Obesity Epidemic: Issues and

Challenges in Malaysia
Prof. Dr.Mohd Ismail Noor FASc, FIUNS
President, Malaysian Association for the study of
Obesity (MASO)
Department of Nutrition and Dietetics
Faculty of Allied Health Sciences
Universiti Kebangsaan Malaysia
Kuala Lumpur

Nestle Media Workshop, 21 July 2006. Cyberjaya

OBESITY:Issues and Challenges
• Global and regional scenario
• BMI Classification issues
• Prevalence of Obesity
• Etiology of Obesity
• Health Implication and cost
• Combating Obesity
• Conclusion
“We are unanimous in our belief that OBESITY is a hazard
to health and a detriment to well-being. It is common
enough to constitute one of the most important MEDICAL
& PUBLIC HEALTH problem of our time, whether we
judge importance by a shorter expectation of life, increased
morbidity, or cost to the community in terms of both
MONEY and ANXIETY”.
Professor Waterloo
MRC Report 1976
• Disease of the New Millennium
IOTF, 1998
• Obesity: a time bomb to be defused
Bray, 2000
• Treatment of obesity: Mission Impossible
Golay, 2000
• Overweight and Obesity: A new nutrition
Emergency?
SCN, WHO 2005
 Global epidemic of obesity

1.7 billion

1.1 billion

>300 million

IOTF (2005)
% of population BMI >30
Obesity Rates Could Double In 30 Years

IOTF, 1998
Overweight and Obesity prevalence among adults in Asia
Country Year Sex OWT Obese Source
(%) (%)
Iran 1999 M 44.1 10.2 Ghassemi*
F 51.0 26.4 2002
Malaysia 1996 M 15.1 2.9 Ismail et
F 17.9 5.7 al* 2002
Korea 1998 M 24.3 1.7 Lee et al*
F 23.5 3.0 2002
Japan 1995 M 22.3 2.2 Popkin et
F 18.3 3.1 al*, 2002
China 1997 M 12.0 2.5 Du et al*
F 13.8 2.4 2002
Thailand 1996 M 13.2 ? Kosulwat*
F 25.0 ? 2002
Philippines 1993 M 11.0 1.7 Solon*
F 11.8 3.4 2002
Hong Kong 1997 M 33.0 5.4 Janus
F (M&F) 7.0 1997
India 1998 M 4.0 0.5 Shetty*
F 4.0 0.5 2002
*Obesity Review, August 2002
Obesity is a key & spreading issue in developed &
developing countries (BMI>30.0)

Ismail, 1998
Prevalence of overweight and obesity in selected
Asian countries ( Urban vs Rural )
Country Year Area OWT OBESE Source
(%) (%)

Iran 1999 U 28.0 12.4 Ghassemi*

R 19.9 6.8 2002

Malaysia 1996 U 17.4 4.5 Ismail et

R 15.5 4.3 al,* 2002

India 1998 U 10.9 1.1 Shetty*

R 7.3 0.8 2002

*Obesity Review, August 2002

 Classification of Body Weight in Adults According to
Body Mass Index, BMI
Classification BMI, kg/m2 Risk of co-morbidities

Underweight < 18.5 Low (but risk of other clinical

problems increased)

Normal range 18.5 – 24.9 Average

Overweight > 25.0
Pre-Obese 25.0 –29.9 Increased
Obese Class I 30.0 – 34.9 Moderate
Obese Class II 35.0 – 39.9 Severe
Obese Class III > 40.0 Very severe

WHO, 1998
 The Asia-Pacific
perspective:

Redefining

obesity
and its
treatment
February 2000

World Health Organization

Western Pacific Region
IASO INTERNATIONAL ASSOCIATION FOR THE STUDY OF OBESITY

International Obesity TaskForce

IOTF (2000)
Proposed Classification of Weight by Body Mass Index
in Adult Asians
Classification BMI, kg/m2 Risk of co-morbidities

Underweight < 18.5 Low (but risk of other clinical

problems increased)

Normal range 18.5 – 22.9 Average

Overweight > 23.0
At Risk 23.0 –24.9 Increased
Obese Class I 25.0 – 29.9 Moderate
Obese Class II > 30.0 Severe

IOTF, 2000
 Issues
Are population specific BMI cut-off points for overweight and obesity
necessary?

