Brunei Darussalam National Multisectoral Action Plan for the Prevention and Control of Noncommunicable Diseases (BruMAP - NCD)

1. Tobacco smoking: In 1997, the overall smoking prevalence amongst Bruneians was 20%. The same survey showed that 31.1% of adult9 males were smokers. In 2011, the overall smoking prevalence was reported as 17%, however, adult male smokers had increased to 32.8% (Figure 8). Figure 8: The prevalence of smoking in adults between 1997 and 2011 in Brunei Darussalam

2. Obesity: In 1997, the prevalence of obesity 10 in adults was 12%. This figure has more than doubled to 27.2% in 2011 as illustrated in Figure 9. However, the prevalence of overweight11 adults only increased marginally from 32.4% in 1997 to 33.4% in 2011. Alarmingly, our children12 are not spared from being overweight (as defined by BMI for age ≥ 1 SD) and obese (as defined by BMI for age ≥ 2 SD) where prevalence in children was found to be 33.5% and 18.3% respectively (Figure 10). 9 Adults is defined as aged >19 years 10 Obesity is defined as BMI ≥30 11 Overweight is defined as BMI 25 -29.9 12 Children is defined as aged 5-19 years 17 Figure 9: Prevalence of Overweight and Obesity in Adults between 1997 and 2011 in Brunei Darussalam Figure 10: Prevalence of Overweight and Obesity amongst Children and Adults in Brunei Darussalam from NHANSS (preliminary data) 18

3. Hypertension: The prevalence of hypertension 13 increased from 28.6% in 1997 to 33.8% in

2011. As shown in Figure 11, hypertension in adult males increased marginally from 35.4% to 36.4% but the increase in hypertension in adult females from 23% in 1997 to 31.7% in 2011 is more alarming. Figure 11: Prevalence of Hypertension in Adults between 1997 and 2011 in Brunei Darussalam

4. Diabetes: As shown in Figure 12, the prevalence of diabetes 14 in 2011 was 12.5%; 12.2% amongst adult males and 12.7% amongst adult females.

5. Hypercholesterolemia: As shown in Figure 12, the prevalence of hypercholesterolemia 15 in 2011 was 11.6%; 12.4% amongst adult males and 10.8% adult females. 13 Hypertension is defined as Blood Pressure of more than 140/90 14 Diabetes is defined as known diabetes or newly diagnosed diabetes based on fasting blood glucose ≥ 7.0 mmol/L and/or 2 hour blood glucose of ≥ 11.1 mmol/L for those with no known diabetes 15 Hypercholesterolemia is defined as fasting total cholesterol of ≥ 6.2mmol/L 19 Figure 12: Prevalence of Obesity, Hypertension, Diabetes, Hypercholesterolemia and Physical Activity in Adults in Brunei Darussalam from NHANSS (preliminary data)

6. Consumption of unhealthy food and beverages: Data from 2011 showed that exclusive breastfeeding rates at 0 - 6 months were only 26.7%. Additionally, 8.7% of children aged 1 year and below were already consuming sweetened drinks. Children were also found to be consuming high amounts of saturated fats and sugary drinks while their intakes of fibre and fruits and vegetables were too low.16 Poor nutrition in Brunei Darussalam is apparent among 2 - 5 year old children where it has been revealed that there is poor intake of fruits and vegetables leading to an extremely low dietary fibre intake of 6.2g (SD±2.1) for males and 6.1g for females (SD±2.1). 16 With this intake not more than 1.0% of the 2-5 year old population met 70% of most international recommended dietary intakes for fibre.17,18 The National Dietary Guidelines recommend 2-3 servings of fruits and 2-3 servings of vegetables per day for the prevention of chronic diseases. In 2011, preliminary results for 5-75 year old showed that only females aged between 30-60+ and males aged 40-60+ met the daily recommendations for vegetable intake. For males aged 39 and below and females aged 29 and below, there is a failure to meet the daily recommendations for vegetable intake. The poorest intakes were among children and adolescents. In terms of fruit intake, on average only two (2) servings of fruits per week were consumed by males and three (3) servings by females for all age categories – significantly lower than the 16 2nd National Health and Nutritional Status Survey (NHANSS) 2009 – 2011(0 to 5 years) 17 Adequate intake for dietary fibre intake is 14g per day (for 1-3 year old) and 18g per day (for 4-8 year old) 18 Nutrient Reference Values for Australia and New Zealand- including recommended Dietary Intakes, Australian Government, Department of Health and Ageing, National Health and Medical Research Council (2005) 20 recommended 14 - 21 servings per week. Dietary fibre intake is therefore extremely poor among Bruneians of all ages. Only 7.8% of Bruneian males and 3.4% of females met most international dietary recommended amounts for fibre intake of 18 - 30 grams per day.18 NHANSS (2009 - 2011) showed that breakfast meals were taken daily in all age categories for both males and females. However this is an exception for males aged 15 - 29 years and females aged 15 - 19 years who tend to miss their breakfast two (2) times per week. This showed that adolescents are missing out on important nutrients for peak growth and development and therefore may have negative implications on scholastic achievements.

7. Physical activity: The prevalence of physical activity in adults (≥ 20 years) from NHANSS is 45.3%, with 42% of males and 48.1% of females performing more than the recommended 150 minutes of moderate physical activity per week. In the same population study, the prevalence of physical activity for children (aged 5 - 19 years) is much lower than the adults at 28.3%, with 28.2% in males and 28.4% in females respectively (Figure 13). Another 21.8% of adults, with 38.9% males and 7.4% females, performed between 75 - 150 minutes of moderate physical activity per week. These figures are lower for all children at 15.8%, with 27% males and 4.6% females respectively, performing between 75 - 150 minutes of moderate physical activity per week. Figure 13: Prevalence of Physical Activity in Brunei Darussalam from NHANSS (preliminary data) 18 Nutrient Reference Values for Australia and New Zealand- including recommended Dietary Intakes, Australian Government, Department of Health and Ageing, National Health and Medical Research Council (2005) 21 Ministry of Health Initiatives on the Prevention and Control of NCDs Increasing focus has been given to address NCDs following the epidemiological shift in the population disease trend over time. The increasing trends on the burden of NCDs over time has led to the development of MOH strategies, policies and programmes to address the prevention and control of NCDs accordingly. Policies and programmes which have been established in Brunei Darussalam is shown in Table 1. Table 1: Current Initiatives on Prevention and Control of NCDs in Brunei Darussalam No. Area Initiatives 1 Policies and • Hepatitis B (HepB) Vaccination (since 1989) programmes on • National Dietary Guidelines (2000) prevention and • Guidelines on School Feeding Schemes (2000) control of NCDs • National Breastfeeding Policy (2002) • Health Promoting School Initiatives (2002) • Ratification of WHO Framework Convention on Tobacco Control (2004) • Tobacco Order 2005 • Tobacco Regulations 2007 • School Canteen Guidelines (revised 2009) • Guidelines on Food and Drinks Served or Sold in Workplaces (2010) • Health Promotion Blueprint 2011 – 2015 (2011) • National Physical Activity Guidelines (2011) • Tobacco Order Amendments (2012) • Human Papilloma Virus (HPV) Vaccination (2012) 2 National and • National Committee on Health Promotion (2000) multisectoral • National Tobacco Control Committee (2009) committees on • Healthy Lifestyle Promotion Committee (2012) prevention and • National NCD Prevention and Control Strategic Planning Committee (2012) control of NCDs • Maternal, Infant and Young Child Nutrition Task Force (2013) 3 Prevention and • Lifestyle risk factor interventions e.g. Smoking Cessation Clinics (2005); control of NCD Weight Management Clinic (KCHS) (2005) services in • Screening – opportunistic and programme-based; occupational health primary care fitness assessment; Well Women’s Clinics; Cervical Cancer Screening and community Programme (2011), Health Screening for NCDs (2013) settings • Diagnosis and management of NCDs and risk factors including hypertension, diabetes, hypercholesterolemia and COPD • Management of NCD complications including diabetic retinopathy through Community Ophthalmology Clinics • Counselling and patient education on NCDs & risk factors – asthma and diabetic nurse educators and dietitians 22 No. Area Initiatives 3 Prevention and • Group counselling, public lectures and health education on healthy control of NCD eating, physical activity, weight management and smoking. services in • School Health Services which encompasses BMI monitoring and primary care obesity clinic and community • Maternal and Child Health services monitoring maternal weight, blood settings glucose level and blood pressure. 4 NCD services in • Specialist treatment, interventions and follow-up for NCDs secondary and • Provision of essential medicine tertiary care • Provision of diagnostic and investigative facilities • Counselling and patient education by asthma and diabetes nurse educators and dietitians • Multidisciplinary rehabilitation services including occupational therapy, physiotherapy, speech therapy, medical social worker services and clinical psychology • Specialised rehabilitation programmes such as cardiac and stroke rehabilitation 5 NCD • NCD risk factor surveys i.e. National Nutritional Status Survey surveillance (NNSS), 2nd National Health and Nutritional Status Survey (NHANSS) • Mortality and morbidity indicators • Birth and Death Registries • National Cancer Registry • Pap Smear Registry • Other Chronic Diseases Registry e.g, diabetes (hospital-based) At the National level, several policy documents guide national actions on prevention and control of NCDs. Specific focus on the prevention of NCDs is emphasised through the promotion of healthy lifestyle under the theme A Nation That Embraces and Practices Healthy Lifestyle, which constitutes one of the 5 themes of the Ministry of Health’s Vision 2035: “Together Towards A Healthy Nation”. The Health Promotion Blueprint 2011-2015, published in April 2011, outlines several strategic objectives and initiatives in addressing prevention and control of NCDs, particularly, in relation to reducing lifestyle risk factors, such as unhealthy diet, insufficient physical activity, smoking and obesity. 23 Several multisectoral mechanisms are in place at different levels such as the National Committee on Health Promotion, which was reviewed and revised in 2011. The committee currently has a Royal Patronage and is chaired by the Minister of Health with members comprising Permanent Secretaries from other government ministries, CSOs and the private sectors. At the operational level, the National Tobacco Control Committee was established in 2009. This committee is chaired by the Minister of Health with membership also consisting of representatives from multisectors including non-health sectors and CSOs. In April 2012, the National NCD Prevention and Control Strategic Planning Committee was established with the prime objective of strengthening NCD initiatives through the development of a National Strategic Action Plan on NCD Prevention and Control using a more comprehensive common risk factors approach. The Committee’s approach is in-line with WHO recommendations19 which emphasise multisectoral actions and active participation from various stakeholders and organisations within and outside of the Ministry of Health using a ‘Whole of Government’ or ‘Whole of Society’ approach as being the key for successful NCD intervention. Furthermore, such actions must be evidence-based as well as aligned and integrated within and across sectors. 19 Sixty-seventh World Health Assembly WHA/67/373 dated 17 Sep 2012 24 Challenges and Opportunities in Addressing NCDs in Brunei Darussalam In the prevention and control of NCDs in Brunei Darussalam key challenges identified are as follows:

1. Changing the behaviour and mindset of people is a complex process requiring enabling environments in addition to health education;

2. NCDs are influenced by multisectoral domains related to food, trade, education, transport, urban planning as well as social services and require engagement and holistic integrated actions by all Ministries as well as other relevant stakeholders;

