with simple
algorithms to identify and treat patients at a high absolute
risk of chronic disease (15% or more over 10 years), would
have a major effect in lowering of total non-communicable
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 Series

Cumulative NCD deaths Combined cost of smoking Voluntary salt reduction Total cost of selected Total cost as proportion of government health
averted (over 10 years)* intervention† (processed foods)‡ interventions spending
Total cost Cost per Total cost Cost per Total cost Cost per Government health Total cost as proportion of
(US$) person per (US$) person per (US$) person per spending per head government health
year (US$) year (US$) year (US$) (US$) spending (%)
Thailand 310 000 10 856 979 0·17 3 630 038 0·06 14 487 018 0·23 47 0·5%
Philippines 317 000 9 907 662 0·13 3 909 945 0·05 13 817 607 0·18 14 1·3%
Indonesia 1 173 000 25 437 702 0·12 8 636 796 0·04 34 074 498 0·16 11 1·5%
Vietnam 378 000 8 901 192 0·11 3 382 112 0·04 12 283 304 0·16 7 2·2%
Myanmar 359 000 5 220 327 0·11 1 775 208 0·04 6 995 536 0·15 77 0·2%

Data extracted from reference 29. The five countries shown in this table were among the 23 high-NCD-burden countries examined as part of a study investigating the health effects and costs of implementing
common interventions to prevent chronic diseases. All costs are shown in US$ (2005). NCD=non-communicable disease. *On the assumption of a 2% per year reduction in NCD death rates. †Smoking
interventions included a revised tobacco tax system, tobacco information and antismoking advertising, smoking restrictions, and bans of advertising. ‡Salt intervention consisted of a voluntary reduction
of 15%, including in processed foods.

Table 3: Estimated annual expenditure for implementation of strategies to reduce salt intake and control tobacco use in selected countries

disease deaths. The total cost would only be US$1·08 per
head per year.56 Making this strategy work would require
national guidelines that set treatment thresholds on the
basis of social values and resources available, rather than
arbitrary thresholds used in wealthy countries.57
Additionally, in low-resource settings, the availability,
affordability, and accessibility of low-cost generic drugs
needs to increase and requirements for laboratory
monitoring minimised (eg, by preferential use of drugs
that do not require regular blood tests, such as β blockers
and, possibly, low-dose diuretic agents).
Defined administrative areas such as cities and
provinces with local governance are well suited to
introduce multisectoral interventions—for example,
implementation of the key elements of the Framework
Convention on Tobacco Control, restriction on the use of
trans fatty acids, provision of pedestrian pathways, food
labelling, and salt reduction. Involvement of opinion
leaders and role models can be beneficial in campaigns
to promote community awareness and knowledge so that
tobacco use can be stopped, physical activity can increase,
and dietary habits can be improved. Strategies that
consider the double burden of malnutrition should be
developed—for example, improving food diversity and
increasing income through agricultural productivity.58
There is also a need to work with local and national food
industries to develop foods that are healthier. Such
collaborations have to be shown to open up new markets
for products and lead to a positive effect commercially.59
Involvement of the urban design and transport sector in
healthy city planning should also be an integral part of
intervention strategies, since increasing urbanisation in
southeast Asia will result in a substantial proportion of
the population living in cities.
Workplaces in private and public organisations offer
another avenue for sustained interventions for prevention
of non-communicable diseases. Healthy workplaces
that have smoke-free policies, healthy diet options,
and facilities for physical activity supported by the
management can go a long way towards shaping the
behaviour and health outcomes of the employees. These
interventions could potentially result in prevention of
non-communicable diseases in the workforce, and could
eventually lead to reduction in sickness, absenteeism, and
medical expenses, and an increase in employee
productivity. A parallel plan can be developed in schools
and in urban and rural communities.
A strong and sustainable national programme for
prevention and control of chronic non-communicable
disease needs to be championed by informed leaders
who are committed to confront difficult situations—for
example, vested interests of tobacco and other market
forces that promote unhealthy habits. Leadership has to
come not only from the health sector, but also from other
sectors, including heads of other ministries or
departments, lawmakers, heads of local government,
and even heads of state. Donors, development partners,
and financial institutions that are involved in health and
development need to consider the economic implications
of an uncontrolled non-communicable disease epidemic
and should prioritise non-communicable disease
prevention and control in their programmes. Civil
society, including coalitions of affected individuals
and their families, should play a major part in
holding governments accountable for delivering on
non-communicable disease commitments.
Leaders in regional alliances such as ASEAN can have
an important role in taking the non-communicable
disease agenda forward. One opportunity to do this is at
the UN High-level meeting on non-communicable
disease in September, 2011.60 A good start has also been
made with the conduct of regular Health Minister’s
meetings. However, health should also be reflected in all
trade and development policies and programmes. High-
income countries in the region carry a greater
responsibility than do those with low incomes, and
should lead the way in this effort. After all, a major goal
of the association is “to alleviate poverty and narrow the
development gap through mutual assistance and
cooperation”.61

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 Series
In conclusion, countries in southeast Asia have spent
very little resources addressing the major health and
development issue of chronic non-communicable
disease. A health crisis is transpiring right before our
eyes. Unless nations recognise the problem and take
appropriate action, premature death and disability will
continue, hindering development where development
is needed most. Inaction affects millions of lives—and
often, we are speaking of the lives of those who have
the least.
Contributors
The authors set the objectives of the paper together from the beginning
and contributed to the search for relevant literature. Tables and graphs
were envisioned as a group, but were produced by NN. Analysis and
interpretation was discussed in face-to-face meetings, skype conferences,
phone calls, or email. The initial draft of the paper was prepared by the
lead author (AD), and then circulated repeatedly until all agreed on a
final version.
Conflicts of interest
RF receives honoraria for her work with the China Medical Board. AD
reports receiving a research grant from AstraZeneca, related to a study
that involves a statin. He also received a research grant and honoraria for
lectures from Boehringer Ingelheim, related to a study on an
angiotensin-converting enzyme inhibitor. EST is a member of several
advisory boards on dyslipidaemia for Merck Sharpe and Dohme, on
liraglutide for Novo Nordisk Pharma, and on diabetes for AstraZeneca
and Bristol-Myers Squibb. He is the recipient of a research grant from
Pfizer, and has received honoraria for lectures from
Merck Schering-Plough, GlaxoSmithKline, and Abbott Manufacturing.
NN, CV, and RB declare that they have no conflicts of interest.
Acknowledgments
The paper is part of a Series funded by the China Medical Board, the
Rockefeller Foundation, and Atlantic Philanthropies. China Medical
Board organised the writing teams, set standards and directions, then
monitored progress and compliance with deadlines. None of the funders
were involved in data collection, analysis, or write-up. No honoraria were
paid for writing of this paper, and the final responsibility for submission
belonged to the authors. Views expressed in this report are those of the
authors and are not the policies or positions of the organisations that
they represent. We thank Leanne Riley from the Department of Chronic
Diseases and Health Promotion of the World Health Organization in
Geneva, Switzerland, for her untiring help in developing table 2 from
various country reports.
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