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Lecture No.3
NCDs and Life in Asia – What Must We Do Now?
SPEAKER
Saunthari Somasundaram
President and Medical Director, the National Cancer Society of Malaysia
Co-chairperson, NCD Malaysia
President-Elect, NCD Alliance
- Profile -
Saunthari SOMASUNDARAM, with over two decades of experience in cancer control, is a leading advocate for cancer awareness, prevention, early detection, and survivorship, primarily through the National Cancer Society of Malaysia (NCSM). During the Covid-19 pandemic, NCSM’s efforts were recognized with the Overall Outstanding Vaccination Contribution by Healthcare Non-Governmental Organisation (Malaysia) Award. Dr. Saunthari’s work extends to international Non-Communicable Disease (NCD) control, contributing to global solutions and local sustainable initiatives, including her advisory role for the Malaysian Ministry of Health and uniting Civil Society Organisations (CSOs) in health sectors. Her international influence includes serving as a Board Member of UICC and contributing to the cancer control agenda regionally and globally.
Locally, Dr. Saunthari has been instrumental in championing the NCD agenda since 2010, establishing the NCD Alliance Malaysia in 2018 and contributing to tobacco control efforts through MyWatch. She is deeply involved in initiatives like the City Cancer Challenge, Greater Petaling, and works directly with cancer patients, providing support and medical counseling. Her diverse skills and extensive experience offer a holistic understanding of the challenges and opportunities in NCD and cancer control in the ASEAN region. In acknowledgment of her significant contributions, she was conferred the Darjah Datuk Paduka Mahkota Perak award in November 2020 by His Royal Highness The Sultan of Perak.
Kosuke MATSUI
Manager, Global R&D Framework Preparation Team, Yakult Honsha Co., Ltd
- Profile -
Kosuke MATSUI is Manager of Global R&D Framework Preparation Team at Yakult Honsha Co., Ltd. He graduated from Tokyo University of Marine Science and Technology in 2008 with a degree from the Department of Ocean Sciences. After joining Yakult Honsha Co., Ltd. in 2008 he worked in various capacities and served in diverse roles, including Home Delivery business in Japan and the International Business Department. In 2012, he moved to Yakult Europe B.V. in the Netherlands (European HQ) as a Manager of the Corporate Planning Office until 2022. In that period, he also worked at Yakult Deutschland GmbH as a Sales & Marketing manager between 2014-2020. He returned to Japan in 2022 and worked as Assistant Manager of the Science & Communications Support Section at the International Operations Department until March 2025, before assuming his current position.
SUMMARY
(1) Introduction to the lecture
Norie KAWAHARA began by reflecting on the previous two lectures. She noted that in the first session, titled “How Can Healthcare Connect Beyond Borders?” Dr. Shinjiro NOZAKI and Dr. Rabindra ABEYASINGHE the WHO Western Pacific Regional Office had discussed the possibilities and imperatives of cross-border collaboration in health care.
They emphasized the importance of shared challenges among Japan and its Asian neighbors, and the need to combine knowledge and capital across national boundaries to improve health and well-being. Drawing on lessons from pandemic response and Universal Health Coverage, Dr. Abeyashinghe had argued for a shift from one-way aid to mutual learning and bilateral cooperation.
The second session, titled “The North–South Asymmetry in the Global Knowledge Structure of Cancer Research,” brought into focus a pressing epistemic issue. Dr. Malcolm MOORE of the Asia Pacific Journal of Cancer Prevention (APJCP) highlighted how the global production of cancer research remains structurally biased— privileging data, funding, and publication from the Global North. He urged for a reconstruction of this knowledge architecture, so that insights from the Global South can stand as equal contributions to the world’s fight against cancer.
Dr. Kawahara noted that in the third lecture, the speaker, Dr. Saunthari SOMASUNDARAM, would focus on the rising burden of noncommunicable diseases (NCDs) across Asia, and how we might respond. It was noted that Dr. Somasundaram draws on her leadership experience not only in Malaysia, but also across regional and global health platforms, to address shared challenges and collective solutions.