3. Sustained efforts in prevention and control of NCDs require expertise and trained manpower at all levels from management to implementation and monitoring and evaluation;

4. Epidemiological and demographic transition means that the health system must be able to cope with the increasing trend in NCDs whilst simultaneously being able to deal with emerging and re-emerging infectious diseases and epidemics;

5. The current Health Information System is in the early phases of implementation and isolated NCD databases exist in various departments which need to be systematically coordinated and integrated into BruHIMS. In addressing the above challenges, there is strong and clear political commitment and acknowledgement from the highest level on the importance of the prevention and control of NCDs as well as the promotion of a healthy lifestyle. The development of this multisectoral action plan for prevention and control of NCDs (2013-2018) including identification of priority areas for action is in response to a strong leadership call and commitment from top levels of Government . This initiative is further driven by concerns at global and regional levels. The United Nations High- level Meeting on the Prevention and Control of Noncommunicable Diseases in September 2011 acknowledged that the global burden and threat of NCDs constitutes one of the major challenges for development.20 Since then the World Health Assembly has:

1. Endorsed the WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020

2. Adopted the Comprehensive Global Monitoring Framework for the Prevention and Control of NCDs

3. Adopted the set of nine voluntary global targets for achievement by 2025 for prevention and control of NCDs, noting that the target related to a 25% relative reduction in overall mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases concerns in premature mortality from NCDs between ages 30 and 70. Regionally, high level ASEAN political commitment to combat prevention and control of NCDs has provided further momentum for NCD prevention and control through the formation of the ASEAN 20 Sixty-sixth World Health Assembly WHA66/10 Agenda item 13.1 and 13.2. 25 Task Force on NCDs in 2012. Opportunities exist in various sectors to enable healthier environments through the adoption of Health in All Policies approach which can result in co-benefits for all sectors involved. Brunei Darussalam can also leverage on various regional and international platforms to build capacities and to collaborate on research related to NCD prevention and control. Effective human resource planning will ensure adequate supply of competent expertise through education, training, recruitment and retention with the provision of relevant career pathways. The scope of the Brunei Darussalam Health Systems and Infrastructure Masterplan (HSIMP) which has been conducted recently includes looking into strengthening capacity in prevention and control of NCDs. Brunei has one of the highest rates of internet usage in the region.21 The opportunities from info- communication and mobile technology can be further explored or enhanced to provide better services which would assist people in making healthier choices or leading healthy lifestyles. The current health information system will be further strengthened to allow for accurate and timely data management. Within the health sector, there is a strong impetus in strengthening primary health care based on the principle of universal health care coverage. The Government of Brunei Darussalam generously subsidises medical and health care to its citizens via government hospitals, health centres and health clinics. A network of health centres and clinics, throughout the country, provides primary health care services. In remote areas that are difficult to access by land or water, primary health care is provided by the Flying Medical Services. The decentralisation of primary health care services in 2000 was initiated to further enhance the accessibility of health care to all in the country. To date, the Ministry of Health provides four government general hospitals, 16 health centres, 15 health and maternal and child health clinics, 5 travelling health clinics and 2 Flying Medical Services teams to the remote areas. This is further supported by 37 medical clinics and facilities including Panaga Health Centre, Jerudong Park Medical Centre, Gleneagles Jerudong Park Medical Centre for Cardiac Services, the Brunei Cancer Centre and the Brunei National Stroke Centre as well as 7 private dental clinics. 21 Data from Research and Development, Department of Policy and Planning, Ministry of Health, Brunei Darussalam 26 Brunei Darussalam National Multisectoral Action Plan for the Prevention and Control of Noncommunicable Diseases (BruMAP-NCD) 2013-2018 ► A. FRAMEWORK ► B. OBJECTIVES AND KEY ACTIONS ► C. MONITORING FRAMEWORK ► D. RESEARCH AGENDA ► E. HUMAN RESOURCE DEVELOPMENT 27 III. Brunei Darussalam National Multisectoral Action Plan for the Prevention and Control of Noncommunicable Diseases (BruMAP-NCD) 2013-2018 The Brunei Darussalam National Multisectoral Action Plan for the Prevention and Control of Noncommunicable Diseases (BruMAP-NCD) 2013-2018 is developed under the overall Vision 2035 of the Ministry of Health, ‘Together Towards A Healthy Nation’. The mission of BruMAP-NCD is to prevent and control NCDs through enabling healthier environments as well as reducing risk factors and better management. The goal of BruMAP-NCD is fully aligned to the global target of a 25% relative reduction in premature mortality from NCDs by 2025 which has been translated to 18% relative reduction by 2018 in Brunei Darussalam. There are two strategic themes, five objectives, and a set of recommended actions for the Ministry of Health, other ministries and stakeholders. Guidance for implementing the actions for objectives 1, 2 and 3 are provided in Annex 1. 29 A monitoring framework including targets and methods of measurement, priority areas for research, and approaches for human resource development are also included. The comprehensive global framework for monitoring prevention and control of NCDs will guide this process (Annex 2). In operationalising the BruMAP-NCD, existing multisectoral mechanisms such as the National Committee on Health Promotion and the National Tobacco Control Committee are to be utilised. The NCD Prevention and Control Unit, Ministry of Health will be the coordinating body for BruMAP-NCD and is responsible for monitoring its implementation and periodic reporting. A. FRAMEWORK Vision 2035: Together Towards A Healthy Nation Mission: Prevention and control of NCDs through enabling healthy environments, reducing risk factors and better management Goal: 18% relative reduction in premature mortality from NCDs by 2018 (“18 by 18”) Five enablers: Policy & Human Patient Effective Research and Legislation Resources Empowerment Communication Innovation Strategic themes Improving Health Through Enabling Improving Health Through Enhancing the Environment and Healthy Choices Continuum of Care for NCDs Objective 1: Objective 2: Objective 3: Objective 4: Objective 5: To reduce To promote To increase To identify people at risk for To improve the quality of tobacco use balanced and physical activity NCDs and manage care and outcome of NCDs healthy diet effectively management National targets to be achieved by 2018 (with baseline value of 2010) • A 30% • A 10% relative reduction in mean • 5 0 % o f e l i g i b l e p e o p l e * • A n 8 0 % a v a i l a b i l i t y relative population intake of salt/sodium and receive drug therapy and of the affordable basic reduction in prevalence of hypertension counselling (including technologies and essential prevalence • Reduction in the rate of increase of glycemic control) to prevent medicines, including of current obesity and diabetes to 1% heart attack and stroke generics, required to treat tobacco use • All school canteen operators stop major noncommunicable in persons selling sugar-sweetened beverages diseases in both public and aged 15+ containing 6 grams or more added sugar private facilities years per 100mls** • All public •50% reduction on ‘regular’ places to be consumption of sweetened drinks by • 10% reduction in CVD, cancer and DM mortality in smoke-free children hospitals, other health centres and clinics. by 2016 • 50% of all workplaces having established healthy workplace programs to promote a healthy lifestyle •A 10% relative reduction in prevalence of insufficient physical activity Priority actions and guidance for implementation Research surveillance and evaluation *Eligible persons (defined as aged 40 years and older with a 10-year cardiovascular risk ≥30%, including those with existing cardiovascular disease) receiving drug therapy and counselling (including glycemic control) to prevent heart attacks and strokes **For milk and soya-based drinks not more than 10 grams of added sugar per 100mls 30 B. OBJECTIVES AND KEY ACTIONS Objective 1: To Reduce Tobacco Use RECOMMENDED ACTIONS FOR MINISTRY OF HEALTH 1) To conduct mass media campaigns to increase public awareness of tobacco control. 2) To improve enforcement of compliance of smoke-free indoor settings to 100% by 2015. 3) To reduce the exposure of children from second-hand smoke in homes by 25% in 2015 through public education. 4) To revise current Tobacco Order 2005 as needed and to coordinate the enforcement mechanism. 5) To work towards the ratification of the protocol for illicit trade in tobacco. 6) To monitor and raise awareness of tobacco industry interference. 7) To advocate and facilitate sustained increase in tobacco tax. 8) To explore the feasibility of implementing plain packaging. 9) To strengthen smoking cessation services. RECOMMENDED ACTIONS FOR OTHER MINISTRIES All Ministries • To enforce 100% smoke-free policies in all government buildings and public places. • To work towards the National goal of a smoke-free Brunei by 2016. Prime Minister’s Office • To strengthen enforcement of all smoke-free policies. • To strengthen efforts on controlling smuggling and illegal trade. • To enforce the ban on tobacco interference. • To support efforts in increasing public awareness on tobacco control. Ministry of Defence • To strengthen smoking cessation services. Ministry of Finance • To increase tobacco taxation up to 100% or more of retail price. • To strengthen efforts on controlling smuggling and illegal trade. Ministry of Foreign Affairs and Trade • To give consideration to and support current tobacco legislations in trade negotiations. • To support efforts on controlling smuggling and illegal trade. • To explore the adoption of the plain packaging. Ministry of Education • To educate and raise awareness amongst students on the harmful effects of tobacco. • To inculcate social norms in educational institutions to support “100% smoke-free public places”. 31 RECOMMENDED ACTIONS FOR OTHER MINISTRIES Ministry of Religious Affairs • To continue to raise awareness on smoking through sermons and other methods. • To work towards smoke-free policies according to Syariah Laws. Ministry of Culture, Youth and Sports • To facilitate the change of social norms to support 100% smoke-free public places. • To create awareness amongst youth about the harms of tobacco use. 32 Objective 2: To Promote Balanced and Healthy Diet RECOMMENDED ACTIONS FOR MINISTRY OF HEALTH 1) To ensure compliance to the National Dietary Guidelines. 2) To develop and implement policies that limit salt, sugar and saturated fat and eliminate partially hydrogenated vegetable oil (PHVO) in processed foods. 3) To develop and implement policies to reduce the impact of marketing of food and non-alcoholic beverages high in sugar, salt and fat to children. 4) To develop and implement mandatory food labelling for all domestic and imported food products including a consumer-friendly labelling to identify healthier food products. 5) To ensure healthier dietary options in schools, workplaces and where children gather. 6) To conduct sustained mass media campaigns to increase consumption of fruits and vegetables. 7) To develop and implement guidance to interact with food industry for implementing policies. RECOMMENDED ACTIONS FOR OTHER MINISTRIES Prime Minister’s Office • To provide directive to all ministries and government offices to develop structured healthy workplace programs emphasising a healthy diet at all government events. • To endorse and incorporate workplace “Fruit and Vegetables Day” and servings of fruits and vegetables in all government events. • To develop and endorse Code of Conduct for marketing of unhealthy food and beverages to children through RTB. Ministry of Finance • To use existing fiscal mechanisms to improve consumption of healthy food and restriction of unhealthy food and beverages. Ministry of Foreign Affairs and Trade • To promote the importation of healthier food products. Ministry of Education • To develop and/or strengthen comprehensive school health programmes and frameworks. • To organise training for Ministry of Education officers and students on healthy lifestyle. Ministry of Development • To incorporate community fruit and vegetables gardens/plots in housing development projects. Ministry of Communications (AITI) • To promote healthy diet among general public through social media / Mobile Health Solutions. • To support implementation of Code of Conduct on marketing of unhealthy food and beverages to children through social media. 33 RECOMMENDED ACTIONS FOR OTHER MINISTRIES Ministry of Industry and Primary Resources • To develop public ‘Fruit and Vegetables Parks / Orchards’ for health, educational and commercial interest. • To incorporate aspects of healthier food (low in sugar, salt and fat) within the existing food security policy. • To work with food industries and importers for reformulation of products low in sugar, salt and fats, restriction and labelling requirements. Ministry of Home Affairs • To incorporate National Dietary Guidelines in ‘One Kampong One Product’ initiative and restaurant grading scheme with menu assessment. • To regulate the advertisement and promotion of food and beverage products and restrict sponsorship of any public events. Ministry of Religious Affairs • To emphasise the importance of healthy eating through Islamic perspective. • To promote planting of fruit trees within mosques and/or religious school compounds. 34 Objective 3: To Increase Physical Activity RECOMMENDED ACTIONS FOR MINISTRY OF HEALTH

