p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 1 0 5 7 e1 0 6 2
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Review Paper
Is obesity an ineluctable consequence of development? A case study of Malaysia T.M. Davey*, P. Allotey, D.D. Reidpath Global Public Health and South East Asia Community Observatory (SEACO), School of Medicine and Health Sciences, Monash University Malaysia, Malaysia
article info
abstract
Article history:
Effective population-level solutions to the obesity pandemic have proved elusive. In low-
Received 22 March 2013
and middle-income countries the problem may be further challenged by the perceived
Received in revised form
internal tension between economic development and sustainable solutions which create
12 September 2013
the optimal conditions for human health and well-being. This paper discusses some of the
Accepted 16 September 2013
ecological obstacles to addressing the growing problem of obesity in ‘aspiring’ economies,
Available online 21 November 2013
using Malaysia as a case study. The authors conclude that current measures to stimulate economic growth in Malaysia may actually be exacerbating the problem of obesity in that
Keywords:
country. Public health solutions which address the wider context in which obesity exists
Obesity
are needed to change the course of this burgeoning problem.
Ecological Public Health
ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Developing nations
Introduction In June 2012, leaders from 193 UN member states agreed, tentatively, on the ‘future we want’: the Rioþ20 outcome document that outlines a process for sustainable development, endorsed, inter alia, efforts to reduce consumption, encourage a greener world, and improve energy systems.1 Critical to the negotiation, however, were the robust objections from low and middle income countries to what was perceived as an attempt to constrain their opportunities for development, poverty alleviation and growth through strategies that had previously been adopted by high income countries; the very countries that are lobbying for restraint and reduced consumption in order to observe and protect ‘planetary boundaries’.1
Similar objections present with other global challenges. The extent of the problem of obesity has been well documented, with its rise being primarily attributed to global changes in the availability of relatively affordable, actively marketed, processed food.2,3 Food processing technology has been an important contributor to economic development and is a key global industry. The changes in patterns of food consumption are part of wider global transitions in the forms of energy used (from human and other animal to fossil fuels), types of economies (from agricultural to industrial and technological), and lifestyles; all of which have interacted to produce a phenomenon of overnutrition which exceeds individuals’ capacity to expend that energy.2e4 There is little controversy about the proximal and the main distal causes of obesity as outlined above in terms of
* Corresponding author. Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway 46150, Selangor Darul Ehsan, Malaysia. Tel.: þ60 3 5514 4453. E-mail address: [email protected] (T.M. Davey). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2013.09.008
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The paper approaches the analysis of the problem of obesity in Malaysia using an Ecological Public Health framework. This model of public health accounts for the multifaceted, continuously changing, and complex interrelationship between human health and the environment.4 According to the model, all of the dimensions of existence e 1) the material or physical, 2) the biological and physiological, 3) the cognitive or cultural, and 4) the social (human interactions) e need to be considered in understanding the environment or context in which human health occurs. Another major premise of the model is the concept of continuous environmental change and the nine key, interacting ‘transitions’; all of which impact on the four dimensions of existence (as listed above). The transitions, as described by Rayner and Lang,4 are what shape human health (and the health of the natural environment) and represent possible intervention points for public health action. They include: demographic; epidemiological and health; urban; energy; economic; nutrition; biological and ecological; cultural; and democratic transitions. Discussion regarding the various Ecological Public Health transitions which have occurred in Malaysia over several decades and more e including the epidemiological transition, the urban transition, the economic transition, the energy transition, the nutrition transition, and the cultural transition e and how these have impacted on the dimensions of existence, helps to help explain how economic growth and obesity in developing nations may be linked.
The prevalence of obesity among adults in Malaysia in 2011 was 15.1% based on the WHO (1998) classification.6 These findings reflect an increase in obesity in Malaysia of 300% in 15 years: 4.4% in 1996 to 15% in 2011.7,8 While there was some variation in the distribution of obesity across the Malaysian population, findings suggest it is a ubiquitous national problem.6 There were no statistically significant differences in 2011 between the obesity prevalence in the urban and rural areas.6 Existing evidence from studies in low-income countries indicates that obesity is more concentrated in urban areas9e11; in high-income countries, the opposite is true.12,13 It is uncertain why this particular data from Malaysia e a high middle-income country e is indicating no difference in the obesity rate between urban and rural populations. With regard to gender in Malaysia, obesity rates were higher in women than in men, and highest in adults in the 45e49 age group, followed by those in the 55e59 years group.6 Statistically significant differences were reported in the prevalence of obesity between the main ethnic groups in Malaysia: Indians had the highest prevalence followed by Malays, and then the Chinese.6 Without subscribing to a simple energy-balance hypothesis of obesity,14 the rise in Malaysia has coincided with a per
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Ecological Public Health e a useful framework for understanding, analysing, and addressing complex public health problems
Nature and extent of the problem of obesity in Malaysia
Grams per Capita per day
general global transitions, and certainly the deleterious health effects associated with increased body mass index, such as type 2 diabetes and cardiovascular disease, are well accepted.2e4 What remains elusive are effective and long-term populationlevel policy solutions, or the documentation of such solutions, in the face of ever increasing rates of obesity across the globe.2,4 While there is empirical evidence which shows a number of effective interventions in terms of both Disability Adjusted Life Years saved and cost effectiveness,5 the majority of interventions have not yet been implemented at the populationlevel, and their sustained effectiveness outside of the controlled empirical setting, is unknown. Given the complexity of the problem of obesity, it is unlikely that long-term solutions are possible without a whole-of-society approach.4 Current approaches based on the uncoordinated solutions offered by the various interest groups, for example the pharmaceutical industry (drugs), psychology (behavioural therapy), surgery (gastric banding) etc., do not seem to be the answer. In this paper, the authors explored from an Ecological Public Health perspective the obstacles to addressing the challenges of the obesity epidemic in aspiring economies, using Malaysia as a case study. The complex, multidimensional, and interacting drivers which currently represent impediments or challenges to addressing obesity in this highmiddle income South-East Asian country context are discussed. The recommendations on the basis of this perspective for addressing the public health problem of obesity in the Malaysian context are also provided.
