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Prof. Dr.Mohd Ismail Noor FASc, FIUNS

President, Malaysian Association for the study ofObesity (MASO)

Department of Nutrition and DieteticsFaculty of Allied Health SciencesUniversiti Kebangsaan Malaysia

Kuala Lumpur

Obesity Epidemic: Issues andChallenges in Malaysia

Nestle Media Workshop, 21 July 2006. Cyberjaya


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OBESITY:Issues and Challenges

Global and regional scenario

BMI Classification issues

Prevalence of Obesity

Etiology of Obesity

Health Implication and cost

Combating Obesity

Conclusion


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We are unanimous in our belief that OBESITYis 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 andANXIETY.Professor Waterloo

MRC Report 1976


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Disease of the New MillenniumIOTF, 1998

Obesity: a time bomb to be defused

Bray, 2000 Treatment of obesity: Mission Impossible

Golay, 2000

Overweight and Obesity: A new nutritionEmergency?

SCN, WHO 2005


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Global epidemic of obesity

1.7 billion

1.1 billion

>300 million

IOTF (2005)


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Obesity Rates Could Double In 30 Years

%

ofpo

pulatio

nBMI>30

IOTF, 1998


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Overweight and Obesity prevalence among adults in Asia

Country Year Sex OWT

(%)

Obese

(%)

Source

Iran 1999 M

F

44.1

51.0

10.2

26.4

Ghassemi*

2002

Malaysia 1996 M

F

15.1

17.9

2.9

5.7

Ismail et al*2002

Korea 1998 M

F

24.3

23.5

1.7

3.0

Lee et al*

2002

Japan 1995 MF

22.318.3

2.23.1

Popkin etal*, 2002

China 1997 M

F

12.0

13.8

2.5

2.4

Du et al*

2002

Thailand 1996 M

F

13.2

25.0

?

?

Kosulwat*

2002

Philippines 1993 M

F

11.0

11.8

1.7

3.4

Solon*

2002

Hong Kong 1997 M

F

33.0

(M&F)

5.4

7.0

Janus

1997

India 1998 M

F

4.0

4.0

0.5

0.5

Shetty*

2002

*Obesity Review, August 2002


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Obesity is a key & spreading issue in developed &

developing countries (BMI>30.0)

Ismail, 1998


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Prevalence of overweight and obesity in selected

Asian countries ( Urban vs Rural )

Country Year Area OWT

(%)

OBESE

(%)

Source

Iran 1999 U

R

28.0

19.9

12.4

6.8

Ghassemi*

2002

Malaysia 1996 U

R

17.4

15.5

4.5

4.3

Ismail et

al,* 2002

India 1998 U

R

10.9

7.3

1.1

0.8

Shetty*

2002

*Obesity Review, August 2002


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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 clinicalproblems 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


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The Asia-Pacific

perspective:

Redefining

obesitytreatment

and its

February 2000

World Health Organization

Western Pacific Region

IASO INTERNATIONAL ASSOCIATION FOR THE STUDY OF OBESITY

International Obesity TaskForce

IOTF (2000)


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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 clinicalproblems 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 ModerateObese Class II > 30.0 Severe

IOTF, 2000


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Are population specific BMI cut-off points for overweight and obesity

necessary?

Recent studies in Hong Kong, Singapore, Indonesia and Japan suggestedthat 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.

Issues


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Asian BMI action point - BMI>23

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


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= Suggested cutpoints for reporting population BMI distribution and specific action

levels for populations and individuals

overweight Obese I Obese II Obese III

Ranges for

determining

public health and

clinical action

levels based on

BMI

underweight

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

Low to Moderate Risk

Moderate to High Risk

High to Very High Risk

WHO

classification

Lancet, 2004


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Waist Circumference

Correlatesabdominal 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)


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The Obesity Epidemic

Malaysian scene


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NATIONAL HEALTH AND MORBIDITY

SURVEY (1996-97)

2.9

5.7

4.5

4.3

5.1

3.5

5.0

15.1

17.9

17.4

15.5

17.3

16.0

20.6

Male

Female

Urban

Rural

Malay

Chinese

Indian

Obese

(BMI > 30 kg/m2)