 Recent studies in Hong Kong, Singapore, Indonesia and Japan

suggested that these populations have a relatively high body fat % at
low BMI
 Meta-analysis in Asian populations revealed:
- Caucasian prediction equation cannot be applied to all Asian
populations.
- In general, both male and female Asians have more body fat
then their European counterparts of the same age and BMI.
- Calculated BMI cut-off points vary considerably from (21.6 –
25.9) for
overweight and from (26.3- 30.8) for obesity

WHO Consultation, July 2002.

Asian BMI action point - BMI>23

Source: THE LANCET • Vol 363 • January 10, 2004 • www.thelancet.com

Ranges for High to Very High Risk
determining
public health and Moderate to High Risk
clinical action Low to Moderate Risk
levels based on
BMI

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

WHO
classification underweight overweight Obese I Obese II Obese III

= Suggested cutpoints for reporting population BMI distribution and specific action
levels for populations and individuals

Lancet, 2004
 Waist Circumference
• Correlates abdominal fat distribution
and associated ill health.
• Increased risk:
– Men > 94 cm (37 in.)
– Women > 80 cm (32 in.)

• Lower values have been proposed for

Asian man
( 90cm for men and 80cm for women)
The Obesity Epidemic

Malaysian scene
 NATIONAL HEALTH AND MORBIDITY
SURVEY (1996-97)
Adults Overweight Obese
(BMI 25-29.9 kg/m2) (BMI > 30 kg/m2)
(%) (%)

Male 15.1 2.9

Female 17.9 5.7

Urban 17.4 4.5

Rural 15.5 4.3

Malay 17.3 5.1

Chinese 16.0 3.5
Indian 20.6 5.0
Lim et al, 2000
 Prevalence of Obesity in Malaysia

16.0

14.0

12.0
Obesity % (BMI > 30)

10.0
NHMS 1996
8.0
MANS 2002/2003
6.0

4.0

2.0

0.0
Men Women

NHMS – National Health & Morbidity Survey- 1996

MANS – Malaysian Adults Nutrition Survey- 2002/03
 PREVALENCE AND TRENDS OF OBESITY1 AMONGST MALE
ADOLESCENTS IN SECONDARY SCHOOLS

1990 1997
School n Obese % n Obese %
no. no.
Section 16, Shah 1383 3 0.2 731 51 7.0
Alam
Seaport, Kelana 1213 12 1.0 1224 71 5.8
Jaya
SSAAS, Shah 1039 9 0.9 936 57 6.1
Alam
Subang Jaya 1119 11 1.0 1127 48 4.3
Total 4754 35* 0.7 4018 227** 5.7

Ratio 1:136 1:18

1
WHO (1995), Ismail & Vickneswary (1998)
*Malay 15 (43%), Chinese 13 (37%), Indian 7 (20%)
**Malay 140 (62%), Chinese 56 (25%), Indian 31 (13%)
 Prevalence of Overweight & Obesity according to
Regions in Peninsular Malaysia (6-12 years)
12
10.9 10.7 10.5
10.1
10

8
Percent (%)

6.3
6.0
6 5.5 5.7

4 n=2845
n = 2875 n = 2825 n = 2719
2

0
North Central South East
Region
n = 11264

UKM/Nestle study 2002

 Prevalence of Overweight in Children
according to age & sex
18 16.9

16 15.415.5
13.8
14 12.612.4
11.9
Percent (%)

12
10.0
10 9.0
7.9
8 6.6 6.7
6 4.9 4.5

4
2
0
6 7 8 9 10 11 12
Age(Years)
N = 11264 Male Female
 Prevalence of Overweight & Obesity according to Sex

12 10.8
10.3
10
Percent (%)

8
5.9 5.8
6 n = 1188
4
n = 661
2

0
Overweight Obese

Male Female
n = 11264

UKM/Nestle study 2002

 Prevalence of Obesity in Children according to age
and sex
9
8.1
8 7.4
7.0
7 6.7
5.9 6.1
Percent (%)

