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World Heart Day on the 29th of September puts cardiovascular disease and prevention in the spotlight. And specific to Malaysia, we have new findings that point to a significant burden of interconnected cardiovascular, renal, and metabolic risks. So, what needs to change in the way we design cardiovascular care? And are patients and caregivers part of those decisions? On this episode of #ConsiderThis Melisa Idris speaks with Professor Dr Murallitharan M., Managing Director of National Cancer Society Malaysia, and Rostam Said, President of Pertubuhan Teras Jantung Malaysia.
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00:10Hello and good evening. I'm Melissa Idris. Welcome to Consider This. This is the show
00:14where we want you to consider and reconsider what you know of the news of the day. World
00:19Heart Day is on 29th of September and it puts cardiovascular disease and prevention in the
00:24spotlight. And specific to Malaysia, we have now new findings that point to a significant burden
00:31of interconnectedness of cardiovascular, renal and metabolic risks. So what needs to change in
00:39the way we design cardiovascular care and are patients and caregivers also part of that design
00:45and decisions? Well joining me on the show today I have Professor Dr. Murali Tharan M who is the
00:50Managing Director of the National Cancer Society of Malaysia as well as Rostam Syed who is
00:56President of Pertubuhan Teras Jantung Malaysia. Welcome to the show both of you. Dr. Murali
01:01may I begin with you? You know when we talk about cardiovascular disease we often see it
01:07as just a heart problem right? But now we know it's or there's more awareness now about the
01:13interconnectedness of diabetes and obesity and hypertension kidney disease as well. All of that is happening
01:21rather than it being an isolated occurrence. So talk to me a little bit about that. I know you have
01:25had
01:26your Saring Community findings of your kind of a report. I found that very interesting. Tell us more.
01:33Okay so it's actually Melissa first of all really thank you for having me on. It's always a pleasure.
01:38I think we need to understand that you were right you were saying like we always think about the heart
01:44and isolation but actually it's a big plumbing problem. Plumbing problem. So why do I call it a
01:49plumbing problem? Essentially your heart pumps blood right and it goes through all these various pipes
01:53which we call blood vessels and then they're supplying blood to all these different houses
01:58your brain your liver your kidney you know and every one of these houses when your central piping is
02:07blocked there's always problems. So we're always talking about central piping heart and then heart
02:12as a heart attack and then we deal with it but there's all these different organs which also suffer
02:17from the same problem which is when the sediment in your pipes there's always blockages and all these
02:24different houses doesn't get a proper water supply exactly that right so when you get sediment sediment
02:31is formed by really cholesterol and and that's what causes all these damages to the to the kidney now
02:38we're seeing liver as well and then of course your brain and all these other peripheral organs like
02:44how to say if you crossed all of them then I we can deal with all your small organs
02:48okay people getting uh foot ulcers and so on so so so so why is it important that we see
02:53this as a
02:53plumbing problem as a a problem that you know the whole house it affects the whole house essentially
02:58because what we're doing is again we are um treat we are not treating blockages or we're not treating
03:05the sediment by right when we talk about prevention I I'm using the plumbing analogy because it it comes
03:12back to very basic things that we understand every now and then your toilet will get blocked right and then
03:17you
03:17have to pour every all these kind of things down like sealant and so on and decongest the the sludge
03:23right
03:23however really if if you were very honest we actually have to do preventive maintenance
03:28every now and then key case every now and then you flush it down yourself nobody does it right
03:32it's the same attitude that we bring to our bodies as well so we let the plug accumulate we get
03:38the
03:39we let the pipes get damaged uh through say hypertension as damages to the pipes and all these has an
03:46effect
03:46the problem is we are only dealing with it at the first heart attack most times and we can do
03:52something about it okay so prevention uh rusa let me bring you into this conversation the the medical
03:58fraternity has long known about the interconnectedness of this but are patients aware are people aware
04:04that this is actually all interconnected or is it like dr morelli said where we're only thinking
04:09about it after the first heart attack okay uh back to your points that's exactly right what we're missing