1. To strengthen the implementation of the National Physical Activity Guidelines (NPAG) 2011 recommendations through: a) the use of a mass media campaign in partnership with relevant agencies; b) the facilitation of structured physical activity programmes in the community and workplace; c) building the capacity of relevant stakeholders to promote physical activity. RECOMMENDED ACTIONS FOR OTHER MINISTRIES Prime Minister’s Office • To issue administrative order requiring all ministries and government offices to develop structured healthy workplace programmes emphasising healthy diet and physical activity. Ministry of Finance • To continue providing financial support for the development and maintenance of physical activity and recreational infrastructure. Ministry of Education • To continuously incorporate Physical Education as part of the National Curriculum. • To improve infrastructure to promote physical activity in school settings. • To strengthen Health Promoting Educational Institutions initiatives to enhance physical activity in schools. • To promote educational institution facilities for the community to access and practice healthy lifestyle. Ministry of Development • To support the development and maintenance of conducive and safe physical activity and recreational environments and infrastructures in all settings. • To connect recreational parks, sport facilities and communities where possible through safe pathways. Ministry of Communications • To promote active transportation in line with the Bandar Seri Begawan Masterplan, Transport Masterplan draft and other urban development plans. Ministry of Industry and Primary Resources • To support the development and maintenance of forest reserve parks conducive to physical activity and recreation. Ministry of Religious Affairs • To support and develop Health Promoting Schools initiative using Islamic teachings as a basis in promoting healthy lifestyle in school settings under the preview of Ministry of Religious Affairs. 35 RECOMMENDED ACTIONS FOR OTHER MINISTRIES Ministry of Home Affairs • To support the development and maintenance of conducive and safe physical activity and recreational areas in districts and local communities. • To ensure that every Mukim has a facility for physical activity promotion. Ministry of Culture, Youth and Sports • To expand the current sports programme, as appropriate, to all age groups. • To develop and implement a sustained mass media campaign for promoting sports. • To provide guidelines to other ministries on age-appropriate physical activity equipment and facilities. 36 Objective 4: To Identify People at Risk of NCDs and Manage Effectively RECOMMENDED ACTIONS FOR MINISTRY OF HEALTH

1. To promote healthy lifestyle and to control obesity among school children through strengthening of the School Health Services and Health-Promoting Schools Initiative.

2. To develop and strengthen a National smoking cessation programme. • To train all health care professionals in smoking cessation. • To develop and expand the current smoking cessation clinics to achieve National coverage with nicotine replacement therapy. • To develop, implement and monitor SOPs for the programme and update Clinical Practice Guidelines (CPG). • To establish a National smoking quit line.

3. To strengthen initiatives to identify people with NCD risk factors (tobacco use, unhealthy diet, insufficient physical activity and obesity) and to provide counselling and referral services in all health facilities. • To adapt WHO PEN Protocol 2 and to develop SOPs. • To train all health workers in implementing the counselling package.

4. To strengthen assessment and management of cardiovascular risks using hypertension, diabetes, obesity and tobacco use as entry points in all health facilities (WHO PEN protocol 1 in Annex 3): • To ensure easy accessibility of CVD risk assessment tools to be incorporated into MOH website including BruHIMS. • To train all health care professionals in implementing the risk assessment and management package.

5. To strengthen cancer screening programme for cancers of the uterine cervix, colorectum and breast: • To develop guidelines and SOPs and to ensure that adequate infrastructure and human resources are available for cervical cancer screening to be available in all health centres; and colorectum and breast cancer in all hospitals. 37 Objective 5: To Improve the Quality of Care and Outcome of NCD Management RECOMMENDED ACTIONS FOR MINISTRY OF HEALTH

1. To improve management of NCDs through services for patients at risk and with NCDs at all levels. For patients at risk of NCDs • To set up a one-stop multidisciplinary clinic for patients with multiple NCD risk factors in health centres. • To develop, implement and monitor referral systems to appropriate specialist clinics in hospitals. For patients with multiple NCDs • To develop multidisciplinary clinics for patients who have multiple co-morbidities.

2. To centralise clinical audits to ensure that all health care professionals are compliant with the NCD CPGs and SOPs through regular audits and reporting.

3. To adopt, implement and monitor the WHO Package of Essential Noncommunicable (PEN) Diseases Intervention for Primary Health Care in all health care facilities (government and private) to improve the management of NCDs.

4. To enhance and improve cancer management through provision of adequately-trained human resources, early detection programmes, patient support systems for compliance to treatment and follow up and cancer registration.

5. To scale up rehabilitation and palliative care services: • To ensure that rehabilitation services are provided to all those who require them. • To provide pain and symptoms relief to all those who require. • To develop and implement SOPs and clinical practice guidelines (CPGs) for rehabilitation and palliative care services. • To strengthen human resources for rehabilitation and palliative care services.

6. To provide a comprehensive and holistic approach for care of older adults:22 • To ensure optimum quality of life. • To increase awareness on the “four giants of geriatric syndrome” namely falls, incontinence, dementia and depression. • To strengthen human resources for provision of services in all settings. 22 Older Adults (WHO, 2013) is defined as 65 years and above. 38 RECOMMENDED ACTIONS FOR OTHER STAKEHOLDERS Stakeholders Objective 1 Objective 2 Objective 3 Objective 4 Objective 5 Government- • Implement • Implement • Provide • Advocate screening linked and enforce National enabling services for NCD risk identification companies 100% smoke- Dietary environment and reduction and private free public Guidelines for physical companies places activity Private health • Implement • Implement • Provide • Provide • To support care facilities and enforce National enabling NCD risk the CPGs 100% smoke- Dietary environment identification and facilitate free public Guidelines for physical and risk referral places activity reduction services services including smoking cessation services Private and • Implement • Implement • Provide • Advocate screening Higher and enforce National enabling services for NCD risk identification education 100% smoke- Dietary environment and reduction institutions free public Guidelines for physical places activity Civil Societies • Advocate • Promote • Advocate • Encourage uptake and and General for tobacco- and support for physical participation of screening for Public free Brunei healthy activity NCDs and compliance to Darussalam cooking and • Support treatment eating physical activity programmes in community settings. 39 C. MONITORING FRAMEWORK Goal: 18% Relative Reduction in Premature Mortality from NCDs by 2018 (“18 by 18”) Data sources: National NCD Risk Factor Survey (STEPS), Global School-based Health Survey (GSHS), Global Youth Tobacco Survey (GYTS), Civil Registration, Cancer and Other NCD Registries and NCD Hospital-based Mortality Registry. Objectives Activities Short-term Intermediate Long term outcomes outcomes outcomes

1. To reduce • Tobacco-free • Increased • All public • A 30% tobacco use mass media proportion of smokers places to be relative campaign and who want to quit smoke-free by reduction in evaluation smoking 2016 prevalence of • KAP survey • Increased current tobacco on tobacco proportion of smokers use in persons prevalence, who attempt to quit aged 15+ years awareness smoking • Smoke free and tobacco • Increased generation dependence proportion of smokers treatment who quit smoking • Scale-up smoking • Increased the cessation services proportion of the • Environmental population whose surveillance by workplace has a non- enforcement unit smoking policy • KAP survey on • Increased the increased size of proportion of the pictorial health population who support warnings on the smoking ban in smokers quit rate public places • Surveillance of • Increased the smoke-free public proportion of women places smokers who stop smoking in early pregnancy • Reduced of smoking prevalence amongst partners during pregnancy • Reduced the exposure to passive smoking amongst working pregnant women • Increased proportion of youth who knows about ill-effects of smoking 40 Objectives Activities Short-term Intermediate Long term outcomes outcomes outcomes

2. To promote • Mass media • Increased the proportion • 5% reduction • A 10% balanced and campaigns on of the adult population in the rate of relative healthy diet. healthy diet and who understand which increase of reduction in evaluation foods are high in sodium diabetes and mean population • Increased the proportion obesity to 1% intake of salt / of population who • 50% of all sodium and believe that healthy workplaces hypertension foods can be cheap, having tasty and enjoyable established • Increased the proportion healthy of the population who workplace are able to correctly programme to state at least 3 ways of promote healthy achieving a healthier lifestyle diet such as eat less salt, sugar, saturated fat, eat more fruit and vegetables, and eat more wholegrains • Reduced the population who express confusion about what constitutes a healthy diet • Increased the proportion of the population who understand how to control their weight through diet • Increased the proportion of people who have access to healthy food at the workplace • School • All school canteen • 50% canteen survey operators stop selling reduction sugar sweetened on ‘regular’ beverages containing consumption of ≥6g/100ml of sugar sweetened drinks by children

3. To increase Workplaces survey • Reduced perceived • 50% of all • A 10% physical activity • To conduct KAP barriers to increase workplaces relative reduction surveys of physical activity amongst having in the prevalence employers on the general population established of insufficient workplace PA • Increased the proportion a healthy physical activity initiative of the population who workplace • Pedometer use receive helpful advice programme to evaluation from their General promote PA Practitioner / Health provider 41 Objectives Activities Short-term Intermediate Long term outcomes outcomes outcomes

4. To identify • Screening • Increased awareness • 50% of • 10% relative people at risk amongst population eligible people reduction in risk for NCDs and of the risk factors receive drug of premature manage associated with NCDs therapy and mortality from effectively • Increased awareness counselling CVD, cancer and amongst population that (including DM it is possible to reduce glycemic control) personal risk of NCDs to prevent heart by practicing healthy attack and stroke lifestyle and adhering to therapy

5. To improve • Audit on adherence to the use of SOPs and • 80% the quality of clinical guidelines availability of the care and • Clinical audit on all health care professionals affordable basic outcome of who are adopting WHO PEN and conducting technologies NCD CVD risk assessment, management and referral and essential management • Clinical audit of rehabilitative and palliative medicines, care services including • Audit of palliative services that reaching generics, 80% of the target population required to treat • Health facility survey major NCDs in both public and private facilities 42 D. RESEARCH AGENDA A set of research topics are provided to support the implementation of BruMAP-NCD. Further prioritisation will be carried out using a set of criteria for implementing the agenda. Due to human resource constraints, most if not all, will be done in collaboration with academic or research organisations such as the University of Brunei Darussalam (UBD) and Centre for Strategic Policy Studies (CSPS), Regional and International Partnerships. Dedicated funding and other resources will need to be identified early for the research to be conducted within the timeframe. Research topics Responsible agencies Objective (1) To reduce tobacco use

1. Study on the impact of trade agreement on importation of tobacco MOH

2. Study on the effect of current tobacco taxation on tobacco MOH consumption Objective (2) To promote balanced and healthy diet

1. Study of dietary consumption patterns among patients with cancer. MOH

2. Conduct Survey of KAP on National Dietary Guideline MOH

3. To investigate factors affecting fruit and vegetable intake across MOH different population groups.

4. Undertake baseline survey on: a. Degree of marketing exposure to children MOH b. Marketing influence on consumer behaviour

5. To determine level of awareness and understanding of nutrition MOH information panel and/or healthier choice logo

6. Study on parental demand of healthier dietary options MOH/MOE

7. Consumer survey on the uptake of Healthier Food Branding. MOH

8. Market research to determine purchasing patterns of food and MOH beverages

9. Study price elasticity or threshold needed to change consumer Department behaviour by increasing taxes of unhealthy food and beverages and providing of Economic subsidies on healthier food and beverages Planning and Development

10. Healthy Workplace Initiatives Survey including baseline KAP Pre- and Post- Survey and Study on compliance to the food and beverages sold at MOH workplaces examples “No Sales” food products by one year.