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Fig. 1 e Estimated number of kilocalories per capita consumed in Malaysia, and the number of grams per day, per capita of fat and protein consumed by the population between 1980 and 2009.
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capita increase in the availability of calories from simple carbohydrates, fats, and proteins.15 It has also coincided with typical markers of decreasing physical activity in a population, such as increasing urbanization,16,17 increasing per capita wealth,18 and the changing nature of work related to industrialization. Fig. 1 shows two graphs. The first is the estimated number of kilocalories per capita, per day in each year from 1980 to 2009. The dotted line marks 2780 Kcal/day. This is an important benchmark because there was no year prior to 1992 (right back to 1961) in which the kilocalories per day exceeded this number, and there is no year after 1992 in which the kilocalories per day fell below this number.19 While it is purely speculative, the decline in calories per day in 1985 may relate to the economic crisis of the day. The bottom graph in Fig. 1 shows the number of grams per day, per capita of fat and protein consumed by the population between 1980 and 2009. The fat consumption initially rose sharply from 1980 (in fact rising steadily from 1961 e when recording of the per capita calorie data commenced), and then oscillates, falling into a steady state from 1995 onwards e around 84 g/day. Protein consumption rises continuously from 1985 (57 g/day) until 1995 (76 g/day) and then also falls into a steady state from 1995 onwards e around 87 g/day.19 The steady state picture of fat and protein, contrasted with the greater variation in kilocalories may be reflected in the carbohydrates data e which was not available. In 2011, 92.5% of adult Malaysians were reported to be consuming less than the WHO recommended five servings of fruit and vegetables per day.6 Unfortunately no comparable population-level data exist prior to 2011 to indicate changes in the patterns of fruit and vegetable consumption over time. Changes since the 1960s have however been reported with regard to increased availability of high calorie fast foods and soft drinks, and restaurants increasing their opening hours to allow for late-night or 24 h dining.20 A reduction in physical activity is the other side of the equation. The Malaysian Adult Nutrition Study also reported that only one third of the adult population had ever exercised, with only 14% of adults reporting levels of exercise considered to be adequate.20 Malaysians have become progressively sedentary over time as a result of increased industrialization, urbanization, technical progress, and availability of personal transport options (i.e., motor vehicles and motor cycles).15 In 1980 42% of the Malaysian population lived in rural areas, with an agricultural population of around 5.4 Million people.19 By 1990 the position had begun to reverse. Fifty percent of the population were now living in urban areas and the agricultural population had declined 12% to 4.8 Million people. In 2010, 72% of the population was urban, and the agricultural population had declined 37% from 1980, to 3.4 Million people. The shift towards a predominantly urban population was, and still is, a central pillar in Malaysia’s development agenda. In 2006, then Prime Minister Badawi expressed the reality of, and the aspiration for urbanization thus: “Towns as engines of economic growth, have a vital role towards attaining the national vision of a developed nation status by year 2020. For the past two decades, the rate of urbanisation has registered a significant increase and in future, is expected to rise further.”
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To put the apparently dramatic increase in obesity in Malaysia in context, an increase in bodyweight of only three grams per day will see a total weight gain of more than a kilogram every year. These kinds of imperceptible individual gains in bodyweight do not require a vast, regular over consumption of food. They require a small over-consumption like that which appears to have occurred from 1995 onwards, matched by no increase or a slight reduction in energy expenditure, and a shift in (or overwhelming of) homeostatic weight regulation. An immeasurably small daily weight gain of three grams per day would see a 20-year-old Malaysian male of average height (1.65 M), weighing 60 kg in 1995 (BMI ¼ 22), overweight by 2003 (BMI ¼ 25.3), and obese by his 40th birthday in 2015 (BMI ¼ 30.1).
Government’s response to the obesity problem In an attempt to address the problem of rising obesity, the Malaysian Ministry of Health has implemented several programmes. The main approaches relate to increasing public awareness, and in improving knowledge in the population regarding nutrition. This has been undertaken through media campaigns, nutritional labelling guides on packaged food, as well as the establishment of nutritional information centres and healthy community kitchens to provide education on food choices and healthy cooking methods. The approach emphasizes the need for individual responsibility for health and wellness. There are also proposals by the Ministry of Health to improve public recreational and sporting facilities, and to introduce the use of screening tools in the primary healthcare setting for early risk identification of noncommunicable, ‘life-style’ diseases. To date there has not been any systematic evaluation of these weight control strategies in Malaysia. However, there is no evidence that these kinds of strategies have been effective at the national level in any country in the world, and there is little reason to believe that what has been ineffective elsewhere would succeed in Malaysia.