04:15here i think is the early early detection or early screening i think uh and the thing with malaysia is
04:25sadly it's getting younger and younger and younger and younger okay just to point out a few statistics that
04:33uh we found out after an epic report we are currently the youngest in the region to be getting diabetes
04:43to be diagnosed with diabetes
04:44we are like the youngest group in the region it's also because we're quite obese at the most obese country
04:51and the second point is we are the number one you know and i found out this when when we
05:00we just
05:00published this report you know the cardiovascular report uh region where six nations uh six nations uh get
05:08together and discuss uh problems regarding cvds uh i found out that heart attack uh average
05:19so you know we are getting it at i think it's 58 59 yeah you know i mean i i
05:27am partly responsible for
05:28bringing that statistic down because i i ken now when i was uh in my 50 you know i was
05:3350 when i
05:34i had definitely write down the the the but you know compared to like uh western world or other
05:42countries were like 10 years younger to get heart attack so i think early screening is like one of the
05:49most important things that we need to educate you know yeah dr marilly but screening is often presented
05:56as the answer to um kind of early detection and that solves the problem but talk to me about the
06:03reality
06:04when you identify someone who is high risk or has this has a first heart attack are how fragmented or
06:10difficult are the next steps how fragmented is that pathway if you're talking about the interconnectedness
06:15of crf okay so i'm going to go back into this interconnectedness of the cardiovascular renal metabolic
06:22thing because it's essentially when they say we hit the nail on the head we talk about screening and so
06:27actually we we are being a bit cautious when you say so screening first answer okay the second answer is
06:34then sustained intervention right so screening open the door first and then after that everything else comes
06:39right so the problem is uh people don't see themselves at risk and that's really why the
06:44both of us are here i think today because um when you look at and to come back to your
06:48first question
06:49initially right when you look at the heart in isolation and then you tell them that hey look your
06:54your hypertension is a bit bad cholesterol okay la cholesterol okay la uh you know and then you when
07:01you start throwing all these other risk factors actually it's not these two things uh your diabetes is
07:05is somewhere in between that's another kind of compounded risk and then your kidney is not doing
07:10well then people start to see that really actually it is not okay la it's actually very very not okay
07:15la
07:16you know so the idea behind us kind of now screening for cardiovascular renal metabolic uh kind of
07:22syndrome is to pick up things before you get disease and one of the big problems so here's where that
07:28the
07:28dichotomy is people don't like to act until um i'm sorry i i shouldn't use the word maybe i don't
07:36know
07:37what is this uh you know so uh and and that's a real problem so we will not act until
07:44that's like
07:45heart attack and then we want to do something about it so what we are trying to present i think
07:49in in
07:50in tandem is something very pretty which is for the first time we know that we look at cardiovascular
07:55renal metabolic before you ever have disease it's the flag you can see your risk much much earlier
08:03before it's too late for you to do something to ever start it happening in the first place so and
08:09that's what the point is yeah like my mantra now whenever i give a talk or share my experience is
08:15always ignorance is not a bliss okay you know in this matter ignorance is not a bliss because you need
08:20to you
08:21to find out you know it's better for you to find out that you're in stage one rather than stage
08:25four
08:26yeah because in stage one or pre-diabetic or pre-whatever you can still take uh you can reverse
08:32yeah okay so so what does that mean when you say it's better to to you can flag it right
08:37so what does
08:38that mean exactly okay so for example right when you start having um ckd chronic kidney disease right when you're
08:45in
08:45stage two three four it's already very difficult to reverse there's the we go back to the plumbing
08:50story your plumbing kidney is actually all your small small pipes when it's spoiled it's pot the
08:56end is is upon you but when you're starting to think about it from a cardiovascular renal metabolic
09:01linear perspective you start seeing at the syndrome level oh there's a bit of damage somewhere okay you
09:07already can start to reverse it so you act there before the damage is permanent and irreversible after
09:12that it's it's everything we're doing is just trying to catch the bus that has already left yeah
