Rokiah DonNutrition Division

Ministry of Health Malaysia

Paper Presented at the Selangor Public Health Conference

11 October 2011

1

CONTENT

Introduction

Obesity situation

- Local

- Global

Disease prevalence

Obesity conceptual framework & factors

Challenges

Recommendations

Conclusion

2

INTRODUCTION

Childhood obesity is one of the most serious public

health challenges of the 21st century.

The problem is global and is steadily affecting many low-

and middle-income countries, particularly in urban

settings.

The prevalence has increased at an alarming rate. In

2007, an estimated 22 million children under the age of 5

years were overweight throughout the world.

More than 75% of overweight and obese children live in

low- and middle-income countries.

3

4

Age (year) % Overweight % Obese

7-12 12.0 11.4

13-17 12.7 8.7

Note: Classification refer to Growth ReferenceWHO, 2000

(NHMS III, 2006)

Age (year)2002

(N=11 242)2008

(N=10 009)

% Overweight % Obese % Overweight % Obese

6 - 12 11 9.7 12.8 13.7

(UKM,2009)

Nutritional Status of School Children and Adolescents

National sample

(0-18 yrs)

Overweight

Wt/Age

(%)

Stunted

Ht/Age

(%)

Underweight

Wt/Age

%

UPM/MOH

(1992-1996)

N = 5,000Rural 2.0 29.0 27.6

NHMS III (2006)

N = 21,000

Urban

Rural

6.3

4.0

13.5

19.4

11.4

16.0

5

Comparison of Nutritional Status

PREVALENCE OF OVERWEIGHT AND OBESITY IN

10 YEAR-OLD BOYS AND GIRLS

CountryBoys 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

* Figure 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)6

NCD & NCD RISK FACTORS:THE CAUSATION PATHWAY FOR CHRONIC

DISEASES

Underlying

Determinants

Globalisation

Urbanisation

Population

Ageing

Common

Risk FactorsUnhealthy diet

Physical inactivity

Tobacco & alcohol

use

Age (non-

modifiable)

Heredity (non-modifiable)

Intermediate

Risk FactorsOverweight/obesityRaised blood sugarRaised blood pressureAbnormal blood lipids

Main NCDs

Heart Disease

Diabetes

Stroke

Cancer

Chronic resp.

diseases

7Ref:NSP-NCD Dec 2010

PREVALENCE OF DIABETES IN MALAYSIA

(1986-2006)

NHMS

(1986)

NHMS II

(1996)

NHMS III

(2006)

NHMS III

(2006)

Age group

Prevalence 6.3% 8.3% 11.6% 14.9%

Known diabetes 4.5% 6.5% 7.0% 9.5%

Newly diagnosed 1.8% 1.8% 4.5% 5.4%

Impaired glucose

Tolerance * /

Impaired Fasting

Glucose **

4.8% * 4.3% * 4.2% ** 4.7% **

In 2006, there is an estimated 1.6 million Malaysians age 18 years and above suffer

from diabetes.

8Source: National Health & Morbidity Survey

PREVALENCE OF HYPERTENSION IN MALAYSIA

(1986-2006)

NHMS I

(1986)

NHMS II

(1996)

NHMS II

(1996)

NHMS III

(2006)

NHMS III

(2006)

Age group

Definition of

hypertension

(mmHg)

Prevalence 14.4% 29.9% 32.9% 32.2% 42.6%

In 2006, there is an estimated 4.8 million Malaysians age 18 years and above

suffering from hypertension.

