Obesity is a complex problem that requires a multifaceted solution, says Noor Asmaliza Romlee.
The Eid al-Fitr season has just ended and once again, we were bombarded by deliciously addictive sugary and food high in saturated fat content at open houses. Yum!
The charm of Raya or any other festive seasons lies in gatherings of family members, relatives and friends bonding together over meals. We Malaysians love eating and there is a strong culture of entertaining guests with food.
But this cultural practice can be a huge downer when we are reminded that Malaysia still has the highest obesity rate (13.3% of the total population) among South East Asian countries.
Obesity is a condition of excess body fat, resulting from an individual’s inability to balance his or her calorie intake from food with energy expenditure. Obesity is not a disease but a syndrome. Being overweight and obese is associated with a host of other chronic diseases such as diabetes, high blood pressure, heart disease and smaller problems like snoring and obstructive sleep apnea.
Fighting the obesity problem in Malaysia goes beyond taxation polices, to the underlying knowledge and skills that influence food choices. Most of the campaigns by the Ministry of Health have been from the angle of what we eat.
Now, we need to look at a wider systemic problem by reflecting on how actively we live and how to achieve a balanced lifestyle that focuses on health and positive behaviour.
1) Change unhealthy cultural habits and lifestyle choices
Culture has a strong influence on our eating and activity habits.
Malaysia’s favourite traditional cuisine, nasi lemak, sparked a debate over its effects on health. In the past, when Malaysia was mainly an agricultural country, the Malay community were mainly farmers and fishermen. They would consume ‘nasi lemak’ as they needed more carbohydrates to provide them the energy to do heavy work.
However, most Malays now work in offices as civil servants, professionals and business folk. Most do not need to do strenuous physical work that requires much energy compared to that required by fishermen and farmers. But old habits die hard: the practice of eating nasi lemak for breakfast continues, passed down from generation to generation. Our working culture has changed but not our culinary culture.
Originally, nasi lemak used just rice and coconut milk (source of carbohydrates), anchovies in shrimp paste (source of calcium), cucumber or traditional salad called ulam (vitamins and minerals) and some hard-boiled egg (protein). Hence, it was a perfect dish for breakfast, containing all the nutrients required to start a day.
But food consumption patterns among Malaysians have changed tremendously, with more people consuming meat, fish, eggs, fats and oils. These days, people tend to eat nasi lemak with fried egg, chicken, beef and even nuggets and sausages. Now that is just a massive amount of calories in a single dish!
Obesity develops gradually from poor diet and lifestyle choices
The 2006 National Health and Morbidity Survey showed that the number of obese adult Malaysians rose from 4.4% in 1996 to 14.0% in 2006 and those overweight climbed from 16.6% in 1996 to 29.1% in 2006.
This meant that in the decade from 1996 to 2006, the prevalence of obesity had soared by almost 220 % and the number of overweight Malaysians rose by 75%. Fat and sugar intake shot up by 80% and 33%, respectively, between the early 1960s and 2000s.
Lifestyles change over time. We don’t move as much as before. Our days are often spent in front of the computer for long stretches of time. Our diets are now tainted by fast food, sugary treats and super-size portions.
And we are not always in control of the situation. We have high-paced lives in often stressful environments and face all manner of challenges that don’t bode well for our diets or general health.
We have moved significantly towards a sedentary lifestyle, leading to a rise in the prevalence of obesity. According to the Malaysian Adult Nutrition Study, only a third of the adult population has ever exercised and only 14% perform adequate levels of exercise (Poh BK, Safiah MY, et al, “Physical activity pattern and energy expenditure of Malaysian adults: findings from the Malaysian Adult Nutrition Survey (MANS)”, Mal J Nutr, 2010; 16(1):13-37).
Maybe hot and tropical weather makes it more difficult to exercise in Malaysia, especially if people do not have access to air-conditioned gyms while physical infrastructure is often not conducive for exercising in open spaces.
Still, over the past five to ten years, a trend has emerged of Malaysians taking part in marathons, walkathons and organised fun runs. However, participating fees of RM50- RM120 make it prohibitive for some people.
2) Encourage healthy lifestyles through innovative urban design strategies
City architecture and urban design strategies can encourage regular physical activity and healthy eating.
Even though the United States tops the chart of the most obese nations in the world, New Yorkers tend to be healthier than those living elsewhere in the nation. In a testament to the principles of the Active Design Guidelines, the city’s dense urban environment, well-connected public transport system and low rates of car ownership mean New Yorkers rely more on their own bodies to move about than most Americans.
More importantly for heart health, studies have shown that New York city residents travel on their feet faster than others. On the other hand, faced with crammed living conditions, expensive convenience store prices and a large variety of restaurants, New Yorkers are more likely to eat out, which is usually a less healthy option. An integrated public transport system may provide a public health bonus by lowering obesity rates.