This lecture is also a concrete response to the North–South asymmetry discussed in the previous lecture: knowledge and practice emerging from Malaysia—such as early screening and community education—offer new pathways beyond traditional models shaped in the Global North. The presentation builds directly on the themes of cross-border collaboration and knowledge equity from earlier lectures, and shifts the conversation toward practical application in addressing one of Asia’s most urgent public health issues.
(2) Lecture 1
NCDs and life in Asia: what must we do now?
Saunthari SOMASUNDARAM began by establishing the stark reality facing Asia and the world today: non-communicable diseases (NCDs) have become the number one killer globally, accounting for over 75% of all deaths globally. While this burden appears concentrated in high-income countries, NCDs are rising rapidly even in lower-income countries, particularly across Asia. Seven of the world's top ten leading causes of death are NCDs, a reality often obscured by the medical community's tendency to discuss these diseases in isolation.
Ischemic heart disease emerges as the world's single biggest killer, responsible for 16% of total deaths, with its mortality rising by more than 2 million deaths since 2000 to reach 8.9 million in 2019. Stroke and chronic obstructive pulmonary disease follow as the second and third leading causes of death. Beyond these headline killers, tracheal, bronchial, and lung cancer deaths have risen from 1.2 million to 1.8 million, while Alzheimer's disease and other forms of dementia rank as the seventh leading cause of death globally, disproportionately affecting women. Perhaps most alarmingly, diabetes—historically viewed as merely a risk factor—has itself entered the top ten causes of death, experiencing a 70% increase since 2000 and an 80% increase in male deaths during the same period.
The impact extends beyond mortality. NCDs are a leading cause of disability throughout the life course. While infectious diseases predominantly affect younger populations, the greatest burden of disability falls upon working-age adults, driven primarily by cancers, cardiovascular diseases, and chronic respiratory conditions (Figure 1).
Figure. 1 The burden of disability
However, the geographic distribution of this burden reveals a critical injustice: lower and middle-income countries experience 82% of all premature deaths from NCDs—those occurring before age 70—affecting 18 million people annually across regions including Asia.
To understand why Asia and lower-income countries suffer disproportionately, one must look beneath the surface using what Dr. Somasundaram termed an “iceberg” framework. Above the waterline lie visible disease categories: cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes. Below the waterline are the true drivers—metabolic risk factors, behavioral risk factors, and crucially, social determinants of health that policymakers frequently ignore or underestimate (Figure 2).
Figure. 2 The “iceberg” of the drivers and determinants of NCDs
Dr. Somasundaram challenged the prevailing narrative around “modifiable” risk factors. Traditionally, public health has emphasized smoking, alcohol consumption, poor diet, and physical inactivity as easily changeable personal behaviors. Dr. Somasundaram argued that this framing obscures fundamental injustices. Can smoking truly be modified when individuals have been exposed to tobacco advertising throughout their lives? Are healthy diets genuinely accessible in all communities, or are they embedded in cultural norms and economic realities? Do living environments actually support physical activity?
More fundamentally, the commercial determinants of NCDs, and the role of health-harming industries, demand greater attention. Industries producing tobacco, alcohol, ultra-processed foods, and fossil fuels aggressively target populations in low and middle-income countries where regulatory frameworks remain weak. These industries interfere with policy adoption, frame NCDs as matters of personal choice rather than structural failure, and deliberately shift responsibility from themselves to consumers. The scale of their influence is significant: 33 health-harming companies generated combined sales of $829 billion in 2017. Coca-Cola spends approximately $4 billion annually on marketing—exceeding the public health budgets of many LMICs—while US tobacco firms spend $1 million per hour on advertising.
Asia faces a uniquely accelerated aging demographic crisis. While European societies transitioned to aging status gradually over more than a century, Asia is experiencing this transformation in just a few decades. In Asia specifically, the population aged 60 and above is projected to nearly double from 77.4 million in 2024 to 173 million by 2050. More alarmingly, the over-60 population across Southeast Asia is estimated to reach 127 million by 2035. Thailand’s transition to an aged society occurred in just 20 years, compared to France’s 115-year transition. This rapid demographic shift creates unprecedented pressure on health systems already ill-equipped to respond.