(%)

Overweight

(BMI 25-29.9 kg/m2)

(%)

Adults

Lim et al, 2000


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Prevalence of Obesity in Malaysi

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

Men Women

Obes

ity%(

BMI>30)

NHMS 1996

MANS 2002/2003

NHMS National Health & Morbidity Survey- 1996

MANS Malaysian Adults Nutrition Survey- 2002/03

PREVALENCE AND TRENDS OF OBESITY1 AMONGST MALE


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PREVALENCE AND TRENDS OF OBESITY1 AMONGST MALE

ADOLESCENTS IN SECONDARY SCHOOLS

1990 1997

School n Obese

no.

% n Obese

no.

%

Section 16, Shah

Alam

1383 3 0.2 731 51 7.0

Seaport, Kelana

Jaya

1213 12 1.0 1224 71 5.8

SSAAS, Shah

Alam

1039 9 0.9 936 57 6.1

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 140 (62%), Chinese 56 (25%), Indian 31 (13%)

*Malay 15 (43%), Chinese 13 (37%), Indian 7 (20%)


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10.9

10.7 10.1 10.5

6.0

5.5

6.3

5.7

0

2

4

6

8

10

12

North Central South East

Region

Percent(

Prevalence of Overweight & Obesity according to

Regions in Peninsular Malaysia (6-12 years)

n = 11264

n=2845n = 2875 n = 2825 n = 2719

UKM/Nestle study 2002


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4.9

6.6

9.0

10.0

12.6

16.9

15.4

4.5

6.7

7.9

11.912.4

13.8

15.5

0

2

4

6

8

10

12

14

16

18

6 7 8 9 10 11 12

Age(Years)

Perce

nt(%)

Male Female

Prevalence of Overweight in Children

according to age & sex

N = 11264


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10.8

5.9

10.3

5.8

0

2

4

6

8

10

12

Overweight Obese

Per

cent(%)

Male Female

Prevalence of Overweight & Obesity according to Sex

n = 11264

n = 1188

n = 661

UKM/Nestle study 2002


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4.95.1 5.0

5.9 5.8

7.48.1

5.1

5.75.3 5.3

6.1

6.77.0

0

1

2

3

4

5

6

7

8

9

6 7 8 9 10 11 12

Age (Years)

Percent(%

Male Female

Prevalence of Obesity in Children according to age

and sex

N = 11264


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10.510.1

11.7

6.2

4.7

6.7

0

2

4

6

8

10

12

14

Malay Chinese Indian

Ethni

Perce

nt(%)

Overweight Obese

Prevalence of Overweight & Obesity according to

ethnic groups

n = 11264

n = 7803n = 2511 n = 950

UKM/Nestle study2002


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Prevalence of overweight/obesity1among

children in Asia Pacific

0 5 10 15 20

Thailand*+

Taiwan*

South Korea

Singapore@

Philippines***

NewZeal.**

Malaysia#

Japan*@

Hong Kong*

China

Australia

%

Boys

Girls

1IOTF, *>120%

** 95th /WHO 1995

***85th, NHANES

# Malaysia: Cole et al 2000;

+ Thailand: both sexes

@ Red bar for younger, purple older age groups


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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 13.9UK 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 standarddefining total overweight as

-


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Influences on Energy Balance and Weight Gain

ENVIRONMENTAL & SOCIETAL INFLUENCES

Individual / Biological

SusceptibilityDietary & Physical

Activity Patterns

BODY FAT STORES

ENERGY REGULATIONINTAKE EXPENDITURE

FAT

CHO

PROTEIN

BMR

TEF

ACTIVITY

STABLE

WEIGHTGAIN LOSS

WHO, 1998


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ENVIRONMENTAL MODIFIERS IN WEIGHT-

REGULATION POTENTIAL THAT INFLUENCE

1.CHOICE & AMOUNT

OF FOOD CONSUMED

2.CHOICE & AMOUNT OF

PHYSICAL ACTIVITY

availability

cost

energy density

fat

sugar

palatability variety

portion size

access to recreational sports

nonmotorized form of

transportation

television

labour-saving devices


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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 andfruits,

the developing nations use their growing

incomes to replace their traditional diets, rich

in fibers and grains, with diets that include agreater proportion of fats and sugars.