Political, economic, and cultural context The efforts of the health sector to address the problem are often in competition with other current political, economic and cultural conditions in Malaysia. The last strategic plan released by the Government, the 10th Malaysia Plan (2011e2015), has a strong emphasis on economic growth with a target to achieve high income country status by 2020. The plan has a focus on economic models that will drive productivity and innovation. This focus is (and has been) the primary driver for policy decisions. The strategy has been successful. An analysis of GDP per capita data from 1980 to 2009 (in constant 2005 international dollars corrected for purchasing power parity) shows a steady increase from around USD$5000 to USD$14,000 per annum. The increase in GDP per capita, however, is also associated with the increase in per capita, kilocalories per day observable in Fig. 1. This relationship between increasing per capita wealth and per capita kilocalories per day holds, even after controlling for time trends in the data. Indeed, controlling for the time trend in the data provides a conservative estimate of
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the relationship between national wealth and kilocalories, and still accounts for a significant proportion of the variance in kilocalories. That is, other things being equal, the policies associated with increases in per capita wealth are also associated with increases in per capita, per day kilocalories. Certainly this positive association between economic growth and obesity has been noted in other contexts,21,22 and the feedback loop between increased growth, obesity, and the subsequent increased requirement for food which in turn increases economic growth through higher demand and consumption of food products, may present ongoing dilemmas for developing countries. The industries external to health that need to be involved in the management of obesity include the food and energy industries to help create the structures that support healthy lifestyles. In Malaysia, however, these are heavily subsidized to fuel economic growth. In 2010, a report from the Prime Minister’s Department described Malaysia as being ‘one of the highest subsidized nations’ in the world, with the lowest prices for fuel, sugar, oil, and flour in the Southeast Asian region. In 2009 it spent the equivalent of USD$24 billion on subsidies, with nearly USD$ 8 billion of that spent on fuel and energy, and USD$ 1 billion on food. The availability of vegetable oil (the majority of which comprises palm oil e which is high in saturated fats)23 in Malaysia increased from 9.5 to 14 kg per capita per year between 1967 and 2007.7 Malaysia ranked 157th in 2008 in the world in terms of lowest fuel prices and first in the Asian region (including China and India) as consumers of fuel per capita. Since 2010, subsidies for fuel (including petrol, diesel, and liquefied petroleum gas) and sugar have been reduced. From July 2010 only small reductions in the sugar subsidy were implemented (20%), with the government providing assurances that there would be, ‘minimum impact on individual families’, and that such subsidies were necessary to reduce government debts and deficits, and increase savings. The government emphasized cost as the major rationalization for such cuts, but also acknowledged the harms of excess sugar to the population and the rising rates of diabetes in the country, as further justification for the reduced sugar subsidy. However, health is only one among a series of competing social, economic, and political goals. For example, fuel was also included as part of a Subsidy Rationalization Program, but the government continues to subsidize it and provides on-going (annual) cash rebates to motorists for the purchase of new cars and motorbikes.24,25 Financial incentives along with the approbation and normalization by authorities for the public to purchase motorized vehicles, to drive, and to use sugar and oil at low cost, is well received by the population, but establishes the conditions conducive to increasing population levels of obesity. The government subsidy policies may all be viewed in the light of their economic advantages for Malaysia. Palm oil and palm kernel oil, which comprises the majority of vegetable oils available in Malaysia,7 and which is subsidized by the government, is also an industry in which the government is heavily invested.26,27 In 2011 palm oil-related export revenues in Malaysia amounted to V20 billion, and the sector was identified by the Malaysian government as one of 12 national key economic areas for development in the 2011e2020
period.27 In terms of total palm oil plantation area in Malaysia, the government owns over a quarter, with some of the major private palm oil plantation organizations also being government-linked.26,27 The government also collects levies on the remaining (approximately) 60% of plantations not owned by the government, and is involved in and collects revenue from the downstream production activities such as refining and production of the end-point products.26 Furthermore, the equity from both government and the non-government plantation and production organizations in the country are largely under Malaysian ownership.26 Domestic consumption of palm oil products, stimulated through subsidies, is therefore expected to stimulate the economy not only through an expanding food industry, but also by helping to reduce the costs of living for Malaysians which may then free up disposable income for them to contribute to the economy in other ways. Similarly, by subsidizing fuel and the motor industry, sectors from which the government also earns large revenue, the Malaysian economy is further stimulated.25 The possible unintended consequences of this kind of strategy were raised by the International Energy Agency. The Agency suggested that energy subsidies were likely to have costly environmental consequences while supporting only short-term economic gains.28 The fast food industry with high calorie processed foods is also a significant feature in Malaysia’s economic development. Eating out has been a strong part of the Malaysian food culture with large numbers of food outlets providing a variety of traditional local and traditional cuisines that reflect Malaysia’s cultural diversity.29 The fusion of foods has resulted in meals that are often high in sugar, fats and carbohydrates.30 However, it is still possible in most traditional makanan (food) outlets, to have meals prepared on site with a range of freshly available vegetables, spices and other ingredients. These makanan outlets now also compete with a growing number of western fast food outlets. Over the last two decades, the number of McDonald’s outlets has increased to just under 200 with ‘family restaurants’ located even in rural communities. While no currently available data exist regarding fast food consumption, this growth in fast food outlets likely indicates notable shifts in the traditional diets of Malaysians. Although more expensive than local foods, successful advertising has made them attractive not only for the food but also for the franchising, and therefore economic opportunities.31 Similar growth is reported by other brands in Malaysia such as KFC, Dominos, and Pizza Hut. There has been some research conducted on price elasticity associated with food (sugar and fat) choices and weight as outcomes.32 Unfortunately, none of it has been conducted in Malaysia. The indications are, however, that food pricing policies (including taxation and subsidization) will affect consumption. A policy that lowers the price of rice, sugar, and oil is likely to see increases in consumption, and visa-versa. The choices made by governments to intervene in food pricing and food availability are complicated because the national outcomes of interest are not just overweight and obesity. There are wider political and economic concerns.