11. To collaborate on research on improving shelf life and storage/transport methods MIPR/MOE of fruits and vegetables, expertise examples farming technologies, health benefits (vocational, of fruits and vegetables, development of healthier menus and marketing of fruits technical and and vegetables UBD), MOH

12. To explore research opportunities on healthier food products in order to assist local food industry examples recipe development, marketing of MOH/MIPR healthier food branding for local products. 43 Research topics Responsible agencies Objective (2) To promote balanced and healthy diet

13. To analyse contents of transfat of foods available in local market MOH/MIPR

14. Literature review on buildings that promote healthy lifestyle: environment, design MOH and innovations. Objective (3) To increase physical activity

1. KAP survey on PA MOH/MOE

2. Literature review on buildings that promote healthy lifestyle: environment, design MOH and innovations.

3. Conduct survey on current facilities in Mukims and Kampongs a. Conduct ‘Connectivity’ survey by 2013-2014 MOH/MOD b. Conduct survey on utilisation of public facilities c. Seek consultation input on shaded walkways

4. Needs assessment on PA infrastructure in Mukims MOH/MOHA

5. Study on the effectiveness of relevant PA initiatives examples increase PMO/MOH productivity, reduce absenteeism and the use of protected time Objective (4) To identify people at risk of NCDs and manage effectively Objective (5) To improve the quality of care and outcome of NCD management

1. Study on facilitators and barriers to medication adherence MOH 44 E. HUMAN RESOURCE DEVELOPMENT In operationalising the BruMAP-NCD, there is a requirement for sufficient numbers of trained and competent professionals at various levels and in different sections / locations in the Ministry of Health. Therefore, a comprehensive human resource mapping exercise should be undertaken taking into account the following; Pre-Service Requirement Professional Qualifications Framework To incorporate as needed and/or as relevant the following topics in the curriculum Medical Degree NCD Prevention and Control, Health Promotion, Health in Nursing Degree and Diploma All Policies (HiAP), Health Economics to assess NCD Burden, Policy planning and evaluation, Health Communication, B.Sc and M.Sc (Allied Health Professional) Biostatistics, Epidemiology, Diseases Registration, Nutrition - Physiotherapy and NCDs, Social Determinants of Health, International - Psychology Classification of Diseases (ICD) Coding, Exercise Physiology, - Biomedical Sciences Ergonomics and Social Marketing. - Rehabilitative Medicine - Dietitics / Nutrition - Exercise Physiology - Health Promotion / Education - Epidemiology - Biostatistic - Health Information Management Technical Professional Qualifications Healthy Lifestyle, NCD Prevention and Control, Health - Clerical and Administrative Communication - Systems Analysis - Medical Laboratory Technology - Information Technology - Graphics Design Executive Development Programme To include HiAP in the programme Courses leading to Public Policy, To include HiAP in the programme Legislation and Administration *Recruitment of the above should be aligned with Ministry of Education who is responsible for awarding scholarship and providing guidelines on training requirement for undergraduates. In-Service Requirement Type of manpower Requirement Human Resource Department in 1. Increase number to support the operationalisation of BruMAP-NCD MOH 2. Strengthen Human Resource Planning and Human Resouce development Health Professionals for NCD 1. Identify and recruit optimal numbers to operationalize BruMAP-NCD. Prevention and Control 2. Participate in Continuous Professional Development (CPD), Continuous Medical Education (CME) and Continuous Nursing Education (CNE). To provide capacity building programme for other sectors and stakeholders in Prevention and Control of NCDs Stakeholders 1. To support other non-health sectors in training programmes on NCD Prevention and Control. 45 His Royal Highness Duli Pengiran Muda ‘Abdul Malik ibni Sultan Haji Hassanal Bolkiah Mu’izzaddin Waddaulah with the National Noncommunicable Diseases Control and Strategic Planning Committee during His Royal Highness’ work attachment at the Ministry of Health, 2013. BruMAP-NCD Pictorial Journey ► The National NCD Prevention and Control Strategic Planning Committee ► BruMAP-NCD Editorial Committee 47 In-house Technical Consultation Officiated by The Honourable Pehin Orang Kaya Johan Pahlawan Dato Seri Setia Awang Haji Adanan bin Begawan Pehin Siraja Khatib Dato Seri Setia Awang Haji Mohd Yusof, Minister of Health on 20th November 2012. Clockwise from top left • The Honourable Minister of Health officiating the In-Country Technical Consultation on the Development of a National Multisectoral Plan for Noncommunicable Diseases Prevention and Control 2013-2018. • Professor Robert Beaglehole addressing the need for multisectoral action on NCD Prevention and Control. • Group photograph with Guest of Honour and participants. • The participants from various sectors. • Dr. Cherian Varghese leading the discussion of the workshop. Group work Brainstorming session to prevent and control NCDs through enabling healthy environments, reducing risk factors and better management. 49 Follow-up Consultation 30th April - 1st & 3rd May 2013 Top left Welcoming and opening remarks by Dr. Hjh Rahmah bte Hj Md Said, Deputy Permanent Secretary (Professional & Technical), Ministry of Health. Top right & bottom left Participants from non-health sectors in discussion based on the strategic theme - Improving Health through Enabling Environment and Healthy Choices. Group work Health professionals from government and private agencies working on the strategic theme - Improving Health through Enhancing the Continuum of Care for NCDs, with Dr. Cherian Varghese as the lead facilitator throughout the 3-day workshop. 50 BruMAP-NCD Working Group in WHO Western Pacific Regional Office, Manila From left to right: Dr. Hai Rim Shin (Team Leader in NCD and Health Promotion, WPRO), Dyg Lubna bte Abd Razak, Dr. Ong Sok King, Dr. Hj Md Syafiq bin Abdullah, Dr. Shin Young Soo (Regional Director, WPRO), Dr. Alice Yong, Dyg Siti Munawwarah bte Awang Tarif, Dr. Hjh Norhayati bte Hj Md Kassim and Dr. Cherian Varghese (Senior Medical Officer, NCD WPRO) 51 THE NATIONAL NCD PREVENTION AND CONTROL STRATEGIC PLANNING COMMITTEE ADVISOR Datin Paduka Dr. Hjh Norlila bte Dato Paduka Hj Jalil Permanent Secretary Ministry of Health CHAIRPERSON Dr. Hjh Rahmah bte Hj Md Said Deputy Permanent Secretary (Professional and Technical) DEPUTY CHAIRPERSONS Director General of Medical Services Director General of Health Services SECRETARIES Dr. Hjh Lailawati bte Hj Jumat Director of Hospital Services Dr. Hjh Norhayati bte Hj Md Kassim Senior Medical Officer Grade 1 HEADS OF PREVENTION AND HEALTH PROMOTION Dr. Hjh Anie Haryani bte Hj Abd Rahman Senior Medical Officer Grade 1 Dr. Hjh Norhayati bte Hj Md Kassim Senior Medical Officer Grade 1 HEADS OF CLINICAL MANAGEMENT Datin Dr. Hjh Haslinda bte Hj Md Hassan Consultant Grade II (Medical) Dr. Hj Md Syafiq bin Abdullah Consultant Grade II (Medical) HEADS OF RESEARCH, SURVEILLANCE AND MONITORING Dr. Alice Yong Moi Ling Consultant Grade I (Medical) Dr. Ong Sok King Specialist (Public Health) 52 HEADS OF CAPACITY BUILDING Awg Abd Walid bin Hj Matassan Acting Director of Administration and Finance Dr. Hjh Lailawati bte Hj Jumat Director of Hospital Services Dyg Hjh Fatimah bte Abdullah Acting Director of Nursing Services HEADS OF LEGISLATION AND POLICY DEVELOPMENT Dr. Zainal Ariffin bin Hj Yahya General Director Dyg Hjh Zahrah bte Dato Paduka Hj Hashim Director of Policy and Planning Director of Environmental Health SECRETARIAT Dyg Hjh Roseyati bte Dato Paduka Hj Yaakub Senior Dietitian Awg Hj Juniadee bin Hj Ahmad Special Duties Officer Awg Norsal bin Hj Salleh Senior Dietitian Dyg Nurasma Aini bte Hj Mat Yassin Community Dietitian Awg Nelson Dennis Dietitian Dyg Lubna bte Hj Abd Razak Research Officer Dyg Siti Munawwarah bte Awg Tarif Health Education Officer Dyg Hjh Kamariah bte Hj Abd Rahman Senior Staff Nurse 53 Editorial Committee Dr. Hjh Rahmah bte Hj Md Said Deputy Permanent Secretary (Professional and Technical) Dr. Cherian Varghese Senior Medical Officer, WHO Western Pacific Regional Office Dr. Hj Md Syafiq bin Abdullah Consultant Grade II (Medical) Dr. Alice Yong Moi Ling Consultant Grade I (Medical) Dr. Yung Chee Kwang Consultant Grade II (Medical) Dr. Ong Sok King Specialist (Public Health) Dr. Hjh Norhayati bte Hj Md Kassim Senior Medical Officer Grade I Dr. Hjh Siti Fatimah bte Hj Md Jaafar Acting Assistant Director of Research and Planning Dyg Hjh Roseyati bte Dato Paduka Hj Yaakub Senior Dietitian Dyg Yeo Sock Sian Senior Dietitian Awg Norsal bin Hj Salleh Senior Dietitian Dyg Nurasma Aini bte Hj Mat Yassin Community Dietitian Awg Han Burt Lee Occupational Therapist Awg Nelson Dennis Dietitian Dyg Lubna bte Hj Abd Razak Research Officer Dyg Siti Munawwarah bte Awg Tarif Health Education Officer Center for British Teachers (CfBT) 54 Annexes ► Annex 1: Guidance for Implementation ► Annex 2: Comprehensive Global Monitoring Framework, Including 25 Indicators, and a Set of Nine Voluntary Global Targets for the Prevention and Control of Noncommunicable Diseases ► Annex 3: Protocols for NCD Risk Reduction and Integrated Management of CVD Risk 55