5.8
6 5.7
5.3 5.3
4.9 5.1 5.1 5.0
5
4
3
2
1
0
6 7 8 9 10 11 12
Age (Years)
Male Female
N = 11264
 Prevalence of Overweight & Obesity according to
ethnic groups
14
11.7
12
10.5 10.1
10
Percent (%)

8 6.7
6.2
6 4.7
4
n = 7803
2 n = 2511 n = 950

0
Malay Chinese Indian
n = 11264 Ethnic
UKM/Nestle study 2002
Overweight Obese
 Prevalence of overweight/obesity1among
children in Asia Pacific

Australia
China
Hong Kong*
Japan*@
Malaysia#
NewZeal.**
Boys
Philippines***
Girls
Singapore@
South Korea
Taiwan*
Thailand*+

0 5 10 15 20
%
1
IOTF, *>120%
** 95th /WHO 1995 # Malaysia: Cole et al 2000;
***85th, NHANES + Thailand: both sexes
@ Red bar for younger, purple older age groups
Prevalence of overweight and obesity in
10-year-old boys and girls
Country Boys Girls
Sample % Overweight* Sample % Overweight*
Italy 334 29.6 344 31.4
Japan 392 27.8 384 18.5
Singapore 1660 25.5 1584 17.6
Germany (Munich) 314 22.9 309 25.9
Hungary 117 20.5 115 13.9
Hong Kong 661 20.3 623 10.1
Germany (Dresden) 415 15.4 369 17.6
Germany (Jena) 114 10.5 122 13.9
UK 1222 9.5 1113 14.4
Netherlands 847 4.5 897 6.7
MALAYSIA 1046 18.4 943 18.5
* Figures includes overweight and obese using the IOTF standard defining total overweight as
BMI > age-specific BMI cutoffs corresponding to BMI 25 at age 18 years (Cole et al. 2000)
Influences on Energy Balance and Weight Gain
ENVIRONMENTAL & SOCIETAL INFLUENCES

Individual / Biological
Susceptibility
Dietary & Physical
Activity Patterns

ENERGY REGULATION
INTAKE EXPENDITURE

ACTIVITY
FAT
STABLE TEF
CHO GAIN WEIGHT LOSS
BMR
PROTEIN

BODY FAT STORES

WHO, 1998
ENVIRONMENTAL MODIFIERS IN WEIGHT-
REGULATION POTENTIAL THAT INFLUENCE

1. CHOICE & AMOUNT 2. CHOICE & AMOUNT OF

OF FOOD CONSUMED PHYSICAL ACTIVITY

 availability  access to recreational sports

 cost  nonmotorized form of
 energy density transportation
 fat  television
 sugar  labour-saving devices
 palatability
 variety
 portion size
 The Global Paradox
While wealthy industrialized nations spend
significant amount of money to convince their
populations to replace dietary fats with a
simpler diet based on grains, vegetables and
fruits,
the developing nations use their growing
incomes to replace their traditional diets, rich
in fibers and grains, with diets that include a
greater proportion of fats and sugars.

Drewnowski & Popkin, 1997

 3100
100
3000

2900 Calories 90

2800 Protein
80
2700 Fat
70
2600

2500 60
2400
50
2300

2200 40

Changes in availability of calories, protein and fat in Malaysia, 1961-1997

Source: Food Balance Sheet of Malaysia (FAO)
 100%

90%

80%

70%
% of Calories

60%

50%

40%

30%

20%

10%

0%
1961-63 1970-72 1979-81 1988-90 1997
Cereals Starchy roots Vegetables & fruits
Pulses Meat, fish, egg Milk-excl butter
Sweeteners Oils & fats Miscellaneous
Changes in sources of calories in Malaysia, 1961-1997
Food Balance Sheet FAO (1961-1997)
 Summary on Nutrition Practice: Fast Foods

• Majority 50% once a month

20% once a week
5% more than twice a week
15% everyday!!