09:18yes sorry the message of prevention often lands on deaf ears because it requires lifestyle change
09:27i'm not at risk as you said earlier this is a future me problem so when you talk to people
09:32about your experience and the need for um prevention preventative care what do you say to them okay based
09:42from this driving cardiovascular action and pressure pacific the report you know uh yes
09:47pertubuhan teras jantung was originally intended for cvd patients and their caregivers but as i moved
09:55through the the you know whatever the situation of our cvd landscape here uh we found out that part of
10:03the
10:03thing that we put in here is the early education especially to young parents and prenatal you know oh
10:13it goes that yeah it goes that because you see we keep getting younger and younger patients right okay one
10:20of the
10:20things that i always you know try to stress is that we as a government as a malaysian government do
10:27you
10:27want to pay 300 million now or like 3 billion down the road you know we need to do something
10:32to
10:32prevent it because okay traditionally always like 50 plus 60 plus people go into the system our healthcare
10:40system with regard to cvd but now you're getting patients young as young as 20 plus and 30 plus into
10:47the
10:47system so can you imagine the burden that the system is yeah is experiencing because now instead of you
10:55you know you're focusing on the late life you know the golden ages you know seniors now you have to
11:01deal with the younger patients coming into the system that is built i'm sure it's not meant to hold
11:07like you know absolutely to sustain like yeah that's a very good point because with more education more
11:12awareness you also are um creating you know more people who want to feed into the system whether or not
11:19the healthcare system can absorb that additional demand is another question where does primary care
11:26fit into this so primary care should be where these people this like individuals people who are who think
11:32or ascertain that they're high risk they should be moving only to primary care okay and actually a lot of
11:38this uh prevention if we're talking about even like not even reaching primary care it's prevention that you
11:45can do at home so that it never uh how to say the situation never arrives that you need to
11:50ever get
11:51to even primary care currently nobody goes to primary care in the sense that by the time they pick
11:55up their diabetes they pick up diabetes because they're in kidney failure yeah and then only like
11:59after that yeah so now we're talking about like okay you go to the doctor you get a health screening
12:05say
12:0630 35 but uh what is this you're already flagging up these risks and now this cardiovascular renal metabolic
12:13kind of syndrome you can already figure out your risks very early so the option is then not to
12:18take that folder go back home i mean sleep with it until next year but um to actually need something
12:25at home make these changes at home and they're not expensive because contrary to what everybody
12:30thinks it doesn't mean that you need to take an expensive drug every day sure things like glp's are
12:36like like super uh super duper solutions now but they don't necessarily need to be the only solution
12:42okay um when you say that the the onus is actually on us to make some changes to our lifestyle
12:48can we
12:49talk a little bit about that because there are socioeconomic determinants of health as well right
12:53it's not just about you know cutting out sugar and the likes there are other areas so how much should
12:59we
13:00think about the responsibility on the the patient on the citizen to prevent for preventative care as
13:06the owners of the individual and preventative care as the owners of um the healthcare system and the
13:12government and and entire you know the entire ecosystem absolutely yeah yeah because we did talk
13:19about this yeah culture plays a part also culture plays a part yeah but for us especially nation food is
13:25like
13:25the number one thing it's a it's a social yeah yeah and the social media you know it doesn't help
13:33because
13:34all you see that you know videos are getting traction or viral it's always like you know the the extra
13:42cheese which is actually not cheese at all just like you know powdered something you know and all those things
13:48the sweet stuff you know the the the sugary drinks those are the one that's popular you know so we
13:58have a hard
13:59time trying to convince people to like you know let's just drink water you know and so that is a
14:08challenge i
14:09would say i can imagine yeah right so i'm i'm coming into just kind of um moving a little bit
14:14uh from what uh
14:15sir saying about micro interventions like at the individual level right i'm here actually really
14:20to push for macro interventions because you're absolutely right there are a lot of things that