Annex 1: Guidance for Implementation To operationalise BruMAP-NCD, guidance is provided for the Ministry of Health, other ministries and stakeholders for objectives 1, 2 and 3. Objective 1: To Reduce Tobacco Use MINISTRY OF HEALTH 1) To conduct mass media campaigns to increase public awareness of tobacco control. 2) To improve enforcement of compliance of smoke-free indoor settings to 100% by 2015. 3) To reduce the exposure of children to second-hand smoke in homes by 25% in 2015 through public education. 4) To revise current Tobacco Order 2005 as needed and to coordinate the enforcement mechanism. 5) To work towards the ratification of the protocol for illicit trade in tobacco. 6) To monitor and raise awareness of tobacco industry interference. 7) To advocate and facilitate sustained increase in tobacco tax. 8) To explore the feasibility of implementing plain packaging. 9) To strengthen smoking cessation services. OTHER MINISTRIES Ministry Guidance All Ministries • To enforce 100% smoke-free policies in all government buildings and public places. ○ To assist in enforcement officers in carrying out surveillance and enforcement activities Prime • To strengthen enforcement of all smoke-free policies. Minister’s • To strengthen efforts on controlling smuggling and illegal trade Office • To work towards the national goal of a smoke-free Brunei by 2016. Attorney General’s Chambers - To review and strengthen tobacco control legislations (Tobacco Order 2005 and Its Regulations 2007) Royal Brunei Police Force - To assist in relevant training on enforcement - To become authorised officers for enforcements of Tobacco Order 2005 and its Regulations 2007 Radio Television Brunei - To continue banning of tobacco promotion and advertisements in national television and radio - To assist in conveying and promoting anti-tobacco policy, education and awareness programmes 57 Ministry Guidance Prime Narcotics Control Bureau Minister’s - To provide assistance in relevant training in enforcement Office - To assist in enforcement of Tobacco Order 2005 and its Regulations 2007 - To incorporate anti-tobacco talks to be included in their anti-drug campaigns Anti-Corruption Bureau - To enforce ban of tobacco industry interference in government workplaces State Mufti Department - To continue working on fatwa that smoking is ‘haram’ in June 2004 to complement the Tobacco Order 2005 and its Regulations 2007 Ministry of • To increase tobacco taxation up to 100% or more of retail price. Finance • To explore plain packaging • To strengthen current role in the enforcement of Tobacco Order 2005 and its Regulations 2007 particularly on labelling of imported tobacco products and to control smuggling of illicit cigarettes and tobacco products • To allocate sufficient funding for all tobacco control activities and distribute to all relevant agencies as appropriate Ministry of • To strengthen smoking cessation services Defence Ministry of International Trade Foreign Affairs - To consider and support current tobacco legislations in trade negotiations and Trade - To explore the adoption of plain packaging - To assist in monitoring and providing information on tobacco industry activities - To review agreements and terms under the World Trade Order - To support efforts to control smuggling and illegal trade Ministry of • To educate and raise awareness amongst students on the harmful effects of Education tobacco: - Include Anti-tobacco education to be included in the school curriculum - Collaborate with relevant stakeholders to organise and conduct programmes in combating the use of tobacco • To inculcate social norms in schools to support 100% smoke-free public places: - Strengthen the enforcement of tobacco-free zones in government and private schools enacted in January 2002 Ministry of Islamic Religious Council Religious - To include anti-tobacco awareness and education in Friday prayer sermons Affairs and religious talks - To become authorised officers for enforcement of Tobacco Order 2005 and its Regulations 2007 - To work towards smoke-free policies according to Syariah Laws. Ministry of District Offices Home Affairs - To become authorised officers for enforcement of Tobacco Order 2005 and its Regulations 2007 - To be responsible for the registration and licensing of retailers under Section 16/17 whose license includes the sale of tobacco products. Ministry of • To facilitate the change of social norms to support 100% smoke-free public Culture, Youth places. and Sports • To integrate and promote anti-tobacco campaigns in their youth, sports and community development programmes 58 Objective 2: To Promote Balanced and Healthy Diet MINISTRY OF HEALTH 1) To ensure the compliance of National Dietary Guidelines. • To review and revise National Dietary Guidelines. • To incorporate mandatory serving of fruit and vegetables as part of refreshments at all events. • To inculcate the use of National Dietary Guidelines in all Ministry of Health’s environment and activities/events. • To promote the benefit of drinking water and promote messages on safety and cleanliness of water. • To develop healthy cook books in line with National Dietary Guidelines. • To promote National Dietary Guidelines in relevant programmes of Ministry of Health e.g. Maternal and Child Health Services. 2) To develop and implement policies that limit salt, sugar and saturated fat and eliminate partially hydrogenated vegetable oil (PHVO) in the food supply • To regulate frameworks on putting limits and labelling on transfat • To educate the public, food industry including local food importers and local food manufacturers on transfat • To offer analytical services on trans-fat to local food industry/importers • To offer consultation services on transfat • To develop inventory of foods with transfat content 3) To develop and implement policies to reduce the impact of marketing of food and non-alcoholic beverages high in sugar, salt and fat to children. • To develop National Guidelines by adapting WHO’s Set of Recommendations on the Marketing of Foods & Non-Alcoholic Beverages to Children (WHO 2012) • To prepare supporting policy recommendation paper on the impact of marketing of food and non-alcoholic beverages high in sugar, salt and fat to children 4) To develop and implement mandatory food labelling for all domestic and imported food products • To develop a uniform consumer-friendly labelling to identify healthier food products • To review and expand the scope of current food labelling legislation to emphasise nutrition labelling (for both imported and local food products) • To review and strengthen registration of imported food products • To explore mechanism of mandatory implementation (legislation) of branding of healthier choice food products • Capacity building towards development of criteria for branding healthier food 59 5) To ensure healthier dietary options in schools, workplaces and where children gather • To develop recommendation paper to propose “Fruit & Vegetables Day” and submit to PMO and MOE for approval and circulation. • To strengthen and continue training of school-leaders, teachers and Parent Teachers Association in healthy eating in schools • To review existing audit checklist on the sales of food & drinks in school canteens 6) To conduct sustained mass media campaigns to increase consumption of fruits and vegetables. • To work with other agencies or stakeholders (PMO, MOHA, AITI, ITPSS, MOH (Information Technology), printed media (Brunei Press, Brunei Times), AGC, MinComm, Data Stream Technology (DST) (Kristal Astro) and (BMobile). 7) To develop and implement guidance to interact with food industry for implementing policies. 8) To develop a Healthy Workplace Programme (on healthy eating). • To review regional and international guidelines on the Healthy Workplace Programme. • To provide leadership and guidance in the promotion of healthy lifestyles at the workplace. • To strengthen and finalise stakeholder consultations within MOH in order to guide on the development of the Healthy Workplace Programme. • To train members of the implementing committee of Healthy Workplace Committee. • To develop and finalise ‘Train the Trainers’ Manual on Healthy Workplace. • To improve and modify as appropriate implementation of Healthy Workplace Programme. • To incorporate future facilities conducive environment to the implementation of the Healthy Workplace Programme. • To formulate guidelines for health facilities within MOH on the Healthy Workplace Programme. • To provide consultancy for other non-health sectors in the Healthy Workplace Programme. OTHER MINISTRIES Ministry Guidance Prime • To provide directive through PMO circulars to all ministries and government Minister’s offices Office - To develop structured healthy workplace programmes emphasising healthy diet. - To endorse and incorporate workplace “Fruit & Vegetables Day” and servings of fruits and vegetables at all government events. - To promote and prioritise healthier food brands. 60 Ministry Guidance Prime • To develop and endorse a Code of Conduct for the marketing of unhealthy food Minister’s and beverages to children in RTB. Office - To regulate sponsorship and promotion of unhealthy foods & beverages through advertisement - To regulate mode and hours of advertisement of unhealthy food and beverages targeting children. - To facilitate a media campaign on National Dietary Guidelines. • To develop a Healthy Workplace Programme (on healthy eating). - To incorporate National Dietary Guidelines into PMO’s policies. - To facilitate inter-ministerial partnership in implementing Healthy Workplace Policy which will pave the way for Health in All Policies (HiAP). - To inculcate the use of healthier food branding in all PMO’s environment and at activities/events. - To support MOH in promoting awareness on salt, sugar and transfat - To inculcate the use of National Dietary Guidelines in all PMO’s environment and at activities/events. - To establish Healthy/Wellness Workplace Committee with defined Terms of References within PMO’s set-up. - To explore and identify existing facilities and programmes within the Government Sector conducive to promoting Healthy Workplace Policy and encourage usage/uptake by all ministries. • To incorporate National Dietary Guidelines into civil servant training. Ministry of • To use existing fiscal mechanisms to improve consumption of healthy food and Finance restriction of unhealthy food and beverages. - To support multi-agency requirement in training, infrastructure and capacity building - To allocate specific funds to enable implementation of Healthy Workplace Programme. • To develop Healthy Workplace Programme (on healthy eating). - To incorporate National Dietary Guidelines into MOF’s policies. - To inculcate the use of healthier food branding in all MOF’s environment and activities/ events. - To support MOH in promoting awareness on salt, sugar and transfat - To inculcate the use of National Dietary Guidelines in all MOF’s environment including canteens and activities/events. - To establish Healthy/Wellness Workplace Committee with defined Terms of References within MOF’s set-up. - To improve and modify as appropriate conducive to the implementation of Healthy Workplace Programme. - To incorporate future facilities conducive to the implementation of Healthy Workplace Programme. - To implement servings of fruit and vegetables as part of refreshments at all Ministerial public events • To support the regulation of advertisement, sponsorship and promotion of unhealthy foods and beverages. Ministry of • To develop Healthy Workplace Programme (on healthy eating). Defence - To incorporate Healthy Workplace features into MinDef’s Infrastructure Guideline Book - To incorporate National Dietary Guidelines into MinDef’s policies. 61 Ministry Guidance Ministry of - To inculcate the use of healthier food branding at all MinDef’s public and Defence military events. - To support MOH in promoting awareness on salt, sugar and transfat - To inculcate the use of National Dietary Guidelines in all MinDef’s environment including military camps, canteens and activities/events. - To establish Healthy/Wellness Workplace Committee with defined Terms of References within MinDef’s set-up. - To improve and modify as appropriate conducive to the implementation of Healthy Workplace Programme. - To incorporate future facilities conducive to the implementation of Healthy Workplace Programme. • To incorporate fruit and vegetable gardens/plots within military camps • To support the regulation of advertisement, sponsorship and promotion of unhealthy foods and beverages Ministry of • To promote importation of healthier food products. Foreign Affairs - To promote healthier food branding guidelines to importers of food products and Trade - To promote National Dietary Guidelines Key Recommendations to importers of food products. • To develop Healthy Workplace Programme (on healthy eating). - To incorporate National Dietary Guidelines into MOFAT’s policies. - To support and promote healthier food brands at all MOFAT’s regional and international trade meetings and activities/ events. - To support MOH in promoting awareness on salt, sugar and transfat - To inculcate the use of National Dietary Guidelines in all MOFAT’s environment including canteens and activities/events. - To establish Healthy/Wellness Workplace Committee with defined Terms of References within MOFAT’s set-up. - To improve and modify as appropriate conducive to the implementation of Healthy Workplace Programme. - To incorporate future facilities conducive to the implementation of Healthy Workplace Programme. • To support the regulation of advertisement, sponsorship and promotion of unhealthy foods and beverages. Ministry of • To develop and/or strengthen comprehensive school health programmes and Education frameworks: - Adopt school policy to promote healthy food including in all school canteens, events and meetings. - Align existing educational curriculum with National Dietary Guidelines. - Continue current and implement proposed initiatives such as “Drink Water Daily” and “Fruits and Vegetables Day” in schools; establishment of Health Clubs in schools; Proposing Healthy Canteen Award (HCA); etc. • To organise training for Ministry of Education officers and students on healthy lifestyle: - Build capacity for members of the Health Promotion Unit, Department of Schools; relevant MOE officers; school teachers and students on National Dietary Guidelines; food safety aspects; etc. 62 Ministry Guidance Ministry of • To incorporate community fruit and vegetable gardens/plots in housing Development development projects • To develop Healthy Workplace Programme (on healthy eating). - To incorporate National Dietary Guidelines into MOD’s policies. - To inculcate the use of healthier food branding in all MOD’s environment and sports activities/events. - To support MOH in promoting awareness on salt, sugar and transfat - To inculcate the use of National Dietary Guidelines in all MOD’s environment including canteens and activities/events. - To establish Healthy/Wellness Workplace Committee with defined Terms of References within MOD’s set-up. - To improve and modify as appropriate conducive to the implementation of Healthy Workplace Programme. - To incorporating future facilities conducive to the implementation of Healthy Workplace Programme. • To support the regulation of advertisement, sponsorship and promotion of unhealthy foods and beverages. Ministry of • To promote healthy diet among the general public through social media / Mobile Communications Health Solutions. - To support the MOH in marketing of healthier food brands - To assist in the dissemination of National Dietary Guidelines Key Recommendations/messages. • To support the regulation of advertisement, sponsorship and promotion of unhealthy foods and beverages to children through social media. • To develop Healthy Workplace Programme (on healthy eating). - To incorporate National Dietary Guidelines into MOC’s policies. - To inculcate the use of healthier food branding in all MOC’s environment and sports activities/events. - To support MOH in promoting awareness on salt, sugar and transfat - To inculcate the use of National Dietary Guidelines in all MOC’s environment including canteens and activities/events. - To establish Healthy/Wellness Workplace Committee with defined Terms of References within MOC’s set-up. - To improve and modify as appropriate conducive to the implementation of Healthy Workplace Programme. - To incorporate future facilities conducive to the implementation of Healthy Workplace Programme. 