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Discussion Institutionalized measures implemented to stimulate economic growth, exacerbate the problem of obesity in Malaysia by providing financial incentives to increase availability of calories and decrease physical activity in the population. They influence it further through cultural change.4 Government subsidies establish the political and economic conditions that foster accepted public beliefs in the necessity of having and driving a motorized vehicle, possibly at the expense of physical activity, and of cooking with and/or purchasing processed food which contains energy dense ingredients like oil and sugar. Efforts to address obesity which emphasize individual health awareness, healthy lifestyle activities, and empowering the population to take responsibility for their own health, are dwarfed by stronger societal drivers which currently go beyond the remit of the ministry of health and other health departments, much less individuals in the population. This is not unlike the situation in most countries around the world but the Malaysian example provides a useful illustration of how analysis of the ecological factors in a particular context, help to explain and illuminate potential solutions and avenues for intervention that may not have been considered by the government. The imperative for economic growth is important precisely because it can lift populations out of poverty, improve health and quality of life and enhance innovation and development. Indeed, the Malaysian government strategy has seen (almost) continuous, real term economic growth over the past 20 years. However there is a real risk that the strategies implemented to achieve economic growth are trading on longer term values to protect broader aspects of a population’s health and wellbeing. As in many aspiring economies, environmental sustainability is something to consider in the future e after one has achieved ‘a place in the sun’. Evidence from high income countries highlights the need for multisectoral collaboration that recognizes a broader definition of population well-being as a marker of success. For the issue of obesity, this means Ministries working together with a common goal to address obesity, bringing together multiple policy instruments such as education, regulation, enforcement, structural change and economic incentives and penalties as appropriate. This is easier said than done and in most countries governments work to an election cycle and hence policies that are likely to yield short term demonstrable outcomes. It is simpler therefore to hand back responsibility for obesity prevention to the individual. And when the imperative is economic growth e as in the case of aspiring economies e it is unsurprising that curtailing the supply-side of the obesity equation is especially unpalatable. It is not certain that good health and economic development are mutually exclusive; indeed obesity is not necessarily the ‘ineluctable consequence of development’. For this to be true, however, economic growth needs to take account of human health, since these are inextricably linked. Human health is in turn inextricably linked with all aspects of the environment e biological, material, social, and cultural e and affected by transitions occurring within that environment. Given this, all nations need to consider the effect that their
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economic development is having on the environment. This is certainly the case if the goal of nations is both good human health and a healthy economy. General recommendations for all countries include: sustainable economic development which is based on renewable energy sources; the protection of the natural environment and the production of healthy food sources which are neither deleterious for the environment nor human health; and the creation of safe infrastructure which promotes active transportation (cycling and walking). This is the set of principles against which all policy decisions need to be developed. Policies which are developed in isolation to achieve a particular purpose, may do so at the expense of other domains. It is therefore imperative that all sectors of government work within a consistent set of principles which have good human and environmental health at their core. And furthermore, there needs to be collaboration between governments, NGOs, the private sector, the media, communities, and individuals, if people want the possibility of being able to create the kind of societies in which everyone would like to live.
Author statements Ethical approval Not required.
Funding None.
Competing interests None.
references
1. Tollefson J. Wealth gap curbs Rio goals. Nature 2012 Jun 26;486(7404):447e8. 2. Swinburn B, Sacks G, Hall K. The global obesity pandemic: shaped by global drivers and local environments. Lancet 2011;378:804e14. 3. French S, Story M, Jeffery R. Environmental influences on eating and physical activity [Internet]. University of Minnesota309e35. Report No.: 22. Available from:, http://www.uic.edu/classes/ psych/Health/Readings/French,%20obesity%20-% 20environmental,%20AnnRevPubHth,%202001.pdf; 2001. 4. Rayner G, Lang T. Ecological public health: reshaping the conditions for good health. Oxon: Routledge; 2012. 5. Gortmaker SL, Swinburn BA, Levy D, Carter R, Mabry PL, Finegood DT, Huang T, Marsh T, Moodie ML. Changing the future of obesity: science, policy, and action. Lancet 2011 Aug 27;378(9793):838e47. 6. Institute for Public Health Ministry of Health Malaysia. National health and morbidity survey 2011; 2011. 7. Khor GL. Food availability and the rising obesity prevalence in Malaysia. IeJSME 2012;6(Suppl. þ1):S61e8. 8. Khambalia AZ, Seen LS. Trends in overweight and obese adults in Malaysia (1996e2009): a systematic review. Obes Rev 2010 Jun;11(6):403e12.
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9. Loret de Mola C, Pillay TD, Diez-Canseco F, Gilman RH, Smeeth L, Miranda JJ. Body mass index and self-perception of overweight and obesity in rural, urban and rural-to-urban migrants: PERU MIGRANT Study. PLoS One(11) [Internet]. [cited 2013 Sep 2]. Available from: http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3508895/, 2012 Nov 28;7. 10. Yadav K, Krishnan A. Changing patterns of diet, physical activity and obesity among urban, rural and slum populations in north India. Obes Rev 2008;9(5):400e8. 11. Physical activity and its relationship with obesity, hypertension and diabetes in urban and rural Cameroon(7). Published online: 21 June 2002. [Internet]. [cited 2013 Sep 2]. Available from: http://www.nature.com/ijo/journal/v26/n7/ full/0802008a.html, 2002 Jun 21e;26. 12. Liu J-H, Jones SJ, Sun H, Probst JC, Merchant AT, Cavicchia P. Diet, physical activity, and sedentary behaviors as risk factors for childhood obesity: an urban and rural comparison8(5):440e8. 13. Glenn LL, Ramsey PW. Obesity and health status in rural, urban, and suburban Southern women. South Med J 2002 Jul;95(7):666þ. 14. Hafekost K, Lawrence D, Mitrou F, O’Sullivan TA, Zubrick SR. Tackling overweight and obesity: does the public health message match the science? BMC Med 2013 Feb 18;11(1):41. 15. Malaysian Association for the Study of Obesity. Causes of obesity [Internet]. Strategy for the prevention of obesity e Malaysia. Available from: http://www.maso.org.my/spom/chap5.pdf. 16. Ramachandran A, Chamukuttan S, Shetty SA, Arun N, Susairaj P. Obesity in Asia e is it different from rest of the world. Diabetes Metab Res Rev 2012 Dec;28(Suppl. 2):47e51. 17. Amin TT, Al Khoudair AS, Al Harbi MA, Al Ali AR. Leisure time physical activity in Saudi Arabia: prevalence, pattern and determining factors. Asian Pac J Cancer Prev 2012;13(1):351e60. 18. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet 21e27 July 2012;380(9838):247e57. 19. FAOSTAT [Internet]. [cited 2013 Feb 27]. Available from: http://faostat3.fao.org/home/index.html. 20. Poh B, Safiah M, Tahir A, Siti Haslinda M, Siti Norazlin N, Norimah A, Wan Manan WM, Mirnalini K, Zalilah MS, Azmi MY, Fatimah S. Physical activity pattern and energy expenditure of Malaysian adults: findings from the Malaysian Adult Nutrition Survey (MANS). Mal J Nutr 2010;16(1):13e37.