This demographic pressure occurs against a background of rapid socioeconomic transition and challenges unique to LMICs, such as the “double whammy” of infectious diseases and NCDs. Nations simultaneously struggle with obesity and malnutrition, rapid economic growth coupled with limited capacity to adapt health systems, and the coexistence of infectious and chronic diseases. Health systems in these regions lag dangerously behind.
While service coverage for infectious diseases has increased substantially and the Universal Health Coverage (UHC) service index has risen, NCD service coverage has remained flat. Awareness, screening, diagnosis, treatment, and adherence gaps persist across every element of the care continuum (Figure 3).
Figure. 3 Challenges faced by LMICs in responding to NCDs
Hypertension exemplifies this failure: 1.2 billion people globally have hypertension, a condition straightforward to diagnose and treat with inexpensive medications, yet almost half remain unaware of their diagnosis. Across ASEAN nations, hypertension affects over one in four adults, yet only one in three are aware of their condition, fewer than 40% receive regular treatment, and among those treated, control rates remain below 20%.
Global financing dramatically lags behind disease burden. NCDs account for the majority of global disease burden yet receive only approximately 2% of global health development financing. The economic toll is enormous: $47 trillion over 20 years through lost productivity due to absenteeism and presenteeism, displaced workers, lost incomes, increased medical expenditures, caretaking burdens, and expanded government and private sector spending beyond direct health costs (Figure 4).
Figure. 4 Economic impact of NCDs
Dr. Somasundaram identified five fundamental reasons for this catastrophic failure: 1) socioeconomic and structural inequalities, 2) commercial and policy determinants, 3) rapid transition, 4) lagged health system response, and 5) demographic pressures. More profoundly, NCDs must be understood not as separate diseases but as components of a deeply interconnected system where economic, social, environmental, and political factors constantly reinforce each other, particularly in Asia where the pace of some changes accelerates while others lag dangerously behind.
Effective response requires a comprehensive approach grounded in guiding principles: life-course approach, community anchored, equity-first framing, co-design, and pragmatic sequencing of interventions. Rather than attempting wholesale transformation, interventions should proceed systematically, starting with achievable targets (“benches”) before advancing to nurse-led care and eventually pension reform. This pragmatism acknowledges that what is politically and financially feasible varies by context and available resources.
Policy responses operate across multiple levels: global, regional, and local. Regionally, establishing data dashboards to track NCD control and nutrition policies is foundational, as “what cannot be measured cannot be improved.” Such systems enable countries to understand their baseline status and identify opportunities for improvement while contributing to regional understanding.
Food systems tracking mechanisms like the Pacific Food Trade Database monitor food movement across borders, revealing how regional trade patterns influence national dietary availability and health outcomes.
Regional frameworks like WHO's Regional Strategy on Healthy Ageing 2024-2030 provide adaptable models that countries can customize for local implementation, facilitating coordinated action across diverse contexts.
In terms of policy levers on the local level, interventions must engage cross-ministerial stakeholders beyond health departments, incorporate public-private-civil society partnerships, and focus on accessible, low-cost clinical interventions like hypertension and diabetes management. This cross-sector approach recognizes that agriculture, education, and trade policies profoundly influence health outcomes.
Public-private-civil society pilots focus on practical food system innovations, such as reformulating existing products to reduce sodium and sugar, supporting fortified staples, negotiating healthier menu options in institutional canteens, and ensuring low-salt alternatives. Healthy public procurement of foods leverages government purchasing power to create market incentives for healthier options. Fiscal tools including sugar taxes and trans-fat bans, combined with restrictions on marketing harmful commodities to children, create structural disincentives to poor dietary choices.
At the clinical and community level, the focus is on low-hanging fruit: detecting, treating, and controlling hypertension and diabetes through accessible, evidence-based interventions. Screening combined with secondary prevention programs based on cardiovascular risk assessment ensure that resources target those at highest risk. Community health workers and digital tools extend reach to older adults, leveraging local knowledge and appropriate technology to achieve equitable coverage. These approaches acknowledge that many effective interventions require neither cutting-edge technology nor massive infrastructure investment, but rather strategic deployment of existing evidence and human resources.