63 Ministry Guidance Ministry of • To develop ‘Public Fruit and Vegetables Parks/ Orchards’ for health, educational Industry and and commercial interest. Primary • To incorporate aspects of healthier food (low in sugar, salt and fat) within the Resources existing food security policy. • To work with food industry and importers for reformulation of products low in salt, sugar and fat; restriction and labelling requirements. - To ensure food industry complies with salt, sugar and transfat restriction and labelling requirement. - To provide analytical services and increase lab capacity on analysis of salt, sugar and trans-fat to local food industry / importers. - To educate local food manufacturers on salt, sugar and transfat - To provide technical and nutritional advisory on salt, sugar and transfat for Small-Medium Enterprises - To establish inventory of food with trans-fat content - To incorporate National Dietary Guidelines Key Recommendation in Small- Medium Enterprises products. • To develop Healthy Workplace Programme (on healthy eating). - To incorporate National Dietary Guidelines into MIPR’s policies. - To inculcate the use of healthier food branding in all MIPR’s environment and activities/ events. - To support MOH in promoting awareness on salt, sugar and transfat - To inculcate the use of National Dietary Guidelines in all MIPR’s environment including canteens and activities/events. - To establish Healthy/Wellness Workplace Committee with defined Terms of References within MIPR’s set-up. - To improve and modify as appropriate conducive to the implementation of Healthy Workplace Programme. - To incorporate future facilities conducive to the implementation of Healthy Workplace Programme. - To implement servings of fruit and vegetables as part of refreshments at all public events • To expand community education on fruit and vegetables on farming examples “Hari Peladang” • To support the regulation of advertisement, sponsorship and promotion of unhealthy foods and beverages. Ministry of • To emphasise the importance of healthy eating through the Islamic perspective. Religious • To promote planting of fruit trees within mosques and/or religious school Affairs compounds. • To develop Healthy Workplace Programme (on healthy eating). - To incorporate National Dietary Guidelines into MORA’s policies. - To inculcate the use of healthier food branding in all MORA’s environment and sports activities/ events. - To support MOH in promoting awareness on salt, sugar and transfat - To inculcate the use of National Dietary Guidelines in all MORA’s environment including canteens and activities/events. - To establish Healthy/Wellness Workplace Committee with defined Terms of References within MORA’s set-up. - To improve and modify as appropriate conducive to the implementation of Healthy Workplace Programme. - To incorporate future facilities conducive to the implementation of Healthy Workplace Programme. 64 Ministry Guidance Ministry of • To develop and strengthen a comprehensive Healthy School Programme based Religious on the Health Promoting School framework encompassing the healthy school Affairs award and nutrition friendly school initiative. - To adopt a school policy to promote healthy eating and healthier food branding in the school environment including school canteens, events and meetings - To review the current situation in awarding religious school canteen operators (Department of Islamic Studies) - To implement, monitor and evaluate current Guidelines on the Sales of Foods and Drinks in School Canteens (MoH, 2009) - To improve school canteens infrastructure conducive to healthier food preparation - To develop comprehensive, evidence-based, interesting pictorial resources to support healthy school canteens. - To establish Healthy Canteen Awards (HCA). - To adopt Drink Water Daily Initiatives in School - To train teachers/educators in Healthy Lifestyles using a holistic approach. • To support the regulation of advertisement, sponsorship and promotion of unhealthy foods and beverages. Ministry of • To incorporate National Dietary Guidelines in ‘One Kampong One Home Affairs Product’ initiative and restaurant grading scheme with menu assessment. - To encourage food and beverage outlets to implement menus in compliance with National Dietary Guidelines. • To regulate the advertisement and promotion of food and beverage products and restrict sponsorship of any public events. - To reduce the size of advertisements of unhealthy food and beverages as well as sponsor’s logo during national events and on billboards, banners and other marketing tools. • To support the regulation of advertisement, sponsorship and promotion of unhealthy foods and beverages. • To develop Healthy Workplace Programme (on healthy eating). - To incorporate National Dietary Guidelines into MOHA’s policies. - To inculcate the use of healthier food branding in all MOHA’s environment and sports activities/ events. - To support MOH in promoting awareness on salt, sugar and transfat - To inculcate the use of National Dietary Guidelines in all MOHA’s environment including canteens and activities/events. - To establish Healthy/Wellness Workplace Committee with defined Terms of References within MOHA’s set-up. - To improve and modify as appropriate conducive to the implementation of Healthy Workplace Programme. - To incorporate future facilities conducive to the implementation of Healthy Workplace Programme. 65 Ministry Guidance Ministry of • To develop Healthy Workplace Programme (on healthy eating). Culture, Youth - To incorporate National Dietary Guidelines into MCYS’s policies. and Sports - To inculcate the use of healthier food branding in all MCYS’s environment and sports activities/ events. - To support MOH in promoting awareness on salt, sugar and transfat - To inculcate the use of National Dietary Guidelines in all MCYS’s environment including canteens and activities/events. - To establish Healthy/Wellness Workplace Committee with defined Terms of References within MCYS’s set-up. - To improve and modify as appropriate conducive to the implementation of Healthy Workplace Programme. - To incorporate future facilities conducive to the implementation of Healthy Workplace Programme. • To educate athletes on the importance of healthy nutrition and well-being as well as sports performance • To support the regulation of advertisement, sponsorship and promotion of unhealthy foods and beverages. 66 Objective 3: To Increase Physical Activity MINISTRY OF HEALTH 1) To strengthen the implementation of National Physical Activity Guideline (NPAG) through: • The use of a Mass media campaign in partnership with relevant agencies to advocate PA programmes and inculcate PA in daily activities in the workplaces, schools and communities. • The facilitation of structured PA programmes in the community and workplace. ○ To facilitate structured PA programmes in Mukims and Kampongs. • Building capacity of relevant stakeholders to promote PA ○ To collaborate with MCYS on increasing the number and strengthening training of PA leaders. 2) To develop and implement healthy workplace programmes and appoint PA leaders / health ambassadors in each department. • To support training / exposure of PA leaders / health ambassadors in all sectors in promoting PA. • To inculcate active living (PA / exercise) in all government offices in accordance with NPAG. • To promote and support infrastructure conducive to PA such as well-lit, safe and accessible staircases. • To support programmes to encourage the use of stairs instead of lifts in the workplace. • To promote awareness among employers of the availability of PA facilities and services OTHER MINISTRIES Ministry Guidance Prime • To issue an administrative order requiring all ministries and government offices Minister’s to develop structured healthy workplace programmes emphasising on healthy diet Office and physical activity: - To appoint PA leaders / health ambassadors in each department. - To support training / exposure of PA leaders / health ambassadors in all sectors in promoting PA. - To inculcate active living (PA / exercise) in all government offices in accordance with NPAG. - To promote and support infrastructure conducive to PA such as well-lit, safe and accessible staircases. - To support programmes to encourage the use of stairs instead of lifts in the workplace. - To promote awareness among employers of the availability of PA facilities and services - To revitalise and enhance services offered at Mentiri Civil Service Club. 67 Ministry Guidance Ministry of • To continue providing financial support for the development and maintenance of Finance physical activity and recreational infrastructure. - Provide financial support for PA facilities and infrastructures for schools and workplaces. • To develop and implement healthy workplace programmes and appoint PA leaders / health ambassadors in each department. - To support training / exposure of PA leaders / health ambassadors in all sectors in promoting PA. - To inculcate active living (PA / exercise) in all government offices in accordance with NPAG. - To promote and support infrastructure conducive to PA such as well-lit, safe and accessible staircases. - To support programmes to encourage the use of stairs instead of lifts in the workplace. - To promote awareness among employers of the availability of PA facilities and services Ministry of • To develop and implement healthy workplace programmes and appoint PA Defence leaders / health ambassadors in each department. - To support training / exposure of PA leaders / health ambassadors in all sectors in promoting PA. - To inculcate active living (PA / exercise) in all government offices in accordance with NPAG. - To promote and support infrastructure conducive to PA such as well-lit, safe and accessible staircases. - To support programmes to encourage the use of stairs instead of lifts in the workplace. - To promote awareness among employers of the availability of PA facilities and services Ministry of • To develop and implement healthy workplace programmes and appoint PA Foreign Affairs leaders / health ambassadors in each department. and Trade - To inculcate active living (PA / exercise) in all government offices in accordance with NPAG. - To promote and support infrastructure conducive to PA such as well-lit, safe and accessible staircases. - To support programmes to encourage the use of stairs instead of lifts in the workplace. - To promote awareness among employers of the availability of PA facilities and services Ministry of • To incorporate Physical Education (PE) as part of the National Curriculum. Education • To improve infrastructure to promote physical activity in school settings: - Promote and support infrastructure conducive to PA with emphasis on safety according to SOP. - Ensure suitability of infrastructure for the forms of PA. • To strengthen the Health Promoting Schools initiatives to enhance PA in schools: - Develop Healthy School Award. - Incorporate National Physical Activity Guidelines (NPAG) in undergraduate curriculum training for teachers. - Ensure sufficient supply of skilled PE Teachers and plan systematically the allocation of PE teachers to schools. 68 Ministry Guidance Ministry of • To promote educational institution facilities for the community to access and Education practice healthy lifestyle: - Develop policies to support the sharing of educational institution facilities with the community. Ministry of • To support the development and maintenance of environments and Development infrastructure in all settings, conducive and safe for PA and recreation - To develop infrastructure based on the MinDef infrastructure guidelines for other government offices. - To provide facilities and infrastructures in schools for Physical Activity (PA) - To provide guidelines for PA-friendly building design (targeted for Authority Of Building Construction Industry contractors, architects, support industries etc. by 2014) - To develop comprehensive and connected walking and cycling parks as well as cycling paths by 2013 - To develop PA facilities in the Mukims. (Targeted goals: To achieve 50% by 2018 and each Mukim should have at least one active recreation facility) • To make facilities more accessible and available for all age groups in the community and to provide guidelines by the end of 2013/early 2014. • To develop and implement healthy workplace programmes and appoint PA leaders / health ambassadors in each department. - To support training / exposure of PA leaders / health ambassadors in all sectors in promoting PA. - To inculcate active living (PA / exercise) in all government offices in accordance with NPAG. - To promote and support infrastructure conducive to PA such as well-lit, safe and accessible staircases. - To support programmes to encourage the use of stairs instead of lifts in the workplace. - To promote awareness among employers of the availability of PA facilities and services 69 Ministry Guidance Ministry of • To promote active transportation in line with the Bandar Seri Begawan Masterplan, Communications Transport Masterplan draft and other urban development plans. - To seek consultation input on pending transport Masterplan by 2014 - To develop traffic light design for cycling in consultation with cyclist groups (example Holland by 2013) • To develop and implement healthy workplace programmes and appoint PA leaders / health ambassadors in each department. - To support training / exposure of PA leaders / health ambassadors in all sectors in promoting PA. - To inculcate active living (PA / exercise) in all government offices in accordance with NPAG. - To promote and support infrastructure conducive to PA such as well-lit, safe and accessible staircases. - To support programmes to encourage the use of stairs instead of lifts in the workplace. - To promote awareness among employers of the availability of PA facilities and services Ministry of • To support the development and maintenance of forest reserve parks conducive Industry and to physical activity and recreation. Primary • To develop and implement healthy workplace programmes and appoint PA Resources leaders / health ambassadors in each department. - To support training / exposure of PA leaders / health ambassadors in all sectors in promoting PA. - To inculcate active living (PA / exercise) in all government offices in accordance with NPAG. - To promote and support infrastructure conducive to PA such as well-lit, safe and accessible staircases. - To support programmes to encourage the use of stairs instead of lifts in the workplace. - To promote awareness among employers of the availability of PA facilities and services Ministry of • To support and develop a Health Promoting Schools initiative using Islamic Religious teachings as a basis in promoting a healthy lifestyle in school settings under the Affairs preview of MORA. - To engage parental volunteers to assist in PA - To train teachers in PA - To promote and incorporate innovative ways to add PA to the school day examples during assembly, Health Clubs activities and other events. • To develop and implement healthy workplace programmes and appoint PA leaders / health ambassadors in each department. - To support training / exposure of PA leaders / health ambassadors in all sectors in promoting PA. - To inculcate active living (PA / exercise) in all government offices in accordance with NPAG. - To promote and support infrastructure conducive to PA such as well-lit, safe and accessible staircases. - To support programmes to encourage the use of stairs instead of lifts in the workplace. - To promote awareness among employers of the availability of PA facilities and services 70 Ministry Guidance Ministry of • To support the development and maintenance of parks and recreational areas Home Affairs in districts and local communities, conducive and safe for PA and recreation. • To ensure that every Mukim has a facility for PA promotion. - Development of PA facilities (Targeted goals: To achieve 50% by 2018 and each Mukim should have at least one active recreation facility) - To facilitate structured PA in Mukims and Kampongs by final quarter 2013 • To develop and implement healthy workplace programmes and appoint PA leaders / health ambassadors in each department. - To support training / exposure of PA leaders / health ambassadors in all sectors in promoting PA. - To inculcate active living (PA / exercise) in all government offices in accordance with NPAG. - To promote and support infrastructure conducive to PA such as well-lit, safe and accessible staircases. - To support programmes to encourage the use of stairs instead of lifts in the workplace. - To promote awareness among employers of the availability of PA facilities and services Ministry of • To develop sports schemes and programmes for all ages. Culture, Youth - To conduct and publicise training programmes on PA and First Aid. and Sports - To promote behaviour conducive to a healthy lifestyle during the programmes. - Make the booking of facilities more user-friendly and accessible to the community • To increase public awareness on PA and sport facilities in Brunei through a mass media campaign. - To update calendar of PA events nationwide on the website • To create a National Task Force for promoting PA. • To provide guidelines to other ministries on age-appropriate PA equipment and facilities (indoor and outdoor). • To develop and implement healthy workplace programmes and appoint PA leaders / health ambassadors in each department. - To support training / exposure of PA leaders / health ambassadors in all sectors in promoting PA. - To inculcate active living (PA / exercise) in all government offices in accordance with NPAG. - To promote and support infrastructure conducive to PA such as well-lit, safe and accessible staircases. - To support programmes to encourage the use of stairs instead of lifts in the workplace. - To promote awareness among employers of the availability of PA facilities and services 71