21. Fat chance; obesity. The Economist 2012 Dec 15;405(8815):16 (US). 22. Egger G. Obesity, chronic disease, and economic growth: a case for “big picture” prevention. Adv Prev Med [Internet]. [cited 2013 Aug 29]. Available from: http://www.ncbi.nlm.nih. gov/pmc/articles/PMC3169376/, 2011;2011. 23. [Internet]Fats, oils, and fatty acids [cited 2013 Mar 16]. Available from:, http://www.nutristrategy.com/fatsoils.htm; 2013. 24. PEMANDU e Performance Management Delivery Unit. Government transformation programme: the roadmap 2.0catalysing transformation for a brighter future [Internet] [cited 2013 Jan 15]. Available from:, http://www.pemandu.gov.my/; 2011. 25. Rahim R. Mustapa: no plans for cash rebate as incentive to buy electric and hybrid cars e nation. The Star Online [Internet]. [cited 2013 Jan 4]. Available from: http://thestar.com.my/ news/story.asp?file¼/2012/10/24/nation/ 20121024125553&sec¼nation. 26. Cheng Hai T. The palm oil industry in Malaysia: from seed to frying pan [Internet]. Malaysia: WWF74. Available from:, http://www.lifeofthelandhawaii.org/Bio_Documents/2007. 0346/bfd/WWF_From_Seed_to_Frying_Pan.pdf; 2002 Nov. 27. Henriksson J. The Malaysian palm oil sector e overview [Internet]:21. Available from:, http://www.ice.gov.it/paesi/ asia/malaysia/upload/173/Palm%20Oil_overview_2012.pdf; 2012 June. 28. International Energy Agency. World energy outlook looking at energy subsidies: getting the prices right. Paris: International Energy Agency; 1999. 29. West BA. Encyclopedia of the peoples of Asia and Oceania. Infobase Publishing; 2009. 30. Far Eastern cuisine: fancy a Malaysian? e features e food & drink. The Independent [Internet]. [cited 2013 Feb 17]. Available from: http://www.independent.co.uk/life-style/food-anddrink/features/far-eastern-cuisine-fancy-a-malaysian2104800.html. 31. I’m lovin’ it! McDonald’s Malaysia [Internet]. [cited 2013 Feb 17]. Available from: http://www.mcdonalds.com.my/abtus/ corpinfo/milestone.asp. 32. Andreyeva T, Long MW, Brownell KD. The impact of food prices on consumption: a systematic review of research on the price elasticity of demand for food. Am J Public Health 2010 Feb;100(2):216e22.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Review Paper
Is obesity an ineluctable consequence of development? A case study of Malaysia T.M. Davey*, P. Allotey, D.D. Reidpath Global Public Health and South East Asia Community Observatory (SEACO), School of Medicine and Health Sciences, Monash University Malaysia, Malaysia
article info
abstract
Article history:
Effective population-level solutions to the obesity pandemic have proved elusive. In low-
Received 22 March 2013
and middle-income countries the problem may be further challenged by the perceived
Received in revised form
internal tension between economic development and sustainable solutions which create
12 September 2013
the optimal conditions for human health and well-being. This paper discusses some of the
Accepted 16 September 2013
ecological obstacles to addressing the growing problem of obesity in ‘aspiring’ economies,
Available online 21 November 2013
using Malaysia as a case study. The authors conclude that current measures to stimulate economic growth in Malaysia may actually be exacerbating the problem of obesity in that
Keywords:
country. Public health solutions which address the wider context in which obesity exists
Obesity
are needed to change the course of this burgeoning problem.
Ecological Public Health
ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Developing nations
Introduction In June 2012, leaders from 193 UN member states agreed, tentatively, on the ‘future we want’: the Rioþ20 outcome document that outlines a process for sustainable development, endorsed, inter alia, efforts to reduce consumption, encourage a greener world, and improve energy systems.1 Critical to the negotiation, however, were the robust objections from low and middle income countries to what was perceived as an attempt to constrain their opportunities for development, poverty alleviation and growth through strategies that had previously been adopted by high income countries; the very countries that are lobbying for restraint and reduced consumption in order to observe and protect ‘planetary boundaries’.1
Similar objections present with other global challenges. The extent of the problem of obesity has been well documented, with its rise being primarily attributed to global changes in the availability of relatively affordable, actively marketed, processed food.2,3 Food processing technology has been an important contributor to economic development and is a key global industry. The changes in patterns of food consumption are part of wider global transitions in the forms of energy used (from human and other animal to fossil fuels), types of economies (from agricultural to industrial and technological), and lifestyles; all of which have interacted to produce a phenomenon of overnutrition which exceeds individuals’ capacity to expend that energy.2e4 There is little controversy about the proximal and the main distal causes of obesity as outlined above in terms of
* Corresponding author. Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway 46150, Selangor Darul Ehsan, Malaysia. Tel.: þ60 3 5514 4453. E-mail address: [email protected] (T.M. Davey). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2013.09.008
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The paper approaches the analysis of the problem of obesity in Malaysia using an Ecological Public Health framework. This model of public health accounts for the multifaceted, continuously changing, and complex interrelationship between human health and the environment.4 According to the model, all of the dimensions of existence e 1) the material or physical, 2) the biological and physiological, 3) the cognitive or cultural, and 4) the social (human interactions) e need to be considered in understanding the environment or context in which human health occurs. Another major premise of the model is the concept of continuous environmental change and the nine key, interacting ‘transitions’; all of which impact on the four dimensions of existence (as listed above). The transitions, as described by Rayner and Lang,4 are what shape human health (and the health of the natural environment) and represent possible intervention points for public health action. They include: demographic; epidemiological and health; urban; energy; economic; nutrition; biological and ecological; cultural; and democratic transitions. Discussion regarding the various Ecological Public Health transitions which have occurred in Malaysia over several decades and more e including the epidemiological transition, the urban transition, the economic transition, the energy transition, the nutrition transition, and the cultural transition e and how these have impacted on the dimensions of existence, helps to help explain how economic growth and obesity in developing nations may be linked.