Drewnowski & Popkin, 1997


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2200

2300

2400

2500

2600

2700

2800

2900

3000

3100

1961

-63

1964

-66

1967

-69

1970

-72

1973

-75

1976

-78

1979

-81

1982

-84

1985

-87

1988

-90

1991

-93

1994

-9619

97

Calories

Protein

Fat

100

90

80

70

60

50

40

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

Source: Food Balance Sheet of Malaysia (FAO)

100%


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Changes in sources of calories in Malaysia, 1961-1997

Food Balance Sheet FAO (1961-1997)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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

%

of

C a

l orie s


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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 nevertaken fast foods were higher than

Malays and Chinese

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


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Know your Fast FoodsKnow your Fast FoodsKnow your Fast FoodsKnow your Fast Foods

A quarter-pound cheeseburger, largefries,

and a 16 oz. sodaprovides

1,166 calories

51 g fat95 mg cholesterol

1,450 mg sodium


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Physical Activity Past Present


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DAILY ACTIVITY PATTERNS OF OBESE SUBJECTS

(min/day)

0

100

200

300

400

500

600

700

Lying/Sleep

Sitting

Standing

Walking

Personal

necessities

Moderate

exercise

Adolescents (13-17

yrs)

Adults (20-24 yrs)

minute

Ismail, 1998

DAILY ACTIVITY PATTERN OF MALAYSIANS


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DAILY ACTIVITY PATTERN OF MALAYSIANS

ACCORDING TO AGE-GROUPS

0

10

20

30

40

50

60

70

80

90

male

female

male

female

male

female

Adolescents

Adults

Elderly

Light

Moderate

Active

1

2

3

Poh et al(1996),

Ismail et al(1993)

Razali & Ismail (1996)

1

2

3

%

of d

ay


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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 1.52Young 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 Forces

29

20-30 5.74 12.08 2.10 NA NA NAElite Athlete30 20-30 6.84 14.91 2.18 5.39 10.67 1.98

25 Yap (2001), 26 Victor (1999), 27 Ismail et al. (1994), 28 Razali (1996),29 Ismail et al. (1996), 30 Ismail et al. (1997)


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Adapting exercise guidelines for energy balanceAdapting exercise guidelines for energy balance

PAL 1.0

PAL 1.8

PAL 1.60

PAL 1.50

BMR

CVD Guideline

Sedentary

Energy Balance

Erlichman, Kerbey & James, 2002. Obesity

Reviews, 3: 257-271 and 273-287.


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How much physical activity is enough to preventunhealthy 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 orapproximately 45-60 minutes per day of moderate activity isneeded.

For children even more activity time is recommended

Stock Conference, Bangkok, March 2002

Issues


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Diabetes

Gall bladder disease

Hypertension

Dyslipidaemia

Insulin resistance

Breathlessness

Sleep apnoea

Greatly increased(relative risk >>3)

Coronary heart disease

Osteoarthritis (knees)

Hyperuricaemia andgout

Moderately increased(relative risk

ca 2-3)

Cancer (breast cancer in

postmenopausal women,endometrial cancer, coloncancer

Reproductive hormoneabnormalities

Polycystic ovary syndrome

Impaired fertilityLow back pain

Increased anaesthetic risk

Foetal defects arising frommaternal obesity

Slightly increased(relative risk

ca 1-2)

Relative risk of health problems associated with

obesity in developed countries .