Active Design Guidelines include:
- urban design strategies for creating neighbourhoods, streets and outdoor spaces that encourage walking, cycling, active transportation and recreation
- building design strategies for promoting active lifestyles through the placement and design of stairs, lifts and indoor and outdoor spaces
- a discussion of synergies between active and sustainable design initiatives
In Malaysia, great initial efforts have been undertaken. In Penang, ThinkCity has transformed Armenian Park in George Town. Over in Kuala Lumpur, the Laneways Project (eg at Lorong Bandar 13) has turned alleys, backlanes and sidelanes – once filled with rubbish, pasar karat (which attracted unsavoury activities) and dark lanes – into new functional spaces for relaxation, exercise, people-watching and recreational events.
But we need to see more such initiatives. It is time for Malaysian local authorities (city, municipal and district councils) – which are responsible for organising, planning and developing all land within the local plan boundary – to work closely together with urban planners and architects. They need to create greener areas and design more spaces in cities to facilitate active public movement and exercise.
3) Implement tighter regulation of ads on top of price regulation
The not-so-sweet truth about sugar
Sugar is a contributor to excess calories in the diet – which leads to weight gain, obesity and a range of non-communicable diseases such as diabetes, heart disease, stroke and cancer.
About 90% of people with type 2 diabetes are either overweight or obese. According to the National Diabetes Institute, Malaysia has the highest rate of diabetes in Asia and one of the highest in the world.
Malaysians’ consumption of sugary drinks has increased dramatically over the past 15 years, in tandem with rising incomes. More than one third (36%) of students have sugary drinks at least once daily. Adolescents are consuming more sugar: their average daily sugar intake has risen from seven teaspoons in 2012 to 10 teaspoons in 2017—higher than the recommended limit for adults. On average, Malaysians consume around 3kg of sugar per year in the form of sugary drinks.
The introduction of a new tax on sugar-sweetened beverages is a lead-off strategy by the Malaysian government to reduce the consumption of these sugary drinks and tackle child obesity. More than 50 countries around the world have already implemented such taxes, including India, South Africa, Brunei Darussalam, the Philippines, and Thailand.
A policy targeted at advertising and packaging laws is necessary to complement the government’s efforts at price regulation. Such a policy has been successful for cigarettes. It is high time similar legislation is applied to junk food and selected fast foods identified as unhealthy.
To reduce exposure to unhealthy food over the mass media, perhaps limits have to be placed on the advertising of junk food and selected fast food.
This proposal is not to go against fast food companies but the fear is, the culture of opting for fast foods or unhealthy snacks will become more entrenched and more difficult to tackle in future.
Studies in Australia have shown that removing junk food advertising from children’s television influences purchase requests and eating patterns. Children tend to snack excessively while watching TV or playing computer games, and so food advertisements may influence them to make unhealthy food choices.
The problem of obesity is not uniquely Malaysian; it is a global syndrome. Adult obesity rates are highest in the US, Mexico, New Zealand and Hungary.
Chile, Iceland, Ireland, and Mexico have put in place bans on advertising food and beverages on TV and radio during hours when children are the main audience. Other bans apply in schools (eg Chile, Poland, Spain and Turkey), in public transport (eg Australia) and other public places (eg Norway).
In May 2016, the European Commission adopted a new legislative proposal amending the Audiovisual Media Services Directive which aims at achieving a balance between competitiveness and consumer protection. This amendment strengthened provisions to protect children from inappropriate audiovisual commercial communications for foods high in fat, salt, sodium and sugar.
4) Use mass communication to raise public awareness
Besides regulation, a number of public health mass media campaigns to increase public awareness of healthier nutritional choices have been launched in OECD countries (see table below).
Some people tend to say that obesity runs in the family – and of course genes contribute to body type. But few people need to be doomed to obesity as it is mostly caused by behaviour we pick up as we go along.
For example, compare a family that has bad eating habits and that sits in front of the TV all day to a family that enjoys outdoor activities and sport. The difference will be obvious and a change in behaviour is often all it takes to be “cured”. We cannot change genes, but we can change our lifestyles.
Fighting the prevalence of diseases remains a big challenge to us. The government has spent a lot of money in its efforts to control obesity. In 2017, the costs involved in dealing with those who are overweight and obese accounted for 13.3% of total health costs or 0.5% of GDP (US$1.7bn). This does not include the indirect costs of lost labour productivity due to absenteeism or medical leave.
Given the multifaced nature of the problem, multiple policy packages are required. This should cover communication, school-based interventions, interventions in primary care settings and broader regulatory and fiscal policies. This all-round, comprehensive approach will be a more affordable and cost-effective way to tackle obesity.
Noor Asmaliza Romlee, an Aliran member, has worked in strategic communications, project management, government relations and public policy affairs. With a background in science communications, she believes in speaking truth to power and expressing herself for the greater good.