Beyond immediate clinical interventions, comprehensive social determinant responses prove essential. Income protection schemes must link health incentives to social protection, ensuring financial security enables rather than impedes healthy choices. Built environment redesign can create “active cities” through safe walking paths, green spaces, and accessible public transport. Food policy shifts make healthy choices the default, shifting responsibility from individuals to systems.
Furthermore, continuous health literacy education throughout the life course—not as one-time interventions but as ongoing support—enables informed decision-making at every stage. Education efforts range from early schooling through tertiary levels, and workplace learning modules on diet and physical activity. Technology deployment deliberately narrows equity gaps through telehealth for remote screening and medication adherence support, AI-enabled diagnostics for lung, breast, and cervical cancer screening in community clinics, and digital inclusion programs for older adults and rural communities.
Governance mechanisms establish whole-of-government accountability frameworks for NCDs, reframing governance beyond health sectors to “health in all policies.” Civil society participation should become institutionalized, not peripheral, within policy design, monitoring, and evaluation. This systematic integration ensures NCD policies align under shared metrics.
The WHO Global Action Plan for the Prevention and Control of NCDs includes four pillars: leadership and governance, prevention, health systems, and research and surveillance. All four of these pillars need to be tackled together for any significant and impactful change to happen.
Examples of system solutions demonstrate feasibility across diverse contexts. Thailand's Universal Coverage Scheme integrates NCD care into benefit packages covering nearly the entire population, embodying the principle that universal health coverage must include NCDs.
The Philippines' Universal Health Care Act and National Integrated Cancer Control Act (NICCA) similarly embeds NCD prevention into national policy frameworks.
Singapore’s “HealthySG” integrates health into urban design and planning, increasing hawker stall offerings of healthier choices and co-funding workplace showers and lockers.
Japan’s Toyama City “compact city” initiative places key amenities within walkable distances while increasing green space, demonstrating how urban planning directly supports healthy lifestyles.
Korea’s comprehensive food policy approach combined reformulation efforts, restaurant engagement, and public awareness campaigns to reduce mean sodium intake by 25%.
Fiji and Tonga, despite their small size and substantial NCD burden, implemented excise taxes and front-of-package labeling on sugar-sweetened beverages, showing that comprehensive food policies remain feasible even with limited resources.
In terms of education, Malaysia’s multifaceted approach exemplifies integrated responses across multiple domains. The BEAUTY program increases health literacy among communities and workplaces through public-private partnerships, particularly reaching populations otherwise marginalized by traditional health systems.
In terms of technology, in Malaysia the LungShield initiative integrates AI-augmented chest X-rays with microinsurance for affordable lung cancer diagnosis, demonstrating how technology directly bridges equity gaps by making advanced diagnostics accessible to underserved populations.
Malaysia has also developed a National Cancer Screening Registry that links community screening, vaccination, and the BEAUTY program, creating integrated systems where separate initiatives reinforce each other. Most significantly, Malaysia institutionalized civil society participation through NCD Malaysia—a memorandum of understanding within the Ministry of Health involving 15 civil society organizations mandating joint activities and formal meetings.
Effective NCD response requires viewing these diseases through a whole-of-system lens implemented through whole-of-society approaches, trickling down to personal and community interventions. Only through such comprehensive, interconnected action addressing both visible disease patterns and invisible structural drivers can Asia and the world adequately respond to the NCD epidemic reshaping global health.
(3) Case study: Aging society in Japan
Kosuke MATSUI began by summarizing the points raised by Dr. Somasundaram emphasizing preventive practices, community engagement, and data collection. He noted that Yakult is a company with a long-standing business philosophy that directly aligns with contemporary public health imperatives around noncommunicable diseases (NCDs) and healthy aging.
Founding philosophy of Yakult
Mr. Matsui explained that Yakult’s relevance to modern health challenges stems from its founder, Dr. Minoru Shirota, who came up with his vision in early 20th-century Japan. Growing up in Nagano during a period when Japan faced severe sanitation deficits, poor nutrition, and limited healthcare infrastructure, Dr. Shirota witnessed infectious diseases like food poisoning and typhoid severely affecting communities and claiming the lives of children. Modern medicine existed but remained prohibitively expensive and accessible only after disease had already developed. This background motivated Dr. Shirota to pioneer an entirely different approach to health.