9Source: National Health & Morbidity Survey

OBESITY

HIGH CALORIE

INTAKE

LACK OF

PHYSICAL

ACTIVITY

NON-CONDUCIVE

ENVIRONMENTMEDICATIONGENETIC

LACK OF

EARLY

DETECTION

PSYCHOLOGICAL

FACTORS

Source: Nutrition Division, 2009

CONCEPTUAL FRAMEWORK

ATTITUDE

TOWARDS FOODS

HIGH CALORIE

INTAKEINADEQUATE

CALORIE INTAKE

Lack Of Regulation

And Enforcement On

Advertisement Of

Fast Foods/Sugary

Drinks And High

Calorie Snacks

PROBLEM TREE

Fast Foods

Service

Delivery

No Control

Of Fast

Food Location

24 Hours Service /

Restaurants

Affordable

Food Prices

EASY ACCESSIBILITY

TO ENERGY-DENSE FOODS

LIMITED HEALTHIER

FOOD CHOICES

Aggressive

Marketing

By Fast Food

Industry

LACK OF

KNOWLEDGE

No Nutrient

Profiling

System

No Consumer

Demand

Lack Of Nutrition

Awareness

Lack Of Nutritionists /

Nutrition Educators

Lack Of Menu

Modification

Lack Of Healthy

Recipes / Menus

Lack Of Nutrition Training

High Cost On

Media Campaign

Limited Healthier

Products In The

Market

Expensive

Fruits, Veges

And Milk

Social,

Culture And

Norms In

Society

Low

Acceptability

To Healthy

Foods Food

Taboos

Inappropriate

Care Practices

Inappropriate

Feeding

Practices

Lack Of

Nutrition

Promotion

Coverage

Low Purchasing

Power

Food

Inavailibility

Lack Of

Ecposure And

Continuity

Through

Lack Of

Education

Materials

Limited

Nutrition

Education By

Settings

Source: Nutrition Division, 2009

PHYSICAL

INACTIVITY

NO STRONGLY

ADDRESSED

POLICIES

NON-SUPPORTIVE

ENVIRONMENT

ATTITUDES,

VALUES, BELIEFS

PROMOTE

INACTIVITY

POOR

SETTINGS

NOT ENOUGH

SUPPORT FROM

SECTORS

(GOVERNMENT AND

NGOs)

WRONG SOCIO-

CULTURAL

TRADITIONS

CONCEPTUAL FRAMEWORK

Source: Nutrition Division, 2009

PROBLEM TREE

POOR

SETTINGS

NOT ENOUGH

SUPPORT FROM

SECTORS

WRONG SOCIO-

CULTURAL TRADITON

LACK OF PHYSICAL

ACTIVITY

Media

Government

No strongly

adressed policies

NGOs

Businesses

Education

Transport

Promote inactivity

Attitudes

Beliefs

Perceptions

Values

Schools

Primary care

Clubs

Work places

Children institution

NeighbourhoodsHomes

Non-supportive

environment

Source: Nutrition Division, 2009

1. Lifestyle- living conditions/environment- sedentary eg watching tv/ playing games

- unhealthy eating practiceslarge portions

excess calories

24 hours

night eating

2. Culture- finishing leftovers

- kenduri

- distorted perception of obesity

- unhealthy dietary practices (high fat/ sugar/ salt)14

Factors that contribute to obesity in

Malaysia

3. Knowledge/ skill

- lack of nutrition promotion initiatives funding & priority

setting

- lack of awareness of healthy eating

- lack of knowledge & skill to make healthy/healthier choices

4. Parenting behaviour/skill

- Eating habit

- Eating together

- Not breastfeeding

- Inappropriate complementary feeding

5. Media & advertising

15

Factors that contribute to obesity in

Malaysia

6. Lack of hard policies for a more supportive

environment- no control on expansion of fast food outlets

- 24hr restaurants

- healthy settings (cafeterias, canteens)