Annex 2: Comprehensive Global Monitoring Framework, Including 25 Indicators, and a Set of Nine Voluntary Global Targets for the Prevention and Control of Noncommunicable Diseases Framework element Target Indicator Mortality and morbidity Premature mortality from (1) A 25% relative reduction in (1) Unconditional probability of dying noncommunicable disease risk of premature mortality from between ages of 30 and 70 from cardiovascular diseases, cancer, cardiovascular diseases, cancer, diabetes, or chronic respiratory diabetes or chronic respiratory diseases diseases Additional indicator (2) Cancer incidence, by type of cancer, per 100 000 population Risk factors Behavioural risk factors Harmful use of alcohol1 (2) At least 10% relative reduction (3) Total (recorded and unrecorded) in the harmful use of alcohol,2 as alcohol per capita (≥ 15 years old) appropriate, within the national consumption within a calendar context year in litres of pure alcohol, as appropriate, within the national context (4) Age-standardized prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context (5) Alcohol-related morbidity and mortality among adolescents and adults, as appropriate, within the national context Physical inactivity (3) A 10% relative reduction in (6) Prevalence of insufficiently physically prevalence of insufficient active adolescents, defined as less physical activity than 60 minutes of moderate to vigorous intensity activity daily (7) Age-standardized prevalence of insufficiently physically active persons ≥18 years (defined as less than 150 minutes of moderate- intensity activity per week, or equivalent) Salt/sodium intake (4) A 30% relative reduction in mean (8) Age-standardized mean population population intake of salt/sodium3 intake of salt (sodium chloride) per day in grams in persons 18 years Tobacco use (5) A 30% relative reduction in (9) Prevalence of current tobacco use prevalence of current tobacco use among adolescents in persons aged 15+ years (10) Age-standardized prevalence of current tobacco use among persons 18 years 72 Framework element Target Indicator Biological risk factors Raised blood pressure (6) A 25% relative reduction in the (11) Age-standardized prevalence of prevalence of raised blood raised blood pressure among pressure or contain the persons ≥ 18 years (defined as prevalence of raised blood systolic blood pressure ≥140 pressure, according to national mmHg and/or diastolic blood circumstances pressure ≥90 mmHg) and mean systolic blood pressure 1 Countries will select indicator(s) of harmful use as appropriate to national context and in line with WHO’s global strategy to reduce the harmful use of alcohol and that may include prevalence of heavy episodic drinking, total alcohol per capita consumption, and alcohol-related morbidity and mortality, among others. 2 In WHO’s global strategy to reduce the harmful use of alcohol the concept of the harmful use of alcohol encompasses the drinking that causes detrimental health and social consequences for the drinker, the people around the drinker and society at large, as well as the patterns of drinking that are associated with increased risk of adverse health outcomes. 3 WHO’s recommendation is less than 5 grams of salt or 2 grams of sodium per person per day. Framework element Target Indicator Diabetes and obesity4 (7) Halt the rise in diabetes and (12) Age-standardized prevalence of obesity raised blood glucose/diabetes among persons aged ≥ 18 years (defined as fasting plasma glucose concentration ≥ 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose) (13) Prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference for school-aged children and adolescents, overweight – one standard deviation body mass index for age and sex, and obese – two standard deviations body mass index for age and sex) (14) Age-standardized prevalence of overweight and obesity in persons aged ≥ 18 years (defined as body mass index ≥ 25 kg/m² for overweight and body mass index ≥ 30 kg/m² for obesity) Additional indicators (15) Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged ≥18 years.5 (16) Age-standardized prevalence of persons (aged ≥ 18 years) consuming less than five total servings (400 grams) of fruit and vegetables per day (17) Age-standardized prevalence of raised total cholesterol among persons aged ≥ 18 years (defined as total cholesterol ≥5.0 mmol/l or 190 mg/dl); and mean total cholesterol concentration 73 Framework element Target Indicator National systems response Drug therapy to prevent heart (8) At least 50% of eligible people (18) Proportion of eligible persons attacks and strokes receive drug therapy and (defined as aged 40 years and counselling (including glycaemic older with a 10-year cardiovascular control) to prevent heart attacks risk ≥30%, including those with and strokes existing cardiovascular disease) receiving drug therapy and counseling (including glycaemic control) to prevent heart attacks and strokes Essential noncommunicable (9) An 80% availability of the (19) Availability and affordability of disease medicines and basic affordable basic technologies and quality, safe and efficacious technologies to treat major essential medicines, including essential noncommunicable disease noncommunicable diseases generics, required to treat major medicines, including generics, and noncommunicable diseases in basic technologies in both public both public and private facilities and private facilities Additional indicators (20) Access to palliative care assessed by morphine equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer (21) Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply, as appropriate, within the national context and national programmes (22) Availability, as appropriate, if cost-effective and affordable, of vaccines against human papillomavirus, according to national programmes and policies (23) Policies to reduce the impact on children of marketing of foods and non- alcoholic beverages high in saturated fats, trans fatty acids, free sugars, or salt (24) Vaccination coverage against hepatitis B virus monitored by number of third doses of Hep-B vaccine (HepB3) administered to infants (25) Proportion of women between the ages of 30–49 screened for cervical cancer at least once, or more often, and for lower or higher age groups according to national programmes or policies 4 Countries will select indicator(s) appropriate to national context. 5 Individual fatty acids within the broad classification of saturated fatty acids have unique biological properties and health effects that can have relevance in developing dietary recommendations. 74