His breakthrough came through research into intestinal bacteria. He recognized that the human gut hosts approximately 100 trillion bacteria representing hundreds of species, collectively known as the intestinal microbiota or microbiome. These bacteria exist in a delicate balance comprising three categories: beneficial bacteria, harmful bacteria, and neutral organisms. When harmful bacteria become too prevalent, they produce compounds adversely affecting health, leading to diarrhea, constipation, and other conditions.
In 1930, Dr. Shirota became the first scientist worldwide to isolate and cultivate a fortified strain of lactic acid bacteria, subsequently named the Lactobacillus casei strain Shirota.
Recognizing that Japanese consumers had no cultural familiarity with consuming live bacteria, Dr. Shirota developed Yakult as a probiotic drink delivery mechanism. Launched around 1950 with its now-iconic bottle design introduced in 1968, Yakult made probiotic consumption accessible and acceptable to the general population.
The product embodied three foundational principles that remain central to Yakult's mission: 1) preventive medicine—maintaining health to avoid disease rather than treating illness after onset; 2) the recognition that healthy intestinal function enables longer, healthier lives since the intestines mediate nutrient absorption; and 3) the commitment to bringing good health to people at an affordable price.
The Yakult Lady system: Community-based health advocacy
Yakult's most distinctive innovation addressing community health and social connection is the Yakult Lady door-to-door product delivery system, established in 1963. Operating for over six decades, this distribution network extends far beyond conventional sales. Yakult Ladies function as community health advisors, studying the science behind products, providing detailed explanations tailored to individual customer needs, distributing general health information, and most importantly, conveying Dr. Shirota's preventive medicine philosophy—including the concept that healthy intestinal function supports longevity.
With more than 82,000 Yakult Ladies visiting customers daily across Japan and internationally, the system creates extraordinary reach for raising awareness of preventive health practices. Their regular community engagement directly reduces long-term NCD risk through promoting healthier lifestyles at the grassroots level.
Addressing elderly isolation and social connectivity
Yakult's response to elderly isolation demonstrates how business operations can simultaneously address social determinants of health. Japanese government data reveals that seniors living alone increased dramatically, reaching 8.73 million single-occupancy households as of 2022 (Figure 5). Since 1972, Yakult has been implementing courtesy visits to elderly people.
Figure. 5 The increasing number of single person elderly households in Japan
As of March 2024, about 2,300 Yakult Ladies are paying regular visits to about 30,000 older people in response to requests from 115 local governments in Japan.
These visits serve multiple health functions. Beyond product delivery, Yakult Ladies’ regular presence in elderly homes enables early intervention when health crises occur. Their role as informal community health monitors has earned recognition from local governments and police departments across Japan. Similar programs operate internationally, with elderly residents in China and Korea similarly benefiting from Yakult Lady home visits designed to verify safety and provide social connection.
A distinctive and underappreciated dimension of Yakult’s aging society response involves employing seniors as Yakult Ladies themselves. Of the 82,000 Yakult Ladies in Japan, more than 5,000 are over 60, representing 16 percent of the workforce. More than 2,000 have worked as Yakult Ladies for over 30 years, their accumulated experience and professional expertise proving indispensable to operations.
In Malaysia and other developing nations still experiencing younger demographic profiles, this model offers a template for incorporating seniors into the workforce as aging societies materialize. Yakult recognizes these senior employees through biennial World Conventions celebrating high-performing, long-serving workers, explicitly demonstrating organizational appreciation for their contributions.
Epidemiological research on probiotics and aging
To substantiate Yakult's preventive health claims beyond anecdotal evidence, Yakult's Central Institute has conducted rigorous scientific research with the Lactobacillus casei strain Shirota. Over 300 peer-reviewed scientific papers document investigations of this probiotic, making it among the most thoroughly researched strains globally.
However, early research focused primarily on short-term interventions lasting four to 12 weeks, measuring outcomes like bowel movement frequency or cold incidence rates—parameters not reflective of actual consumer consumption patterns, which typically span years or decades.