The prevalence of obesity among adults in Malaysia in 2011 was 15.1% based on the WHO (1998) classification.6 These findings reflect an increase in obesity in Malaysia of 300% in 15 years: 4.4% in 1996 to 15% in 2011.7,8 While there was some variation in the distribution of obesity across the Malaysian population, findings suggest it is a ubiquitous national problem.6 There were no statistically significant differences in 2011 between the obesity prevalence in the urban and rural areas.6 Existing evidence from studies in low-income countries indicates that obesity is more concentrated in urban areas9e11; in high-income countries, the opposite is true.12,13 It is uncertain why this particular data from Malaysia e a high middle-income country e is indicating no difference in the obesity rate between urban and rural populations. With regard to gender in Malaysia, obesity rates were higher in women than in men, and highest in adults in the 45e49 age group, followed by those in the 55e59 years group.6 Statistically significant differences were reported in the prevalence of obesity between the main ethnic groups in Malaysia: Indians had the highest prevalence followed by Malays, and then the Chinese.6 Without subscribing to a simple energy-balance hypothesis of obesity,14 the rise in Malaysia has coincided with a per
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Ecological Public Health e a useful framework for understanding, analysing, and addressing complex public health problems
Nature and extent of the problem of obesity in Malaysia
Grams per Capita per day
general global transitions, and certainly the deleterious health effects associated with increased body mass index, such as type 2 diabetes and cardiovascular disease, are well accepted.2e4 What remains elusive are effective and long-term populationlevel policy solutions, or the documentation of such solutions, in the face of ever increasing rates of obesity across the globe.2,4 While there is empirical evidence which shows a number of effective interventions in terms of both Disability Adjusted Life Years saved and cost effectiveness,5 the majority of interventions have not yet been implemented at the populationlevel, and their sustained effectiveness outside of the controlled empirical setting, is unknown. Given the complexity of the problem of obesity, it is unlikely that long-term solutions are possible without a whole-of-society approach.4 Current approaches based on the uncoordinated solutions offered by the various interest groups, for example the pharmaceutical industry (drugs), psychology (behavioural therapy), surgery (gastric banding) etc., do not seem to be the answer. In this paper, the authors explored from an Ecological Public Health perspective the obstacles to addressing the challenges of the obesity epidemic in aspiring economies, using Malaysia as a case study. The complex, multidimensional, and interacting drivers which currently represent impediments or challenges to addressing obesity in this highmiddle income South-East Asian country context are discussed. The recommendations on the basis of this perspective for addressing the public health problem of obesity in the Malaysian context are also provided.
Protein
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1980
1985
1990
1995 Year
Fig. 1 e Estimated number of kilocalories per capita consumed in Malaysia, and the number of grams per day, per capita of fat and protein consumed by the population between 1980 and 2009.
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capita increase in the availability of calories from simple carbohydrates, fats, and proteins.15 It has also coincided with typical markers of decreasing physical activity in a population, such as increasing urbanization,16,17 increasing per capita wealth,18 and the changing nature of work related to industrialization. Fig. 1 shows two graphs. The first is the estimated number of kilocalories per capita, per day in each year from 1980 to 2009. The dotted line marks 2780 Kcal/day. This is an important benchmark because there was no year prior to 1992 (right back to 1961) in which the kilocalories per day exceeded this number, and there is no year after 1992 in which the kilocalories per day fell below this number.19 While it is purely speculative, the decline in calories per day in 1985 may relate to the economic crisis of the day. The bottom graph in Fig. 1 shows the number of grams per day, per capita of fat and protein consumed by the population between 1980 and 2009. The fat consumption initially rose sharply from 1980 (in fact rising steadily from 1961 e when recording of the per capita calorie data commenced), and then oscillates, falling into a steady state from 1995 onwards e around 84 g/day. Protein consumption rises continuously from 1985 (57 g/day) until 1995 (76 g/day) and then also falls into a steady state from 1995 onwards e around 87 g/day.19 The steady state picture of fat and protein, contrasted with the greater variation in kilocalories may be reflected in the carbohydrates data e which was not available. In 2011, 92.5% of adult Malaysians were reported to be consuming less than the WHO recommended five servings of fruit and vegetables per day.6 Unfortunately no comparable population-level data exist prior to 2011 to indicate changes in the patterns of fruit and vegetable consumption over time. Changes since the 1960s have however been reported with regard to increased availability of high calorie fast foods and soft drinks, and restaurants increasing their opening hours to allow for late-night or 24 h dining.20 A reduction in physical activity is the other side of the equation. The Malaysian Adult Nutrition Study also reported that only one third of the adult population had ever exercised, with only 14% of adults reporting levels of exercise considered to be adequate.20 Malaysians have become progressively sedentary over time as a result of increased industrialization, urbanization, technical progress, and availability of personal transport options (i.e., motor vehicles and motor cycles).15 In 1980 42% of the Malaysian population lived in rural areas, with an agricultural population of around 5.4 Million people.19 By 1990 the position had begun to reverse. Fifty percent of the population were now living in urban areas and the agricultural population had declined 12% to 4.8 Million people. In 2010, 72% of the population was urban, and the agricultural population had declined 37% from 1980, to 3.4 Million people. The shift towards a predominantly urban population was, and still is, a central pillar in Malaysia’s development agenda. In 2006, then Prime Minister Badawi expressed the reality of, and the aspiration for urbanization thus: “Towns as engines of economic growth, have a vital role towards attaining the national vision of a developed nation status by year 2020. For the past two decades, the rate of urbanisation has registered a significant increase and in future, is expected to rise further.”