14:24society needs to do which is actually relatively cheap to empower and enable people to do something
14:31okay because uh for example the this ncsm boring and hype starting a community thing that we did
14:37essentially focused on urban poor people we wanted it's a very specific subset we looked at 5 000 people
14:44living in in urban uh poverty conditions and looked at their kind of health levels and our
14:52recommendations are things like for example every ppr in care do they even have access to a park at night
15:00you know see why i'm talking about parks at night um everybody i mean all of us work two or
15:07three jobs
15:07right this is our our our colleagues or our family members who are within ppr settings or whatever they work
15:14two or three jobs people are coming home nine ten o'clock in japan or even thailand you don't need
15:18to go to japan and all that it's very too far in bangkok okay parks are open until about midnight
15:23wow and you'll be really surprised take a walk and you'll find there's thousands of people at night
15:30exercising at night because it's hot also right yeah absolutely so floodlights kept on safety is there
15:36is it too difficult to do no not at all but when you don't enable that uh how people ever
15:42going to
15:42exercise we keep on telling them oh you need to walk 10 000 steps a day but you know i
15:45said you know
15:47not everybody has a fitness membership at a gym it's illogical right right so leave that aside now next is
15:54for example we talk about screening or we talk about things that i can address like for example i want
15:59to
16:00monitor my blood pressure i went to a screening somebody saying oh your blood pressure is a bit on the
16:03dodgy
16:03side can you then go look at it now at one time we had this community clinics in all your
16:10pprs and
16:11all that that has gone away now again i'm not entering into the politics of it but that was an
16:16important equitable solution so it enabled people to get access to health care primary health care
16:24at in the evenings in the nights on saturdays on sundays these are the times when people who i mean
16:30not the atas people who are like nine to five yeah yeah everyone's working yeah yeah so that's when
16:36they have access when they have access they can get intervened on so things as simple as this so i'm
16:42i'm
16:42here to talk to you about the micro interventions that society no i i love that uh i know rostam
16:48you are
16:48also very big on patient advocacy right having the patient's voice heard in systems design in policy
16:54design in decision making that affects patients lives what what do you hear from from your peers
17:00from people around you about what kind of um decisions that patients would like to be heard about
17:08i think uh we are just entering because we're very very very new only about a couple of years and
17:15this is
17:16like some of the parts that we we want to know because we are the patient that experience this you
17:22know rather
17:22than just doctors who prescribe or you know diagnosed you and i think uh for us patient i think it
17:31needs
17:32for like for me i when we talk about the crm thing i was diagnosed quite early uh as a
17:40diabetes uh at 38
17:42okay very young yeah but when i you know when i found out about it and the doctor was you
17:49know there was no
17:50explanation that you know what you should take care of this because you know it could lead to dialysis
17:56it could lead to heart attack it could lead to you know a lot of other things but there was
18:00you know
18:01it was never mentioned it was just like okay your diabetes you know you need to keep your sugar low
18:05and
18:05that's about it you know so i think that that is one of the most important thing that we need
18:10to know
18:11okay you know we need to have access to all the information and as a patient so you need to
18:16ask
18:17you know it's not just them telling you but you need to know especially with now with the you know
18:23information available you know freely quite easily you we need to know as a patient also you need to take
18:32the step to understand what your disease is you know rather than just take take take the medicine can i
18:38ask
18:38both of you how do we close that knowledge gap both from the patient side and both from the the
18:44medical
18:45um professional side i'm sure that this knowledge is widely available among in um the kind of
18:50clinical pathway but is there a lack of translating that into that knowledge from the professional to
18:58the patient so um i i would agree because uh sometimes in our settings we're a bit too gentle to
19:05our
19:05patients in the sense that what you know no what what what we tend to not make them so stressed
19:13you know
19:14okay high cholesterol it's not hey do something about it but i don't think we are aggressive enough
19:21to prescribe non-pharmacological interventions so i think that's something which is changing as well
19:28so a lot of colleagues now are basically for example putting aside a prescription an exercise