- import of quality food products

- food prices/taxes

- playgrounds & gyms in housing areas

- proper town planning

- subsidies

16

Factors that contribute to obesity in

Malaysia

7. School/institution setting

- canteen guidelines

- food premises

- physical activity

- curriculum

8. Genetic

- Family at high risk

9. Maternal nutrition- LBW babies

17

Factors that contribute to obesity in

Malaysia

SOLUTION TREEREGULATION ON 24HRS

FAST FOOD SERVICE /

OUTLETSINCENTIVE TO FOOD INDUSTRIES

EXAMPLE : REDUCE TAX ON

HEALTHIER FOOD CHOICES

Lack Nutrition

Awareness

ESTABLISHMENT OF

NATIONAL INFORMATIC

AND COMMUNICATION CENTRE

INCREASE NUMBER

OF NUTRITIONISTS/

RELATED

PROFESSIONALSINCREASE

GOV. TAX ON

FAST FOODS

FOR NUTRTION

ESTABLISHMENT

OF NATIONAL

NUTRITION LAB

HEALTHY

CATERING

HEALTHIER

TRADITIONAL

MENU

IMPROVE QUALITY

NUTRITION

TRAINING

IN INSTITUTIONS

INCREASE

TRAINING

INCREASE

NUTRITION

PROMOTION

THROUGH

MEDIA

INCREASE BUDGET

High Cost On

Media Campaign

HEALTHY

CATERING /

CAFETARIA

HEALTHY

KITCHEN

NUTRITION

INFORMATION

CENTRE

HEALTH

CARE FACILITIES

HEALTHY EATING

THROUGH HEALTHY

SHOPPING

HEALTHY

SCHOOL

CANTEEN

Lack Of

Nutrition &

Promotion

Through

Media

COMPULSORY

HOME

SCIENECE OF

FOR FORM 1 TO

FORM 3

Lack Of Exposure And

Continuity Through Media

Lack Of

Education

Materials

Limited Nutrition

Education By

Settings

HIGH CALORIE

INTAKEINADEQUATE CALORIE

INTAKE

Lack Of

Nutrition

Promotion

Coverage

Lack Of Nutrition

Education

Lack Of Trained Nutrition

Educators

Food

Taboos

LACK OF

KNOWLEDGE

LIMITED

HEALTHIER

FOOD CHOICES

EASY

ACCESSIBILITY

TO FOODS

Food

Inavailability

ATTITUDE TOWARDS

FOODS

Social, Culture & Norms In

Society

Low Acceptability

To Healthy Foods

Lack Of Healthy

Recipe & Menu

Modification

No Consumer

Demands

Limited Healthier

Products In The

Market

ESTABLISHMENT

OF NUTRIENT

PROFILING

SYSTEM

No Control Of

24hrs Fast Food

Services And

Location

REGULATION ON

FAST FOOD /

SUGARY DRINK

AND HIGH

CALORIE SNACK

ADVERTISEMENT

Home/Office

Delivery

Aggressive

Marketing By Fast

Food Industry

INCREASE TAX

ON FAST

FOODS,

SUGARY

DRINKS,

UNHEALTHY

SNACKS

REDUCE

SUBSIDIES ON

SUGAR AND

PALM OIL

PROVIDE

FOOD AID TO

VULNERABLE

GROUPS

Affordable

Prices

Low Socio-

economic

StatusLow Purchasing

Power

Source: Nutrition Division, 2009

SOLUTION TREE

POOR

SETTINGS

NOT ENOUGH

SUPPORT FROM

SECTORS

WRONG SOCIO-

CULTURAL TRADITON

LACK OF PHYSICAL

ACTIVITY

Media

GovernmentNGOs

Businesses

Education

Transport

PROMOTE ACTIVITY

Attitudes

Beliefs

Perceptions

Values

Schools

Primary Care

Clubs

Religion

Places

Work Places

Children Institution

NeighborhoodsHomes

DEVELOP SUPPORTIVE

ENVIRONMENTENCOURAGE

COLABORATION

PROMOTE STRONGLY

ADDRESS POLICIES

20

INTERVENTIONS

21 21

PREVENTION AND REHABILITATION PROGRAMME

FOR OBESITY

Trainingo In service training (Makan Secara Sihat)

o Healthy catering

o Kafeteria sihat

Nutrition Promotion / Educationo Talks

o Conferences

o Media writing

o Cooking demonstrations

o Radio/TV talks

o Pre-school healthy menus

o Healthy school canteens

o Healthy eating through healthy shopping (supermarket

tours)

22

Kantin SekolahSihat

23

HEALTHY SETTING

Healthy Catering

24

HEALTHY SETTING

HEALTHY SETTING

Healthy Eating Through Healthy Shopping

25

Wellness

o Nutrition Information Centre

o Health Promotion Centre

Rehabilitation

o Nutrition Counselling

o Focus Group Discussion

o Weight Management

o SOPs

26

o Up to 286 clinics have provided the service in 2011.

o Conducted by clinic-based nutritionists.

o Follow-up duration for clients 3 to 6 months.

o Individual or group nutrition counselling.

o Each nutritionist covers 6 to 14 clinics per district.

27

Nutrition Counselling Services

Booklet

Posters

28 28

EDUCATION MATERIALS AND GUIDELINES

DEVELOPED

29

Malaysian Dietary Guidelines

30

Malaysian Food Pyramid