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To put the apparently dramatic increase in obesity in Malaysia in context, an increase in bodyweight of only three grams per day will see a total weight gain of more than a kilogram every year. These kinds of imperceptible individual gains in bodyweight do not require a vast, regular over consumption of food. They require a small over-consumption like that which appears to have occurred from 1995 onwards, matched by no increase or a slight reduction in energy expenditure, and a shift in (or overwhelming of) homeostatic weight regulation. An immeasurably small daily weight gain of three grams per day would see a 20-year-old Malaysian male of average height (1.65 M), weighing 60 kg in 1995 (BMI ¼ 22), overweight by 2003 (BMI ¼ 25.3), and obese by his 40th birthday in 2015 (BMI ¼ 30.1).
Government’s response to the obesity problem In an attempt to address the problem of rising obesity, the Malaysian Ministry of Health has implemented several programmes. The main approaches relate to increasing public awareness, and in improving knowledge in the population regarding nutrition. This has been undertaken through media campaigns, nutritional labelling guides on packaged food, as well as the establishment of nutritional information centres and healthy community kitchens to provide education on food choices and healthy cooking methods. The approach emphasizes the need for individual responsibility for health and wellness. There are also proposals by the Ministry of Health to improve public recreational and sporting facilities, and to introduce the use of screening tools in the primary healthcare setting for early risk identification of noncommunicable, ‘life-style’ diseases. To date there has not been any systematic evaluation of these weight control strategies in Malaysia. However, there is no evidence that these kinds of strategies have been effective at the national level in any country in the world, and there is little reason to believe that what has been ineffective elsewhere would succeed in Malaysia.
Political, economic, and cultural context The efforts of the health sector to address the problem are often in competition with other current political, economic and cultural conditions in Malaysia. The last strategic plan released by the Government, the 10th Malaysia Plan (2011e2015), has a strong emphasis on economic growth with a target to achieve high income country status by 2020. The plan has a focus on economic models that will drive productivity and innovation. This focus is (and has been) the primary driver for policy decisions. The strategy has been successful. An analysis of GDP per capita data from 1980 to 2009 (in constant 2005 international dollars corrected for purchasing power parity) shows a steady increase from around USD$5000 to USD$14,000 per annum. The increase in GDP per capita, however, is also associated with the increase in per capita, kilocalories per day observable in Fig. 1. This relationship between increasing per capita wealth and per capita kilocalories per day holds, even after controlling for time trends in the data. Indeed, controlling for the time trend in the data provides a conservative estimate of
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the relationship between national wealth and kilocalories, and still accounts for a significant proportion of the variance in kilocalories. That is, other things being equal, the policies associated with increases in per capita wealth are also associated with increases in per capita, per day kilocalories. Certainly this positive association between economic growth and obesity has been noted in other contexts,21,22 and the feedback loop between increased growth, obesity, and the subsequent increased requirement for food which in turn increases economic growth through higher demand and consumption of food products, may present ongoing dilemmas for developing countries. The industries external to health that need to be involved in the management of obesity include the food and energy industries to help create the structures that support healthy lifestyles. In Malaysia, however, these are heavily subsidized to fuel economic growth. In 2010, a report from the Prime Minister’s Department described Malaysia as being ‘one of the highest subsidized nations’ in the world, with the lowest prices for fuel, sugar, oil, and flour in the Southeast Asian region. In 2009 it spent the equivalent of USD$24 billion on subsidies, with nearly USD$ 8 billion of that spent on fuel and energy, and USD$ 1 billion on food. The availability of vegetable oil (the majority of which comprises palm oil e which is high in saturated fats)23 in Malaysia increased from 9.5 to 14 kg per capita per year between 1967 and 2007.7 Malaysia ranked 157th in 2008 in the world in terms of lowest fuel prices and first in the Asian region (including China and India) as consumers of fuel per capita. Since 2010, subsidies for fuel (including petrol, diesel, and liquefied petroleum gas) and sugar have been reduced. From July 2010 only small reductions in the sugar subsidy were implemented (20%), with the government providing assurances that there would be, ‘minimum impact on individual families’, and that such subsidies were necessary to reduce government debts and deficits, and increase savings. The government emphasized cost as the major rationalization for such cuts, but also acknowledged the harms of excess sugar to the population and the rising rates of diabetes in the country, as further justification for the reduced sugar subsidy. However, health is only one among a series of competing social, economic, and political goals. For example, fuel was also included as part of a Subsidy Rationalization Program, but the government continues to subsidize it and provides on-going (annual) cash rebates to motorists for the purchase of new cars and motorbikes.24,25 Financial incentives along with the approbation and normalization by authorities for the public to purchase motorized vehicles, to drive, and to use sugar and oil at low cost, is well received by the population, but establishes the conditions conducive to increasing population levels of obesity. The government subsidy policies may all be viewed in the light of their economic advantages for Malaysia. Palm oil and palm kernel oil, which comprises the majority of vegetable oils available in Malaysia,7 and which is subsidized by the government, is also an industry in which the government is heavily invested.26,27 In 2011 palm oil-related export revenues in Malaysia amounted to V20 billion, and the sector was identified by the Malaysian government as one of 12 national key economic areas for development in the 2011e2020