WHO, 1997


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Social Consequences

Community

Loss of productivity

Sick days

Individual

Employment prospects

Marriage/DivorceStress/Self esteem

Quality of Life


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Annual direct costs of disease in relation to BMI

Wolf and Colditz, 1996

Ann

ual

co

st ( U

S$bi llion

s)


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Published Costs of Obesity

Direct

USA 1998

$51.6 billion (5.7%)

NZ 1996

$135 million (2.5%)

France 1995

FF 12 billion (2%)

Netherlands 1995

DG 1 billion (4%)*

Indirect

$47.6 billion

FF0.57 billion

* 3% from BMI 25-30

Caterson & Broom (2001)


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Published Costs of Obesity

Direct

Canada 1999 (2.4%)

$1.8 billion* UK 1994 (15%)

GBP30 million

England 1999 (1.1%)

GBP130 million

GBP15 million

Indirect

* BMI > 27

GBP165 million

Overweight

Obese

Caterson & Broom (2001)


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Williamson DF et al, Am JWilliamson DF et al, Am J EpidemiolEpidemiol 19951995

Lean MEJ et al, Diabetic Med 1990Lean MEJ et al, Diabetic Med 1990

Benefits of 10 % weight lossBenefits of 10 % weight loss

20% reduction20% reductionin all-causein all-causemortalitymortality

30% reduction30% reductionin diabetes-in diabetes-associatedassociated

mortalitymortality

Life expectancy increases w ith w eight lossLife expectancy increases w ith w eight lossamong obese diabetic patientsamong obese diabetic patients

Weight loss (kg) in first 12 monthsWeight loss (kg) in first 12 months

Lean et al.Lean et al. DiabetDiabetMed, 1990; 7: 228Med, 1990; 7: 228--3333

Life

expectancy

(yea

rs)

Life

expectancy

(yea

rs) 1818

1616

1414

1212

1010

88

0000 22 44 66 88 1010 1212 1414 1616

95% confidence interval95% confidence interval


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A Vicious Circle

Disrespect of

obesity asa serious

condition

Overemphasis

on cosmetic

weight loss

Advocatingabsurd body

weight idealsProfessional

Public

Media

Rossner, 1997

CAUSAL WEB OF SOCIETAL INFLUENCES ON OBESITY PREVALENCE


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INTERNATIONALFACTORS

Development

Globalizationof

Markets

SchoolFood

WORK/SCHOOL/

HOME

Infections

Labor

WorksiteExercise

SchoolActivity

LeisureActivity/Facilities

WorksiteFood

Agriculture/Gardens/

Local Markets

COMMUNITIES

Health CareSystem

PublicSafety

PublicTransport

Manufactured/Imported

Food

Sanitation

NATIONAL/STATE

Food Policy

Urbanization

TransportPolicy

EducationPolicy

Health Policy

OBESIT

Y

PREVALENCE

INDIVIDUAL

EnergyExpenditure

FoodIntake:

NutrientDensity

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


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Strategy for thePrevention of

Obesity- Malaysia

G lNPANM II ( 2006-2015 )


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Incorporating nutrition objectives and strategies into policies and

programmes of relevant agencies

Foundation

strategy

Facilitatingstrategies

Improving household food security especially among the low income

Promoting optimal infant & young children feeding practices

Preventing and controlling nutritional deficiencies

Promoting healthy eating and active living

Supporting efforts to protect consumers in food quality & safety

Specific objectivesTo improve

nutritional

status of all

To preventand control

diet-related

non-communicable diseases

TO ACHIEVE AND MAINTAIN THE NUTRITIONAL WELL-

BEING OF MALAYSIANS

General

Objective

Enablingstrategies

Ensuring

all have

access tonutrition

information

Continuousassessment

and monitoringof the nutrition

Situation

Promotingcontinuous

researchanddevelopment

Ensuringnutrition

anddietetics arepractised

by trainedprofessionals

Strengthening

institutionalcapacity innutritionalactivities

NPANM II ( 2006 2015 )

Specific objective 1


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p j

To Improve nutritional status

The nutritional status of all Malaysians can be furtherenhanced through:

Improving breastfeeding and complementary feedingpractices

Improving food intake and dietary practices

Reducing protein-energy malnutrition

Reducing micronutrient deficiency

Reducing overweight and obesity


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Formation of Malaysian Council for ObesityPrevention (MCOP)

Initiated 3 working groups namely:

1) Childhood Obesity Prevention

2) Increasing Awareness

3) Research on Obesity Prevention


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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


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