• Twice as many rural children compared to

urban had never taken fast foods

• By ethnic: percentage of Indians who had never

taken fast foods were higher than
Malays and Chinese

UKM/Nestle report (2002)- 11500 Primary school children in Peninsular Malaysia

 Know your “Fast Foods”

A quarter-pound cheeseburger, large fries,

and a 16 oz. soda provides

1,166 calories
51 g fat
95 mg cholesterol
1,450 mg sodium
 Physical Activity
Past Present
 DAILY ACTIVITY PATTERNS OF OBESE SUBJECTS
(min/day)
minute
700

600

Adolescents (13-17
500 yrs)

400
Adults (20-24 yrs)
300

200

100

0
Standing

necessities
Lying/Sleep

Sitting

Walking

Moderate
exercise
Personal

Ismail, 1998
 DAILY ACTIVITY PATTERN OF MALAYSIANS
ACCORDING TO AGE-GROUPS
Light
90 1
Adolescents
80
70 Adults 2

60 3
Elderly
% of day

50
40
30
20 Moderate
10 Active
0
female

female
male

male

female

male
1 Poh et al (1996),
2
Ismail et al (1993)
3
Razali & Ismail (1996)
 Basal metabolic rate (MJ/day), total daily energy
expenditure (MJ/day) and physical activity level (PAL)

Subjects Age Male Female

(yr) BMR TDEE PAL BMR TDEE PAL

Adolescent25 12-14 5.08 7.89 1.55 4.80 7.09 1.48

Adolescent26 16-18 5.76 8.64 1.50 5.02 7.64 1.52
Young Adults27 18-30 5.85 9.40 1.61 4.77 7.58 1.59
Adults27 30-60 5.66 9.53 1.68 4.79 8.17 1.70
Elderly28 >60 4.92 7.35 1.50 4.37 6.74 1.54
Armed Forces29 20-30 5.74 12.08 2.10 NA NA NA
Elite Athlete30 20-30 6.84 14.91 2.18 5.39 10.67 1.98
25
Yap (2001), 26Victor (1999), 27Ismail et al. (1994), 28Razali (1996),
29
Ismail et al. (1996), 30Ismail et al. (1997)
Adaptingexercise
Adapting exerciseguidelines
guidelinesfor
forenergy
energybalance
balance

Energy Balance

PAL 1.8

PAL 1.60 CVD Guideline

6061.6
PAL 1.50
0 Sedentary
1.75
PAL 1.0 BMR

Erlichman, Kerbey & James, 2002. Obesity

Reviews, 3: 257-271 and 273-287.
 Issues
How much physical activity is enough to prevent
unhealthy weight gain?
 Current guidelines of 30 minutes of moderate activity daily is
important for limiting health risks to chronic diseases
 For preventing weight gain or regain, compelling evidence suggest
a 60-90 minutes of moderate activity
 To prevent a transition to overweight and obesity, a PAL of 1.7 or
approximately 45-60 minutes per day of moderate activity is
needed.
 For children even more activity time is recommended

Stock Conference, Bangkok, March 2002

Relative risk of health problems associated with
obesity in developed countries .

Greatly increased Moderately increased Slightly increased

(relative risk >>3) (relative risk (relative risk
ca 2-3) ca 1-2)
Diabetes Coronary heart disease Cancer (breast cancer in
Gall bladder disease Osteoarthritis (knees) postmenopausal women,
endometrial cancer, colon
Hypertension Hyperuricaemia and cancer
gout
Dyslipidaemia Reproductive hormone
Insulin resistance abnormalities
Breathlessness Polycystic ovary syndrome
Sleep apnoea Impaired fertility
Low back pain
Increased anaesthetic risk
Foetal defects arising from
maternal obesity
WHO, 1997
 Social Consequences
• Community
– Loss of productivity
– Sick days

• Individual
– Employment prospects
– Marriage/Divorce
– Stress/Self esteem
– Quality of Life
 Annual direct costs of disease in relation to BMI
Annual cost (US$ billions)

Wolf and Colditz, 1996

 Published Costs of Obesity

Direct Indirect
• USA 1998
$51.6 billion (5.7%) $47.6 billion
• NZ 1996
$135 million (2.5%)
• France 1995
FF 12 billion (2%) FF0.57 billion
• Netherlands 1995
DG 1 billion (4%)* * 3% from BMI 25-30