period.27 In terms of total palm oil plantation area in Malaysia, the government owns over a quarter, with some of the major private palm oil plantation organizations also being government-linked.26,27 The government also collects levies on the remaining (approximately) 60% of plantations not owned by the government, and is involved in and collects revenue from the downstream production activities such as refining and production of the end-point products.26 Furthermore, the equity from both government and the non-government plantation and production organizations in the country are largely under Malaysian ownership.26 Domestic consumption of palm oil products, stimulated through subsidies, is therefore expected to stimulate the economy not only through an expanding food industry, but also by helping to reduce the costs of living for Malaysians which may then free up disposable income for them to contribute to the economy in other ways. Similarly, by subsidizing fuel and the motor industry, sectors from which the government also earns large revenue, the Malaysian economy is further stimulated.25 The possible unintended consequences of this kind of strategy were raised by the International Energy Agency. The Agency suggested that energy subsidies were likely to have costly environmental consequences while supporting only short-term economic gains.28 The fast food industry with high calorie processed foods is also a significant feature in Malaysia’s economic development. Eating out has been a strong part of the Malaysian food culture with large numbers of food outlets providing a variety of traditional local and traditional cuisines that reflect Malaysia’s cultural diversity.29 The fusion of foods has resulted in meals that are often high in sugar, fats and carbohydrates.30 However, it is still possible in most traditional makanan (food) outlets, to have meals prepared on site with a range of freshly available vegetables, spices and other ingredients. These makanan outlets now also compete with a growing number of western fast food outlets. Over the last two decades, the number of McDonald’s outlets has increased to just under 200 with ‘family restaurants’ located even in rural communities. While no currently available data exist regarding fast food consumption, this growth in fast food outlets likely indicates notable shifts in the traditional diets of Malaysians. Although more expensive than local foods, successful advertising has made them attractive not only for the food but also for the franchising, and therefore economic opportunities.31 Similar growth is reported by other brands in Malaysia such as KFC, Dominos, and Pizza Hut. There has been some research conducted on price elasticity associated with food (sugar and fat) choices and weight as outcomes.32 Unfortunately, none of it has been conducted in Malaysia. The indications are, however, that food pricing policies (including taxation and subsidization) will affect consumption. A policy that lowers the price of rice, sugar, and oil is likely to see increases in consumption, and visa-versa. The choices made by governments to intervene in food pricing and food availability are complicated because the national outcomes of interest are not just overweight and obesity. There are wider political and economic concerns.
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Discussion Institutionalized measures implemented to stimulate economic growth, exacerbate the problem of obesity in Malaysia by providing financial incentives to increase availability of calories and decrease physical activity in the population. They influence it further through cultural change.4 Government subsidies establish the political and economic conditions that foster accepted public beliefs in the necessity of having and driving a motorized vehicle, possibly at the expense of physical activity, and of cooking with and/or purchasing processed food which contains energy dense ingredients like oil and sugar. Efforts to address obesity which emphasize individual health awareness, healthy lifestyle activities, and empowering the population to take responsibility for their own health, are dwarfed by stronger societal drivers which currently go beyond the remit of the ministry of health and other health departments, much less individuals in the population. This is not unlike the situation in most countries around the world but the Malaysian example provides a useful illustration of how analysis of the ecological factors in a particular context, help to explain and illuminate potential solutions and avenues for intervention that may not have been considered by the government. The imperative for economic growth is important precisely because it can lift populations out of poverty, improve health and quality of life and enhance innovation and development. Indeed, the Malaysian government strategy has seen (almost) continuous, real term economic growth over the past 20 years. However there is a real risk that the strategies implemented to achieve economic growth are trading on longer term values to protect broader aspects of a population’s health and wellbeing. As in many aspiring economies, environmental sustainability is something to consider in the future e after one has achieved ‘a place in the sun’. Evidence from high income countries highlights the need for multisectoral collaboration that recognizes a broader definition of population well-being as a marker of success. For the issue of obesity, this means Ministries working together with a common goal to address obesity, bringing together multiple policy instruments such as education, regulation, enforcement, structural change and economic incentives and penalties as appropriate. This is easier said than done and in most countries governments work to an election cycle and hence policies that are likely to yield short term demonstrable outcomes. It is simpler therefore to hand back responsibility for obesity prevention to the individual. And when the imperative is economic growth e as in the case of aspiring economies e it is unsurprising that curtailing the supply-side of the obesity equation is especially unpalatable. It is not certain that good health and economic development are mutually exclusive; indeed obesity is not necessarily the ‘ineluctable consequence of development’. For this to be true, however, economic growth needs to take account of human health, since these are inextricably linked. Human health is in turn inextricably linked with all aspects of the environment e biological, material, social, and cultural e and affected by transitions occurring within that environment. Given this, all nations need to consider the effect that their
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economic development is having on the environment. This is certainly the case if the goal of nations is both good human health and a healthy economy. General recommendations for all countries include: sustainable economic development which is based on renewable energy sources; the protection of the natural environment and the production of healthy food sources which are neither deleterious for the environment nor human health; and the creation of safe infrastructure which promotes active transportation (cycling and walking). This is the set of principles against which all policy decisions need to be developed. Policies which are developed in isolation to achieve a particular purpose, may do so at the expense of other domains. It is therefore imperative that all sectors of government work within a consistent set of principles which have good human and environmental health at their core. And furthermore, there needs to be collaboration between governments, NGOs, the private sector, the media, communities, and individuals, if people want the possibility of being able to create the kind of societies in which everyone would like to live.
Author statements Ethical approval Not required.
Funding None.
Competing interests None.
references
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