To address this gap, researchers led by Dr. Hiroshi Makino at Yakult Central Institute collaborated with the Tokyo Metropolitan Institute for Geriatrics and Gerontology to conduct longitudinal epidemiological research in Nakanojo, a rural Japanese municipality in Gunma Prefecture with approximately 15,000 residents and an aging rate exceeding 40 percent—among Japan's highest. This research investigated relationships between consumption patterns of Lactobacillus casei Shirota (LcS) products and health outcomes in adults aged 65 and older, a population for which Japan has the world's highest aging rate, with approximately 30 percent of Japanese citizens now being over 65 years of age. Data was collected once a year.
This study has resulted in various papers being published, one which documents the reduction in risk of developing hypertension.
Hypertension affected 47.9 percent of elderly people in Nakanojo, and prevention and control of hypertension can make an important contribution to the improvement of elderly health. The study sought to investigate whether consumption of LcS products has a preventive effect on hypertension. Among 628 initial participants, 352 completed the five-year study. Researchers compared two groups: those consuming LcS products less than three days weekly versus those consuming them three or more days each week.
It was found that participants consuming LcS products three or more days weekly experienced a hypertension incidence rate of 6.1 percent over five years, compared to 14.2 percent in the less-frequent consumption group—a statistically significant difference. After controlling for confounding factors including age, gender, body mass index, smoking, and alcohol consumption, the relative risk of developing hypertension in the high-consumption LcS group was less than half that of the low-consumption group. These findings suggest that regular fermented milk product consumption—a low-cost, accessible intervention—may substantially reduce hypertension risk in elderly populations, directly supporting the preventive medicine principle Dr. Shirota articulated decades ago.
Assignment to students
Mr. Matsui gave students the following assignment.
NCD prevention and control require collaboration across multiple disciplines.
Describe you own area of specialization, and discuss how your field can contribute to this multidisciplinary endeavor. Reflect critically on the relevance, challenges, and potential impact of your discipline within this domain.
Discussion
Dr. Kawahara noted that Dr. Somasundaram’s presentation highlighted that tackling NCDs requires a whole-of-society approach. From that perspective, Mr. Matsui’s presentation was particularly interesting, particularly the part about entering local communities to study people’s daily lifestyles. It would appear that such work is not only research, but also has an educational element, as it raises awareness among the community itself. She asked whether this kind of initiative could be expanded not only in Japan but also across Asia, and if so, what kinds of challenges or barriers might be anticipated.
Mr. Matsui responded that while studies such as the one in Nakanojo are extremely important, the biggest challenge is data collection. For the Nakanojo study Yakult worked in collaboration with an academic institution to accumulate large-scale health data. It would likely have been impossible for Yakult to obtain the data alone, which is why collaboration with academia and government are so important.
A student asked about confounding factors in the Nakanojo study, and whether the study had taken into account other probiotics, such as natto.
Mr. Matsui responded that in the study it was very difficult to exclude other probiotics from the study, but efforts were made to exclude other factors such as smoking or high salt intake, etc.
A student asked about regional differences in the products that Yakult sells in the different countries of Asia, or any differences in the activities of the Yakult Ladies in different countries.
Mr. Matsui responded that the recipe for Yakult differs according to country or region, and the size of the Yakult bottle also differs (65ml vs. 100ml, for example). In some countries it is too challenging to set up a Yakult Lady system, due to a lack of such a delivery-based culture.
Dr. Kawahara noted that Mr. Matsui has spent many years working overseas. She asked Mr. Matsui to share information about the kind of career path that led you to his current position, and what his thoughts are about what is most important when working beyond borders.
Mr. Matsui responded that he had worked in the Netherlands and Germany for more than 10 years, having previously only worked in Japan. He initially had no intention to work abroad, but the experience in Europe was very worthwhile, and led to his growth as a businessperson. The difference in cultures between Asia and Europe was very interesting, but the important thing is to enjoy the differences that exist. Although it can be challenging to live and work abroad, it is also very rewarding.
Dr. Kawahara expressed the hope that lecture series students could join her in visiting Yakult Headquarters, as a means of learning directly from the in-house experience at Yakult.
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