Caterson & Broom (2001)

 Published Costs of Obesity

Direct Indirect
• Canada 1999 (2.4%)
$1.8 billion* * BMI > 27
• UK 1994 (15%)
GBP30 million GBP165 million
• England 1999 (1.1%)
GBP130 million Overweight
Obese
GBP15 million

Caterson & Broom (2001)

 Benefits of 10 % weight loss

Life e x p e cta n cy in cr e a s e s w ith w e ig h t lo s s

a m o n g o b e s e d ia b e tic p a tie n ts • 20% reduction
in all-cause
18 9 5 % confidence interval
mortality
Life e x p e cta n cy (y e a r s )

16

14 • 30% reduction
12
in diabetes-
10

8
associated
0
mortality
0 2 4 6 8 10 12 14 16
W e ig h t lo s s (k g ) in fir s t 1 2 m o n th s
Lean et al. Diabet Med, 1 9 9 0 ; 7 : 2 2 8 -3 3

Williamson DF et al, Am J Epidemiol 1995

Lean MEJ et al, Diabetic Med 1990
 A Vicious Circle

Disrespect of
obesity as Advocating
a serious Professional Media absurd body
condition weight ideals

Public
Overemphasis
on cosmetic
Rossner, 1997 weight loss
 CAUSAL WEB OF SOCIETAL INFLUENCES ON OBESITY PREVALENCE

INTERNATIONAL NATIONAL/ COMMUNITIES WORK/ INDIVIDUAL

FACTORS STATE SCHOOL/
HOME

Public Leisure
Education Activity/
Policy Transport O
Facilities
B
Globalization E
of School
S
Markets Public Energy I
Activity
Expenditure
Safety T
Transport
Policy
Y
Worksite
Exercise P
R
Sanitation
E
Labor
Food V
Development Urbanization Intake: A
Nutrient
Infections
Density
L
Health Care
System
E
N
Health Policy Worksite
C
Manufactured/ Food
E
Imported
Food
School
Food Policy Food
Agriculture/
Gardens/
Local Markets

Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipatis V. IOTF website 1999: http://www.iotf.org

Strategy for the
Prevention of
Obesity
- Malaysia
 General NPANM II ( 2006-2015 )
Objective TO ACHIEVE AND MAINTAIN THE NUTRITIONAL WELL-
BEING OF MALAYSIANS

To prevent
To improve and control
Specific objectives nutritional diet-related
status of all non-communicable diseases

Improving household food security especially among the low income

Promoting optimal infant & young children feeding practices

Enabling
strategies Preventing and controlling nutritional deficiencies

Promoting healthy eating and active living

Supporting efforts to protect consumers in food quality & safety

Ensuring
Continuous Promoting Ensuring
all have assessment and continuous nutrition
Strengthening
monitoring research institutional
access to and
Facilitating of the nutrition and dietetics are
capacity in
nutrition nutritional
strategies Situation development practised
activities
information by trained
professionals

Foundation
strategy Incorporating nutrition objectives and strategies into policies and
programmes of relevant agencies
Specific objective 1
To Improve nutritional status

The nutritional status of all Malaysians can be

further enhanced through:

 Improving breastfeeding and complementary

feeding practices

 Improving food intake and dietary practices

 Reducing protein-energy malnutrition

 Reducing micronutrient deficiency

 Reducing overweight and obesity

Formation of Malaysian Council for Obesity
Prevention (MCOP)

Initiated 3 working groups namely:

1) Childhood Obesity Prevention
2) Increasing Awareness
3) Research on Obesity Prevention
• The current nutrition and health scenario suggests that
Malaysia have not benefited from the western experience

• We need to intervene strategically before the typical

dietary
pattern associated with western affluence become
widespread and established within our population

• The problem is “real” and need urgent attention for it may

be just the tip of the ice-berg.

• There is a need to carry out National Nutrition Survey

periodically

• There is a need for Health Economic Analysis

Slide 9