19:33prescription you start seeing that for the first time now okay or a dietary prescription you know to change
19:39things besides so then you might need in addition to that some pharmacological intervention like drugs
19:46or tables or whatever but now we people need to address this holistically because also for physicians
19:52we need to understand that a lot of patients get very turned off when you know you start prescribing
19:57medication straight away yeah so it's not the only option but a lot of my colleagues are realizing that
20:01as well so we're entering into this much more wider space i think the issue is um one side needs
20:08to talk
20:09more in a language that the other side will listen to yes you're right and i also think that based
20:16from like a lot of discussions that they need to include the patient voice early on i mean whatever like
20:23kkm or you know when it comes to policy and you know discussion or anything that has to do with
20:30like involves patients lives the patient voice should be heard early on before you set something up you
20:37know rather than you do it you did everything done and then you include the patient because you come in
20:45and it's like oh okay you already decide on this why do you think that the patient voice is not
20:49included early on currently
20:53i don't know maybe they don't think it's important enough you know you just you know one way i think
20:58it's more like a one-way uh street doctor knows best yes probably you know you're not supposed to
21:05you know you're not supposed to question me or anything all right okay all right so so in the time
21:09that we have left i'm glad that we've raised this issue because i think it is it's good this part
21:13of
21:13this is bringing education and awareness to people who may not think they are at risk what would you like
21:19to
21:19leave our audience with in terms of what what message you would like to have them think about tonight
21:24but also what you would like to see changed going forward when we think about cardiovascular care
21:29that entire clinical pathway and the integrated patient voice pathway what would you like to see
21:35rostan if i may begin with you yeah i would start off with early education education because okay our age
21:43my
21:44age like 50s we're already there we're already in the zone but we should be as a nation looking at
21:51the
21:51younger you know the younger group of of because we don't want to call them future patients because
21:56hopefully you know i wish they're not going to they'll never be yeah but this group of toddlers up to
22:04like you know 12 years old you know maybe it's not the time for you to bring them to uh
22:09mama and order
22:11mill of eyes for them you know that kind of education right you need to to start early good good
22:17um
22:18lifestyle yes what what kind of education will you recommend to people who who want to equip
22:23themselves with information and you know be able to be empowered to ask their doctors and advocate for
22:30themselves i think it should be early on like school and also young parents that kind of education you know
22:36you
22:36you need to you need to you need to to to start looking into healthier alternatives you know rather
22:42than you know roti telur at mama don't take it for granted right that that you're young and healthy yeah
22:47yeah so for me i think um if i were to give a a message out there is one i
22:54think i just put one statistic
22:57from the study of about 5 000 people 97.8 percent had at least one cardiovascular metabolic renal risk
23:06four risk factors still almost two-thirds almost 70 over percent so we're not a healthy country the
23:15problem is we've this looked at risk factors long before people had active disease you know and this is
23:23really the intervention point so one is hey look we we're we're not not at risk you're really at risk
23:29it's time for you to wake up understand that you know uh the immortality has has no it's worn off
23:36you know so we we need to start intervening intervention does not need to be expensive it needs to be
23:42simple lifestyle change simple dietary change and as sir says i think behavior change um our food culture
23:49is it's just it's lovely but it's killing us you know uh so that everything's centered around food
23:57in this country right uh and so that those are things that we can change actively okay so small
24:02things to change and intervention and ignorance is not bliss so i'm going to end on that now no thank
24:07you
24:07both for coming and sharing some of your insights this has been a wonderful um and illuminating
24:11conversation especially for me i might also go get some screaming done early detection and save lives thank you so
24:17much for your time thank you for inviting us that's all the time we have for you on this episode
24:22of
24:22consider this i'm melissa idris signing off for the evening thank you for watching and good night