Annex 3: Protocols for NCD Risk Reduction and Integrated Management of CVD Risk WHO PEN Protocol 1 Prevention of Heart Attacks, Strokes and Kidney Disease through Integrated Management of Diabetes and Hypertension (Best Buy) When could this Protocol be used? ● The protocol is for assessment and management of cardiovascular risk using hypertension, diabetes mellitus (DM) and tobacco use as entry points ● It could be used for routine management of hypertension and DM and for screening, targeting the following categories of people: ► age > 40 years ► smokers ► waist circumference ( ≥ 90 cm in women ≥100 cm in men) ► known hypertension ► known DM ► history of premature CVD in first degree relatives ► history of DM or kidney disease in first degree relatives Follow instructions given in Action 1 to Action 4, step by step Action 1. Ask about: ● Diagnosed heart disease, stroke, transient ischemic attack, DM, kidney disease ● Angina, breathlessness on exertion and lying flat, numbness or weakness of limbs, loss of FIRST VISIT weight, increased thirst, polyuria, puffiness of face, swelling of feet, passing blood in urine etc ● Medicines that the patient is taking ● Current tobacco use (yes/no) (answer yes if tobacco use during the last 12 months) ● Alcohol consumption (yes/no) (if `Yes`, frequency and amount) ● Occupation (sedentary or active) ● Engaged in more than 30 minutes of physical activity at least 5 days a week (yes/no) ● Family history of premature heart disease or stroke in first degree relatives References World Health Organization. Prevention and control of noncommunicable diseases ; Guidelines for primary health care, 2012 World Health Organization. Scaling up action against noncommunicable diseases. How much will it cost?, 2011 World Health Organization. Prevention of cardiovascular diseases; Pocket guidelines for assessment and management of cardiovascular risk, 2008 75 WHO PEN Protocol 1 Prevention of Heart Attacks, Strokes and Kidney Disease through Integrated Management of Diabetes and Hypertension (Best Buy) Action 2. Assess (physical exam and blood and Action 3. Estimate cardiovascular risk (in those not urine tests): referred): ● Waist circumference ● Use the WHO/ISH risk charts relevant to the WHO ● Measure blood pressure, look for pitting odema subregion (Annex and CD) ● Palpate apex beat for haeving and displacement ● Use age, gender, smoking status, systolic blood ● Auscultate heart (rhythm and murmurs) pressure, DM (and plasma cholesterol if available) ● Auscultate lungs (bilateral basal crepitations) ● If age 50-59 years select age group box 50, if 60- ● Examine abdomen (tender liver) 69 years select age group box 60 etc., for people ● In DM patients examine feet; sensations, pulses, age < 40 years select age group box 40 and ulcers ● If cholesterol assay cannot be done use the mean ● Urine ketones (in newly diagnosed DM) and cholesterol level of the population or a value of protein 5.2 mmol/l to calculate the cardiovascular risk) ● Total cholesterol ● If the person is already on treatment, use ● Fasting or random blood sugar (diabetes= fasting pretreatment levels of risk factors (if information blood sugar≥7 mmol/l (126 mg/dl) or random is available to assess and record the pretreatment blood sugar ≥11.1 mmol/l (200 mg/dl) risk. Also assess the current risk using current FIRST VISIT (Point of care devices can be used for testing levels of risk factors) blood sugar if laboratory facilities are not ● Risk charts underestimate the risk in those with available) family history of premature vascular disease, obesity, raised triglyceride levels Action 4: Referral criteria for all visits: ● BP >200/>120 mm Hg (urgent referral) ● Any proteinuria ● BP ≥140 or ≥ 90 mmHg in people < 40 yrs (to ● Newly diagnosed DM with urine ketones 2+ or in lean exclude secondary hypertension) persons of <30 years ● Known heart disease, stroke, transient ischemic attack, ● Total cholesterol >8mmol/l DM, kidney disease (for assessment, if this has not been ● DM with poor control despite maximal metformin with done) or without sulphonylurea ● New chest pain or change in severity of angina or ● DM with severe infection and/or foot ulcers symptoms of transient ischemic attack or stroke ● DM with recent deterioration of vision or no eye exam ● Target organ damage (e.g. angina, claudication, haeving in 2 years apex, cardiac failure) ● High cardiovascular risk ● Cardiac murmurs ● Raised BP ≥140/90 (in DM above 130/80mmHg) while on treatment with 2 or 3 agents If referral criteria are not present go to Action 5 76 WHO PEN Protocol 1 Prevention of Heart Attacks, Strokes and Kidney Disease through Integrated Management of Diabetes and Hypertension (Best Buy) If referral criteria are not present go to Action 5 Risk < 20% ● Counsel on diet, physical activity, smoking cessation and Additional actions for avoiding harmful use of alcohol individuals ● If risk < 10% follow up in 12 months with DM: ● If risk 10 - < 20% follow up every 3 months until targets ● Give an antihypertensive are met, then 6-9 months thereafter for those with BP ≥ 130/80 mmHg Risk 20 to ● Counsel on diet, physical activity, smoking cessation and ● Give a statin to all with <30% avoiding harmful use of alcohol type 2 DM aged ≥ 40 ● Persistent BP ≥ 140/90 mm Hg consider drugs (see below years ** Antihypertensive medications) ● Give metformin for type ● Follow-up every 3-6 months 2 DM if not controlled by diet only ● (FBS>7mmol/l), and Risk > 30% ● Counsel on diet, physical activity, smoking cessation and if there is no renal avoiding harmful use of alcohol insufficiency, liver ● Persistent BP ≥ 130/80 consider drugs (see below ** disease or hypoxia. Antihypertensive medications) ● Titrate metformin to ● Give a statin target glucose value ● Follow-up every 3 months, if there is no reduction in ● Give a sulfonylurea cardiovascular risk after six months of follow up refer to to patients who have next level FIRST VISIT contraindications to metformin or if metformin does not Important Consider drug treatment for following categories improve glycaemic practice points ● All patients with established DM and cardiovascular disease control. (coronary heart disease, myocardial infarction, transient ● Give advise on foot ischaemic attacks, cerebrovascular disease or peripheral hygiene, nail cutting, vascular disease), renal disease. If stable, should continue treatment of calluses, the treatment already prescribed and be considered as with appropriate footwear risk >30% and assess feet at risk ● People with albuminuria, retinopathy, left ventricular of ulcers using simple hypertrophy methods (inspection, ● All individuals with persistent raised BP ≥ 160/100 mmHg; pin-prick sensation) antihypertensive treatment ● Angiotensin converting ● All individuals with total cholesterol at or above 8 mmol/l enzyme inhibitors and/ (320 mg/dl); lifestyle advice and statins or low-dose thiazides are recommended as first-line treatment of hypertension. Beta ** Antihypertensive medications blockers are not ● If under 55 years low dose of a thiazide diuretic and/or recommended for initial angiotensin converting enzyme inhibitor management but can ● If over 55 years calcium channel blocker and/or low dose be used if thiazides or of a thiazide diuretic angiotensin converting ● If intolerant to angiotensin converting enzyme inhibitor or enzyme inhibitors are for women in child bearing age consider a beta blocker contraindicated. ● Thiazide diuretics and/or long-acting calcium channel ● Follow up every 3 blockers are more appropriate as initial treatment for certain months ethnic groups. Medications for compelling indications should be prescribed, regardless of race/ethnicity ● Test serum creatinine and potassium before prescribing an angiotensin converting enzyme inhibitor 77 WHO PEN Protocol 1 Prevention of Heart Attacks, Strokes and Kidney Disease through Integrated Management of Diabetes and Hypertension (Best Buy) Advice to patients and family ● Avoid table salt and reduce salty foods such as pickles, salty fish, fast food, processed food, canned food and stock cubes ● Have your blood glucose level, blood pressure and urine checked regularly Advice specific for DM FIRST VISIT ● Advise overweight patients to reduce weight by reducing their food intake. ● Advise all patients to give preference to low glycaemic-index foods ( e.g.beans, lentils, oats and unsweetened fruit) as the source of carbohydrates in their diet ● If you are on any DM medication that may cause your blood glucose to go down too low carry sugar or sweets with you ● If you have DM, eyes should be screened for eye disease (diabetic retinopathy) by an ophthalmologist at the time of diagnosis and every two years thereafter, or as recommended by the ophthalmologist ● Avoid walking barefoot or without socks ● Wash feet in lukewarm water and dry well especially between the toes ● Do not cut calluses or corns, and do not use chemical agents on them ● Look at your feet every day and if you see a problem or an injury, go to your health worker SECOND VISIT Repeat ● Ask about: new symptoms, adherence to advise on tobacco and alcohol use, physical activity, healthy diet, medications etc ● Action 2 Assess (Physical exam) ● Action 3 Estimate cardiovascular risk ● Action 4 Refer if necessary ● Action 5 Counsel all and treat as shown in protocol 78 WHO PEN Protocol 2 Health Education and Counselling on Healthy Behaviours (to be applied to ALL) Educate your patient to Eat a heart healthy diet ● Take regular physical activity Salt (sodium chloride) ● Eat a “heart healthy” diet ● Restrict to less than 5 grams (1 teaspoon) per day ● Stop tobacco and avoid harmful use of alcohol ● Reduce salt when cooking, limit processed and fast foods ● Attend regular medical follow-up Fruits and vegetables ● 5 servings (400-500 grams) of fruits and vegetable per day ● 1 serving is equivalent to 1 orange, apple, mango, banana or 3 tablespoons of cooked vegetables Fatty food ● Limit fatty meat, dairy fat and cooking oil (less than two tablespoons per day) ● Replace palm and coconut oil with olive, soya, corn, rapeseed Take regular physical activity or safflower oil ● Progressively increase physical activity to moderate ● Replace other meat with chicken (without skin) levels (such as brisk walking); at least 30 minutes per day on 5 days of the week Fish ● Control body weight and avoid overweight by reducing ● Eat fish at least 3 times per week, preferably oily fish such as high calorie food and taking adequate physical activity tuna, mackerel or salmon Stop Tobacco and avoid harmful use of Alcohol: Adherence to treatment ● Encourage all non-smokers not to start smoking ● If the patient is prescribed a medicine/s: ● Strongly advise all smokers to stop smoking and support ○ teach the patient how to take it at home: them in their efforts ○ explain the difference between medicines for long- term ● Individuals who use other forms of tobacco should be control (e.g. blood pressure) and medicines for quick relief advised to quit (e.g. for wheezing) ● Alcohol abstinence should be reinforced. ○ tell the patient the reason for prescribing the medicine/s ● People should not be advised to start taking alcohol for ● Show the patient the appropriate dose health reasons ● Explain how many times a day to take the medicine ● Advise patients not to use alcohol when additional risks ● Label and package the tablets are present, such as: ● Check the patient’s understanding before the patient leaves ○ driving or operating machinery the health centre ○ pregnant or breast feeding ● Explain the importance of: ○ taking medications that interact with alcohol ○ keeping an adequate supply of the medications ○ having medical conditions made worse by alcohol ○ the need to take the medicines regularly as advised even if ○ having difficulties in controlling drinking there are no symptoms 79 WHO PEN Protocol 2 Health Education and Counselling on Healthy Behaviours; Counselling on Cessation of Tobacco use Reinforce message that A1: ASK Do you use tobacco? NO tobacco increases risk of heart disease Advise to quit in a clear, strong and personalized manner A2: ADVISE YES “Tobacco use increases the risk of developing a heart attack, stroke, lung cancer and respiratory diseases. Quitting tobacco use is the one most important thing you can do to protect your heart and health, you have to quit now.” A3: ASSESS Are you willing to make a quit attempt now? YES NO Assist in preparing a quitting plan Promote motivation to quit Set quit date Provide information on Inform family and friends health hazards of tobacco and A4: ASSIST Ask for their support give leaflet to the patient Remove cigarettes/tobacco Remove objects/articles that prompt you to smoke Arrange follow up visit* At follow-up visit A5: ARRANGE Congratulate success and reinforce If patient has relapsed, consider more intensive follow-up and support from family * Ideally second follow-up visit is recommended within the same month and every month thereafter for 4 months and evaluation after 1 year. If not feasible, reinforce counselling whenever the patient is seen for blood pressure monitoring. 80